My 2 Cents

Monday, May 20, 2013

Breast Cancer Genetics: The Role of Your Family Physician Part 2

So now that the furor over Angelina Jolie's disclosure has died down, I thought I'd take a closer look at the US Preventive Services Task Force evidence review published last month in Annals of Internal Medicine in which they concluded that selective estrogen receptor modulators can reduce the risk of breast cancer. However, if you'll recall that there's no such thing as a free lunch, then it shouldn't come as a surprise that use of tamoxifen was associated w/greater risk of thromboembolism & endometrial cancer than raloxifene, albeit tamoxifen reduced breast cancer risk better than raloxifene.

The authors arrived at their conclusions after finding 89 fair-to-good quality trials in which both SERMs reduced risk of invasive breast cancer w/tamoxifen getting the edge over raloxifene but at the cost of the above noted complications. Of note, taking one of two SERMs did not reduce either cancer-specific nor all-cause mortality. On the other hand, both medications lowered the rate of fractures.

So what should you do? Start w/your family doc who should know your medical history & family history. Then use one of several online calculators to determine your risk for breast cancer. Consider genetic testing if your risk is high eneough. And finally ask your doc about chemoprophylaxis vs prophylactic mastectomy if your genes demonstrate high enough risk.

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Sunday, May 19, 2013

Q&A Session at HealthTap.com

What age can u start taking birth control pills?

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I have allergic rhinitis and i am taking muntelukast and zyrtic , nasonex sterimar for almost 3 months , still i have nasal congestion what can i d0?

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My blood pressure has been too low and I've been having daily headaches can I just stop taking toprol xl for a few days to see if my headaches go away?

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Im always feeling Loss of energy and I don't have interest in any work even in sex.

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I had a two foot long bowel movement and like two inches wide. Could something be wrong?

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After taking pyridium for two days.. I still have to pee alot. And with septra when shall i notice a change in my uti. On septra for 7 days. So far 3?

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What happens to my penis when i lose my virginity?

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So my dr cant figure out what to put me on.i need something to put me to sleep that wont make me grogy in the morning but shut my brain off at night?

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My bf fingered me and I just got off my period he used the hand he cum with could I be pregnant?

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Friday, May 17, 2013

Crystal Ball: Diabetes vs All-Cause Mortality

Get out your crystal ball. An analysis of the 679 patient Gargano Mortality Study and the 936 patient Foggia Mortality Study was published earlier online this month in Diabetes Care in which the authors noted that all-cause mortality can be predicted based upon a model that includes age, body mass index, diastolic blood pressure, LDL cholesterol, triglycerides, HDL cholesterol, urine albumin:creatinine ratio, and blood pressure & insulin therapies, with validated accuracy. A web-based online version of this calculator is available. While it may be intuitive, use of this model might assist a patient or family about the appropriateness of any given procedure. Or it might provoke a patient into improving some aspect of his/her life in order to reduce all-cause mortality. Just something to ponder . . .

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Thursday, May 16, 2013

Commentary on Men's Journal June 2013 Article Part 3

So where were we? Ah yes! Discussing the June 2013 issue of Men's Journal, specifically their "New Guide to Heart Health" article. The section on "Food for Your Heart", the author recommends red yeast rice even after acknowledging it as the precursor to present day statins. Granted it's not required to be manufactured to Food & Drug Administration standards, but why take something in which the active ingredient is actually considered a prescription medication but can vary in strength by 100 fold?

Current standard is to recommend a goal LDL-cholesterol of less than 100mg/dL if your risk of heart disease is greater than 20%. Depending upon how much you need to drop your LDL, you could potentially opt for lifestyle modification. However, if despite your best efforts, your LDL hasn't reached your goal, perhaps you could then consider a statin. Consumer Reports suggests choosing either lovastatin or pravastatin if you need to drop your LDL by less than 30%. Better yet, these drugs are typically available for $4/mo or $10/3mo. If you need to drop your LDL by more than 30%. consider either simvastatin or atorvastatin. But there's really no reason to pay $500/mo for a brand name statin, so why succumb to scare tactics as mentioned in the article?

Bottom line: if you're trying to choose the best medication, find one w/clinical outcome benefit. Don't settle for one that just improves numbers; instead, find one that has demonstrated ability to lower all-cause mortality. Remember that you want to do more than lower cholesterol: you want to avoid heart attack & stroke. If you're going to take a statin, be sure you get one covered/paid for by your insurance company. Then make sure you can tolerate the formulation w/o muscle aches.

And by the way, unlike the author, don't bother w/inositol hexaniacinate. Real niacin (nicotinic acid) is converted in the body into niacinamide. It's this conversion process that leads to flushing and improved cholesterol numbers. By avoiding the flushing with these other "niacin", you also lose any purported cholesterol benefit, if any. And remember that a recent study demonstrated no benefit whatsoever from niacin.

Part 2: http://alvinblin.blogspot.com/2013/05/commentary-on-mens-health-june-2013_14.html

Part 1: http://alvinblin.blogspot.com/2013/05/commentary-on-mens-health-june-2013.html

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Wednesday, May 15, 2013

Breast Cancer Genetics: The Role of Your Family Physician

Timing is everything. If you've been following along, I was going to end my 3 part commentary on Men's Journal's June 2013 issue on statin use and cholesterol testing. However, if you were anywhere near any form of news dissemination, whether traditional newspaper, television, or radio, or glued to your Facebook and/or Twitter accounts, no doubt you heard about Angelina Jolie's self-penned article published yesterday in the New York Times opinion pages.

In it, she details some of the science & statistics behind her decision to undergo a prophylactic double mastectomy w/reconstruction to minimize her risk for breast cancer based upon Myriad Genetic's $3,000 BRCA1 & BRCA 2 testing for two breast cancer genes that significantly increase one's risk. It should be interesting to see whether she makes public her decision regarding prophylactic oophorectomy, given her increased risk for ovarian cancer, too, as her genetic testing revealed.

So what does your family physician have to do with all this? For starters, we should already be familiar w/your family history, which can go a long way towards ascertaining your risk. Next, we can use any number of risk calculators, such as the Breast Cancer Risk Assessment Tool (commonly known as the Gail model), SeeMyRisk Breast Cancer Calculator, and even Hall's Detailed Breast Cancer Risk Calculator. The Pink Ribbon folks at the Susan G. Komen Foundation help you understand some of the statistics & implications of the Gail model.

But as I mentioned yesterday, just because you can (afford to) do a test doesn't mean you should. After all, what are you going to do with that information? Worse, what's your insurance company going to do with that information, at least before the pre-existing condition prohibition of the Affordable Care Act kicks in next year! A couple more points to ponder. Are you willing to undergo major surgery in an attempt to reduce your cancer risk? If not, why bother saving for the test? More importantly, something that Ms. Jolie didn't discuss, who's going to pay for said prophylactic surgeries? After all, you don't have a disease, just a risk for one, albeit higher than average.

Don't get me wrong. I'm not advocating that you avoid or skip the BRCA1/2 tests. But I am strongly encouraging you to run your own risk assessments using the above risk calculators (I receive no remuneration of any kind from anybody as I am but a lowly state employee) and then discuss the implications w/your family physician and your family. Together, we can help you make the best decision(s) for you.

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Tuesday, May 14, 2013

Q&A Session at HealthTap.com

Is Jolessa and Quasense the same thing or not?

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Is there a difference between hydrocodone an codeine?

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How does the injection form of birth control work?

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Commentary on Men's Journal June 2013 Article Part 2

Yesterday, I wrote about the basic premise of the June 2013 Men's Journal article "The New Guide to Heart Health" in which the author quotes a cardiologist making a recommendation to "Upgrade Your Cholesterol Test". The author suggests checking out your ApoB, VAP and/or PLAC results. I'd put up Berkeley Heart Lab against VAP as they both purport to provide more indepth analysis of your LDL cholesterol. However, one of the basic ideas that we stress to our family medicine residents is to do something because it will make a difference, not just because you can.

So would I actually recommend any of these tests as first line diagnostics? Absolutely not! Why? If your LDL is high (above your goal as calculated by Framingham, Reynolds Risk, or QRISK2), what additional information will these $50-100 tests give you/me? How will it change your management? You'll still need to change your nutrition anyway. You'll still need to exercise regularly anyway. Do you really need to pay $50-100 per blood test to tell you that? Do you really need an $800 coronary artery calcium scan to tell you to get off your fat ass?

OK, so let's take it to the next level. Let's say that you're low risk for heart disease (less than 10% over the next 10 years) and you've managed to meet your goal LDL of less than 160mg/dL. Now what? Should you get one of the tests? I would posit that you should really aim for a goal LDL of less than 70mg/dL (considered optional for those at highest risk of heart disease). After all, why wait until you've finally had an event to tell you that your goal LDL is now less than 70mg/dL. Only after you've reached that goal would I recommend additional testing.

In other words, if you know that heart disease is the number one killer in both women & men, why would you accept a "good enough" LDL? And even though we accept that LDL is only part of the picture when it comes to heart disease, what will these $50-100 blood tests and $800 CAC scans tell us to do? Lower our LDL!!!

Stick around one more day as I answer the question: which statin is best?

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Monday, May 13, 2013

Q&A Session at HealthTap.com

For Mother's Day I want to know if my due date is August 29th did I get pregnant from sex in December? :) thanks

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My eyes r red with pain n gunk coming out what is the reason?

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Aside from acyclovir, what are other recomended cheap anti viral oral mdicine to cure herpes zoster?

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Commentary on Men's Journal June 2013 Article

I finally got around to reading the June 2013 issue of Men's Journal, you know, the one w/Mark Ruffalo on the cover. I was particularly interested in the article, "The New Guide to Heart Health", starting on page 69. Unfortunately, I couldn't find the article online to offer you a link so you'll need to download your copy electronically or go old school and either purchase it at a newsstand or borrow it from your public library.

As with a lot of information parsed out by the lay press, some of it is misinterpreted, but for the most part, the author got it right. For instance, if you don't have known heart disease, taking a statin won't offer you much benefit. Over 5 years, no lives were saved, although 1 heart attack & 1 stroke were prevented for every 60 persons and for every 268 persons, respectively, taking a statin. Balance this against the fact that 1 in 67 developed diabetes and 1 in 10 developed muscle aches/damage. And as the author noted, eating along the lines of the Mediterranean diet was associated w/almost 1 in 3 lower risk of heart attack in a study published earlier this year.

However, I was disappointed that there was no mention of using any calculator to determine risk of heart disease but rather a suggestion to "Upgrade Your Cholesterol Test" by getting a CT scan of the heart to measure coronary artery calcium. Sure, CAC helps stratify risk but it's really only useful in those at intermediate risk. So rather than expose everyone to unnecessary radiation, why not calculate one's risk for a future event in the next 10 years using Framingham criteria, Reynolds Risk score, or even QRISK2 (if you're an Anglophile). For point of reference, low risk is considered less than 10% while high risk is greater than 20%. Intermediate risk is therefore in between or 10-20% over the next 10 years.

Check back in tomorrow when I discuss ordering those additional tests.

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Sunday, May 12, 2013

Q&A Session at HealthTap.com

Bloodwork for fasting insulin. how is this different that a glucose tolerance test or a fasting glucose test?

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What is difference between fasting insulin test and glucose test?

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Would it be possible to live with untreated diabetes by controlling the amount of sugar you eat subconsciously or not?

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How to remove puffy nipples in man?

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Yesterday fasting glucose was 98 today it was 92 am I heading towards diabetes? I'm not overweight an eat fairly healthy

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If someone suffers from the shingles really bad and then catches herpes would that make theherpes just as bad.

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Saturday, May 11, 2013

Q&A Session at HealthTap.com

When I eat seems like food is sitting on top of stomach middle of gut what could it be I get bloat can it be air?

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I am a woman and have a small amount of hair on my upper back. Is this normal? I can't afford wax or laser so how do I accept this?

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I have a tsh of 10. How much dosage of thyronorm should be consumed?

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Relentless, painful headache x4 days,CT next Tues, I was given 2 shots&RX for pain. Hasn't helped at all! Go back, call, ER? I just want cause/relief.

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