Saturday, November 26, 2011

Can PTSD be passed from one person to another like a virus, or lead to cancer?

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What should I do to enlarge my penis?

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What are the sympyoms of a kidney infection?

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Friday, November 25, 2011

My Crystal Ball Predicts 27.4% Cut in Medicare Payment on 1/1/12

The Congressional Super Committee tasked with finding a way to reduce the federal deficit officially failed to come to an agreement the day before Thanksgiving. In reality, they had agreed to disagree last weekend as they needed the Congressional Budget Office to review their numbers prior to an official announcement this past Wednesday.

So what does this mean for you and me? I don't know about you, but it means that unless Congress finds a way to deal with Medicare's budgetary woes in the next 4 weeks, I will face a 27.4% cut in reimbursement from Medicare starting January 1st, 2012. Perhaps that wouldn't be so bad if I focused my practice on aesthetics or cash-only procedures. But I'm a geriatrician. Fellowship trained & board certified. That's what I do. Take care of older patients.

This is the frustration that lead me to leave academia 8 years ago when I faced the yearly threat of a reduction in my reimbursement. In one sense, it's nice to know that some things don't change. But after 8 years, I was hoping that Congress would have fixed the sustainable growth rate (SGR) fiasco which has led to this annual debacle. Granted, Congress has always annually made an end run around the pay cut, but who likes to work at a job where one's livelihood is threatened each year.

Earlier this month, the Associated Press put out a nice article on the decline in geriatricians like myself. Unless we re-prioritize our medical education & training, care for the sickest of the sick isn't going to look very pretty in the near future. Do yourself a favor. and send a letter to Congress telling them they need to fix Medicare. This e-letter is a pretty simple thing to send. Just go to http://www.capwiz.com/aafp/issues/alert/?alertid=55362501&type=CO and fill in the required information and hit send. Then off it goes. While I am not ready to compare our current Medicare to evil, I think that this quote, often misattributed to Edmund Burke, is apropos: All that is necessary for the triumph of evil is that good men do nothing.

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Thursday, November 24, 2011

Let's Give Thanks to Aging Wherever We May Best Do So

Let me add my wishes to you & your family for a wonderful & happy Thanksgiving today. Perhaps it's a bit early to start talking about living will and durable healthcare power of attorney. And perhaps it's too early to talk about do no resuscitate orders and desires for aggressive medical intervention.

But as you gather w/friends & family, an article published 3 days ago in USA Today could be the perfect conversation starter with the older generation, eg your parents, aunts, uncles & grandparents as to their plans for the future and what they want to do.

While they still have a say, now is a good time to consider if they desire to continue living where they currently are. Are they attached to the family home? Or have all their friends (and family) left? Have they considered moving closer to you? If so, do you have room in your humble abode? Are you ready to become another member of the sandwich generation, raising your kids and watching over your parents while working full-time?

Are their other living options in your area? Medicare wants everyone to be aware of the options. Independent living facilities? Assisted living facilities? Continuing care retirement communities? Each has its pros & cons, even the CCRC as noted in the Wall Street Journal last year.

You might not arrive at an answer tonight but it's worth starting the conversation while you still can under non-emergent circumstances.

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Wednesday, November 23, 2011

Exercise vs Niacin re Postprandial Triglycerides

Better start fasting now in preparation for tomorrow's celebration of & ode to gluttony. But how can we have our cake and eat it, too? Figuratively speaking, of course!

In yesterday's Wall Street Journal's Health & Wellness section, a detailed analysis of some recent studies was published. In one review, the authors noted that preprandial exercise, eg walking, decreased (postprandial) triglyceride formation the following day after a heavy meal. Of course, I had to find the July 2008 study that supported the WSJ author's contention. In another analysis published this August in the PNAS, the authors came to the same conclusion as 3yrs earlier.

This is especially important because while niacin has been demonstrated to improve lipid numbers (especially preprandial TG), it has yet to conclusively demonstrate an improvement in clinical outcomes.

Also published in yesterday's WSJ, other authors attempted to address the infamous food coma or postprandial somnolence, as its known in medical circles.

For now, the key is regular exercise but if that's not feasible, then at least one 30 minute session prior to the Big Meal will help mitigate the conversion of carbohydrates into triglycerides. Good luck! You've been warned!

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Tuesday, November 22, 2011

Latest Canadian Mammogram Recommendations

Here's a study to stir up controversy & liven up conversation around the family table this Thanksgiving! Our physician neighbors to the north just published guidelines in CMAJ (their version of JAMA) giving their opinion on mammogram screening frequency for specific age groups.

Let's just say that all of you who follow your compass with regards to how much better you believe the Canadian system is better than what we've got here in the good ol' US of A had better look elsewhere for mammograms if you don't fit the Canadian demographics.

Having said that, they do allow for individual patient preference . . .

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Proof of Concept: T3 > T4

In conventional medicine, hypothyroid patients are treated w/levothyroxine which is the synthetic sodium salt of natural thyronine. Since the 1930s, L-T4 has been used because of several (potential) benefits: lack of antigenicity, chemical stability, uniform potency, and once daily dosing. This compares to dessicated porcine thyroid which can be antigenic (think of porcine insulin which has largely been replaced by synthetic but essentially bio-identical insulin) and varies in potency (T3:T4 varies from batch to batch, although T7 remains about the same).

The use of L-T4 (levothyroxine) presumes that T4 is converted into T3 uniformly throughout the body. Yet many patients complain of persistence of hypothyroid symptoms even when their TSH is fully corrected w/T4. Recent animal studies have demonstrated that, in fact, peripheral conversion of T4 into T3 is not always consistent w/TSH which represents pituitary levels.

In a small and short but elegant study published this month in JCEM, the authors randomized 14 patients w/hypothyroidism to either L-T4 or L-T3. To account for and blind both the researchers and patients to the short-half life of L-T3, all patients were given their thyroid medications in a three times a day regimen. Bear in mind that in the real world, this regimen frequency would lead to very poor adherence and thus poor (dissimilar) results. However, in this ideal setting, the authors demonstrated that L-T3 lead to weight loss & improvement in lipids without any side effects when compared to L-T4 dosed to achieve the same TSH over 6 weeks.

Additionally, I should point out that the authors aimed for a TSH of 0.5-1.5mU/L which is at the low end of the typical normal reference range 0.4-4.5mU/L. In the real world, most physicians declare their patients adequately replaced as soon as their TSH drops below 4.5mU/L such that the numerical result is no longer highlighted, boldfaced, and/or labeled abnormal. But if you recall my grade school analogy, that's the same as tutoring a failing student to a D minus grade rather than the helping the student reach his/her potential.

Regardless, I think this small, short proof-of-concept raises several points to ponder. First and easiest, consider replacing L-T4 to achieve a lower TSH than commonly accepted, assuming no side effects. Just bear in mind that bone loss might become more problematic. Second, if hypothyroid symptoms persist once TSH is pushed to the lower limit of normal, consider supplementing w/L-T3 (liothyronine) three times daily, assuming that the patient's medication adherence is better than most.

But remember that even the authors admitted that compliance will be the biggest issue with which to deal, at least until pharmaceutical manufacturers develop a slow or extended release version of L-T3.

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Monday, November 21, 2011

Physical Activity vs CVD Mortality

So just how many studies do you need to read that describe the link between physical activity & your mortality before you get out of your recliner? Well, just in case you haven't been convinced yet, another observational study was published this month demonstrating that physical activity is associated with lower risk of cardiovascular disease mortality regardless of the more typical risk factors.

The authors followed 10,261 participants of NHANES III for more than 13yrs on average in order to arrive at their conclusion. Granted, physical activity was assessed via questionnaire rather than measured by a more objective & realistic measure. Worse, the assessment was performed just once (at baseline). Still, this finding is consistent with all previous studies.

To be more specific, vigorous activity was described as those w/MET value of at least 6 at least 3 times/wk. Moderate activity was described as a frequency of at least 5 times/wk with no more than 2 activities of vigorous nature. Light activity was defined as neither vigorous nor moderately so.

Interestingly, those engaging in light activity had the best mortality (survival) outcomes with moderate-vigorous activity placing a close but statistically significant 2nd, compared to inactivity, which is also consistent w/more recent studies. So what are you waiting for? Get out there and do something, anything of at least 15min duration!

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