Super Obese, but Super Healthy?

A recent study shows that cholesterol levels in older Americans has gone down significantly thanks to an increased use of the statin medications. The most prescribed medications were Zocor, Lipitor and Pravachol. However due to a sharp increase in the obesity rates, this information is very confusing. This is due to thinking that rationales a double death cheeseburger is ok, because I have 20 milligrams of a magic pill that will wash it away. I particularly like this quote : "Statins are great but if you put statins in the water supply, cardiovascular disease would still be the leading cause of death in America," said Dr. Steven Nissen, from the Cleveland Clinic. A nice reminder that says just because one is on a statin, does not make them immune to the cardiac effects of that double rack of barbecue ribs.

Like all fans at this time, I am saddened at the departure of the Yankees from the playoffs. I will say that the Sunday night game I was fortunate enough to attend, was one of the best. Better luck next year, and ugh, good luck to the Jets, who unfortunately lost two quarterbacks in seven plays. But Vinny's back!

Recently featured on the Today show: for those of you who enjoy doing some ergonomic exercises while sitting at your desk, this is for you.

And finally, it seems that feeding kids almost anything during their upbringing in the especially when they are babies doesn't have any difference from a structured diet. e.g. vegetables early in life followed by fruits, etc..

Free Golf Balls

Salutations Dear Friends....For Those of you who golf, here's a treat: 2 free golf balls from Pinnacle...Enjoy!


2 Free Pinnacle Golf Balls

Goodbye Summer

The summer is over and done, but this will be a summer that we will remember forever. We witnessed the horrible spectacle that Katrina left behind in Louisiana and the surrounding areas. To see a whole city completely immersed and the tremendous loss of life made our own problems pale in comparison. This is just another of life's reminders to try to enjoy life to the fullest; because one minute you're watching TV in your den and the next minute you're up to your neck in river water. In this situation, the "let's try to wait it out approach didn't work."
However, in the field of medicine, a recent study shows that when treating a "minor" heart attack, waiting for clot dissolving medications to work, is comparable to rushing a patient to the Cath lab. Working a cardiac arrest is a harrowing experience. To wait around for a medication to function may prove to be a task for patient physicians, and to the "cowboys" that hear the
Mighty Mouse theme in their heads during an emergency may prove to be almost impossible. As they say though, medicine is a dynamic field and can sometimes even contradict itself in the course of history.
The end of summer also welcomes the second VIOXX trial , which gives trial lawyers dreams of sugar plums and breaks the rest of the health care system in the process.
On a brighter note, the Yankees are doing some good things and am hopeful to see them in the playoffs. So we say fare the well dear summer, and await what new beginnings and hopefully better times the spring will hold for us.

You Made My Day

One thing that a seasoned medical provider can share as truth, is that most men do not like going to the doctors' office. Whether its the poking and the prodding or the criticisms that we must endure, the combination of men and medicine go together like oil and water. In recent times however, we are seeing a change in this tradition. The advent of the wonderful phosphodiesterase inhibitors, aka Viagra, Levitra and Cialis have changed the rules dramatically. All of a sudden, men found a newborn interest in going to see their doctor. The most important part of this occurrence was that a large amount of cardiac and other varied illnesses were picked up and treated much earlier than if previously ignored.
In some cases men are encouraged by their wives and loved ones to seek some sort of medical care. And in some cases, that internal clock rings and one knows that something is wrong with one's body.
It was about six in the evening and I was working the second part of my day at the office. The next patient to be seen was a 46-year-old white male. After the introductions and history taking were completed, we delved into the chief complaint. For about a month, the patient complained of having a dry mouth all the time and "peeing like a racehorse." He had to drink all the time to keep his mouth from being dry. After the physical exam, and putting the pieces of the puzzle, Diabetes was at the top of the list. A full blood profile was drawn as well as a routine finger stick which showed a whopping 360 mg/dl. I started the patient on Glucophage and instructed him to watch his diet and take it easy on the alcohol.
A follow up visit was scheduled to make sure the new medication was agreeing with him and there was no other impending health issues accompanying his new diagnosis. A week went by and the patient was prompt for his scheduled appointment. He was doing well with the new medication, and all symptoms were just about gone. "I'm peeing a lot less and I'm not even that thirsty anymore." So the medication was doing its job, and so was I, which entailed of keeping the patient happy and healthy. At the end of the visit when I routinely shake hands with the patient, he grabbed my held and held on. He looked me right in the eye, and said "I just want you to know, I finally feel comfortable and I'm really really glad you're taking care of me."
And then it hit me; amidst all the running around, the HMO battles, the productivity quotas, a comment like this really puts things in perspective. It redefines why one chose this path instead of others. Taking care of our patients day after day, and them in turn, making our day.

Over the Counter or Out of the Question?

Recently, there has been a big push to change many medications from prescription to over the counter status. A stroll through the pharmacy will reveal many of the medications that were only dispensed with prescriptions are now available to all. This last point is an important one. When medications are approved over the counter, both the beneficial and more importantly the negative effects of that medication must be examined with close scrutiny.
Claritin, Pepcid and Prilosec are examples of the OTC's that have been approved. The influencing factors are many, and sometimes can be cumbersome. There has been a trend in some HMO's as of late to deny prescriptions for different medications in the same classes. Many a patient was denied coverage for an antihistamine, and was told to purchase its OTC counterpart. This may sound like an acceptable solution, and it is, for the most part. However when considering that a box of Claritin tablets OTC go for about ten dollars, this cost ends up being picked up by the patient instead of being covered by the HMO in the usual manner.
The benefit of having such medications is being able to go to the pharmacy and tending to your GERD or allergies etc, whether one ran out of their prescribed medications or simply to treat a transient illness. The caveat here is to beware of using any of these medications chronically without some kind of medical evaluation periodically at the very least. The patient that takes a PPI (proton pump inhibitor) or H2 blocker (histamine type 2 blocker) for that terrible belly pain he has can be detrimental if there exists a carcinoma or some sort of peptic ulcer disease.
The most recent medication that entered into the FDA approval process was Mevacor, manufactured by Merck. The actual chances given to the approval was 50-50. In mid January, the medication was not recommended by the FDA advisory panel and would not be approved by the FDA. They cited that a doctor's advice was necessary with the use of these medications. Two of the examples given represented the different ends of the patient population. The people that wanted to buy it to be "more healthy"; and the people who were very ill and took the medication as a minimal effort to take care of themselves. The dangers of both are apparent. The healthy population did not qualify and were exposed to the secondary effects of the medication unnecessarily. The ill population bought the medication out of guilt, but had serious health issues that needed to be addressed immediately by a physician.
Thinking about all the serious side effects from statins made sense to keep the medication behind the "white pad." Secondary effects that can range from muscle cramps to full blown liver failure or rhabdomyolysis need to be addressed and managed appropriately. The public is not qualified to titrate medication doses and interpret lab results with their own lives at risk.
This just the beginning of the run for over the counter status. It is both lucrative for the drug companies and fills a specific need of the public. The sage decisions of such advisory panels should be continued and supported. Certainly many appropriate medications will be approved, so until then, keep watching the shelves at your local drug store.

Learning Bluetooth Without a Dentist

I recently purchased a cell phone that I insisted must be Bluetooth capable. I had all sorts of plans for it, but somehow they never came to fruition. I had plans of buying the wireless headset, but the fact that (luckily), my driving is minimal did not encourage me. After discovery of a bluetooth adapter that was connected via USB opened the doors.
A little background on the wireless protocols. Currently, for the practices of consumer and businesses alike there are two major systems. There exists the WiFi system, which is represented by the 802.11 a/b/g, with g offering the fastest transfer rate. This is what popular systems such as the Intel Centrino run on. The other side is represented by a bluetooth technology. Bluetooth has been around for a while, however the main argument against it are its security flaws.
The practical uses of bluetooth can be used in personal day to day use, and also in the business world. Bluetooth phones, printers, PDA's and even the advent of bluetooth capable home phones (Uniden, Spring '05) prove that this is something that will go the distance. A connection from a PDA (Pocket PC or Palm) to a cellular phone provides one with an instant internet connection. Files beamed from a phone to a bluetooth capable printer can cut transfer times and make scheduling a snap. On a personal level, I was able to connect my cellphone to the desktop PC via bluetooth with a USB adapter that plugged into the PC. From the PC, the contacts were retrieved and managed, but more useful was the ability to add or remove any ringtones or pictures. The usefulness of camera phones come to an abrupt halt when one actually does get that cool picture, but needs to remove it from the phone. This way there are no charges to pay for uploading to a cellular picture server and hoping that the picture is found at a later time. With the bluetooth connection, all pictures from the phone are easily managed and edited in file explorer format. For phones that have MIDI capable rings (audio format), careful browsing of the internet to find free MIDI's and the ability to transfer them directly to the phone eliminates the need to purchase ringtones.
A few of the positive points of bluetooth were touched on above. Now the security breaches must be addressed. There are a few classes of bluetooth products. Class 1 has a one meter range of broadcast, Class 2 has ten meters and class 3 has 100 meters. Most experts will tell you that the shorter connectivity is one of the security features. For example using a class 3 device will leave one more vulnerable to to the range of the signal. The recommended PC adapter is usually class 2, which is close enough to connect to ones peripheral, but not enough range to be corrupted by outside forces. The other nightmare story takes place in an airport or large thoroughfare. A laptop being manipulated by a criminal force tries to connect to all bluetooth phones in the range of the signal. The damage lies in the form of long distance calls charged to the victims phone because the bluetooth was left on in a public place.
With a little prevention and keeping an eye on security, the bluetooth wireless protocol can be a handy one; from easy fast connectivity to decreasing time spent on timeconsuming tasks like scheduling and managing contacts. Car manufacturers like Acura and BMW have jumped on the bluetooth bandwagon by offering instant connectivity to cellular phones via bluetooth built into the vehicles. Car dashboards displaying the telephone number of an incoming call is now a reality. What tomorrow's connectivity technology holds will be even more incredible.

Dancing the Triplicate Tango

One of the big concerns today is pain management. Of course when laws have to be passed about medical practices, it is usually as a result of some ridiculous lawsuit instead of concern for a patient's wellbeing.
The story of the patient who was dying of cancer and whose pain was not treated by their respective physician is an absolute tragedy (eg. Tomlinson case). In plain English, this patient was not just cared improperly for, he was left to die in torture during the last days of his life. The reason this happened is inexcusable, whether is was from some stupid paper foul up or from just not getting the proper care he deserved. It is obvious to all, clinician or lay person, that this was a disaster and opposed everything the Hippocratic Oath professes, which we are sworn to uphold.
The repercussion of this tragedy was skewed to represent someone else's interpretation or benefit is the twist to the tale. The legal system had its way with it, and a pain management initiative was begun. I would like to say flat out, that absolutely no one should endure any discomfort. Pain should be treated and managed to help maintain the "quality of life." That being said I think is preposterous that a few years ago, nurses stopped doing the usual vital signs and would hand us a sheet full of happy and angry smiley faces. Long gone was the blood pressure or temperature, now I have to hear about my patients' pain in second hand format. To be blunt, if you're a clinician, and you can't pick up that a patient is in pain, and worse don't treat it, then its time to hang up the Littman.
We grumble and complain, but accept that yet another bureaucratic change has been made. The worst part of it was that clinicians were being heavily scrutinized for their practicing habits, especially when writing triplicates. This was compounded with the news of the junkies who illicitly used via inhalation and injection, the narcotic based drug"Hillbilly Heroin", aka Oxy Contin.
The fact is there are many patients who rely on benzodiazepines and other similar medications for day to day life. These are legitimate issues that were addressed and treated, yet they still cause concern when the actual scripts need to be written. The fear that some unknown computer is counting the amount of triplicates being written lingers in the prescribers' pen.
Some people will question whether this actually exists or whether the repercussions are real. The reality exists in the form of the physician who was handcuffed in front of his patients, his pregnant wife handcuffed like a common criminal and being hauled off to jail. Why did this scene happen? The physician prescribed pain medication to a chronically ill patient who became over sedated and later expired. Whether the patient took too much medication or the presence of any other variable, the disgrace of the physician will never be erased. He and his wife were later released with some mumbled apologies, thanks to our shoot first and ask later society. This particular physician is currently rebuilding his practice, but the damage has been done.
The DEA started to make initiatives to protect prescribers, and later backed away. So to put it mildly, clinicians are stuck in limbo. Walk the fine line of appropriately treating a patient's pain, and not writing too many medications that would raise a flag. This is also a reason why we are a COX happy society. Non-Steroidals, COX 1, COX "1.5" (Mobic), and COX 2 medications are written in tremendous amounts. Could some of the renal and gastrointestinal repercussions that many patients suffer from have been mitigated with different management?
The bottom line as previously stated is to identify pain, try to treat it at the root of the problem instead of masking it (a common practitioner error), and providing comfort to our patients. Regardless of who is watching or counting, we must satisfy our consciences and tailor our management so it satisfies our patient care and equally important, falls within the law.