On Friday February 24, 2012, Skip & I discussed several interesting topics. We started with the helpful hint that you should prepare for all doctor's visits by writing down what you want the doctor to know. This should include your symptoms & concerns, how long you've been ill, what refills you need (& whether you need 1 month vs. 3 months at a time), & any new medications or tests ordered recently by other physicians. In fact, it is very helpful to briefly tell all of this to the staff which gets you ready for the doctor... as they can sometimes get the refills or test results in advance of his arrival, thus making the visit much more effective. By having everything written down, you can expedite things, & it is more likely that the doctor will address all of your issues, or at least he will help prioritize the concerns into a gameplan of future visits & tests.
There was an e-mail question regarding screening for Hepatitis C. Hepatitis C is a viral infection which attacks the liver, & can lead to liver failure & thus death. It is spread like HIV infection... by blood. Thus you are at risk if you use IV drugs & share needles, if you receive a blood transfusion or an organ transplant from someone who is Hep. C positive (though the Blood Bank screens blood & organs for this... at least since 1992!), & if you are a healthcare worker who is exposed to a Hep. C positive patient's blood via a needle stick. Unprotected sex is another option for spread, & although this is not the most common way, the risk increases if you have multiple sex partners. Since it is passed to others via blood, note that it can even spread via a shared toothbrush or razor! Two weeks to six months after exposure a person might have acute flu-like symptoms which can be benign enough to go unnoticed, while others never have symptoms from the acute infection. Once you have the Hepatitis C virus, you likely ALWAYS have the virus, though it is sneaky in that it usually causes no symptoms for years, though you can certainly spread it to others during this time! It is most often diagnosed when a person has routine blood work & is found to have elevated liver enzymes, as this is a reflection of liver inflamation. If your liver tests are elevated, your doctor will do more tests to try to find out why... usually to include a hepatitis profile which includes Hepatitis A, B, & C tests. It might also be found when a person tries to donate blood as the Blood Bank screens every unit for this... & they will politely call to request you NEVER donate again if you are found to be positive! Once a person is diagnosed with Hepatitis C, further tests can determine how sick his liver is, & this will dictate treatment. Some people who are not very ill might opt for watchful waiting while at the same time being kind to their livers by avoiding liver-toxic agents such as alcohol, Tylenol, & certain other medications. Others might need medication, such as Interferon & Ribovarin, though these are harsh agents which often make the patient feel ill & all too often do not lead to a cure. Just recently the FDA approved a new drug Incivek (=Telaprevir) which is to be used with Interferon & Ribovarin, & which is reported to have a 90% CURE rate... exceptional news as we have not had anything like this before! Lastly, patients who are very ill with liver failure due to Hepatitis C may need a liver transplant. Though this buys valuable time, it is not a cure, as the person still has the virus in his body & it obviously will infect his new liver! Thus you can see the excitement over this new drug Incivek, as it offers a good chance of a cure. Another interesting point is that there is NO vaccination fo prevention of Hepatitis C, but anyone with Hepatitis C infection should get Hepatitis A & Hepatitis B vaccinations as obviously you would not want a sick liver to get a 2nd or 3rd infection! And finally to answer the question, "yes" screening would likely decrease the spread of Hepatitis C, but it must be done as early as possible in the disease process & this is difficult to pinpoint as it will likely vary person to person. So if you have never been tested, do so, especially if you have risk factors. This can be done either via a Hepatitis C antibody test (which is the most specific test), or with a Comprehensive Metabolic Profile (=CMP) which measures liver enzymes as well as multiple other common tests, or even via a blood donation. And if you are found to be positive for Hepatitis C, see a Gastroenterologist to get further studies & treatment options, & be careful not to expose friends, family, sex partners, or healthcare workers to your blood!
And on to a timely topic... obesity! With so many of us being overweight, God knows we need help! Now, I agree with everyone that there are no easy answers, & that proper diet & exercise are an absolute necessity, but it looks like we just got some much needed assistance in the form of a newly approved medication named Q-Nexa! I was involved with one of the studies of this drug, so I have some experience with it. I also worked years ago in an obesity clinic where we prescribed PhenFen, & I myself had a suction lipectomy in 1984, so obesity is a topic of special interest to me! Q-Nexa is not really a new drug. It is simply a combination of 2 old drugs... a bit like PhenFen which was never ONE drug, but rather 2 drugs made by 2 different Pharmaceutical companies, used in combination by doctors. However, unlike PhenFen, Q-Nexa has actually had clinical trials done which evaluated the safety & efficacy (how well it works) of the drug combination, thus leading to its approval as ONE drug. It is an interesting combination of Phentermine (an amphetamine which causes increased metabolism & decreased appetite) and Topamax (which is an anti-seizure medication which causes weight loss as a side-effect). Each drug can be used in low dose as they both cause weight loss, & their side-effects are minimized not only by the low-doses, but also because they offset one another. Whereas Topamax causes drowsiness & sedation, the Phentermine acts like "speed" to awaken the person. Where Phentermine can increase blood pressure & heart rate, Topamax does not. So keep your eyes open for this new option to help with weight loss, but remember diet & exercise will speed the process if done in addition to just swallowing the pill. Also, since Q-Nexa is just 2 old drugs in a combination, consider asking your doctor to get you the 2 generic drugs instead of buying the expensive name-brand. And for the record, Phentermine which is a component of Q-Nexa is in fact the same Phentermine which was part of PhenFen, as only the Fenfluramine component of PhenFen was taken off the market.
Another listener asked for information about gout as he has had some recurrent pain in his feet. Gout is a disease in which the person has a high level of uric acid in his body. This can occur due to a genetic predisposition or due to one's diet. Foods that increase your uric acid level include: alcohol (especially beer), fructose-sweetened sodas, rich cream sauces, certain seafood, & organ meats... as well as many other foods, so you might want to search for a list if you have concerns yourself. It has long been known as a "rich man's" disease as in the past only wealthy men could afford to indulge in the rich foods & alcohol that lead to its development. Gout is often diagnosed by the history: a red, hot, swollen, terribly painful joint, especially the joint of the big toe where you get bunions, athough it can affect the ankle, knee, wrist, or elbow. Usually the pain is so bad that even your bedsheets touching the joint or the wind blowing over the joint can be excruciating! This history along with a blood test showing a high uric acid level usually leads to the diagnosis of gout, & typically your primary care doctor or a podiatrist will make the diagnosis. If there is a question regarding the diagnosis, the doctor can stick a needle into the affected joint to aspirate fluid, which in turn should show uric acid crystals. Uric acid in the blood is not a problem, but if the blood level gets high enough, the uric acid can form crystals in the joints causing gout or in the kidneys causing kidney stones. These crystals look like a pin with 2 sharp points, so you can imagine how painful it is when these poke around in the joint, resulting in inflamation of the joint bursa! Treatment of gout requires us to realize that there are 2 aspects with which we must deal: the high uric acid level itself, & the painful flare-up when the crystals are actively irritating the joint. If you have the painful flare-up, you need an anti-inflamatory medication such as Colcrys, Indocin, Ibuprofen, or even Prednisone. Do NOT start treatment to lower your uric acid level DURING an acute flare! Instead, wait until 1-2 weeks later, then start one of these anti-inflamatory medications to decrease the risk of a flare-up being so painfully debilitating. After you are stable on this "prophylactic" (=preventive) medication for 1 week, you then begin a medication to help remove the uric acid from your body... such as Allopurinol, Febuxostat, or Probenicid. These drugs must be monitored for safety as well as to see how well they lower the uric acid level, as the goal is to find the dose that gets the uric acid level below 6.0. Once that level is achieved & maintained for 6 months, it is unlikely that an acute flare-up will occur, so at this point the anti-inflamatory can be discontinued... but the uric acid lowering medication is continued indefinitely in order to maintain the uric acid below 6.0! Though gout is an old disease, it is often mistreated, so understanding the above will help you to get the best treatment with the least amount of pain!
Again, I hope you find this interesting & helpful... if not for yourself, hopefully for someone for whom you care! Here's to our health!
Doctor Gigi
PS As you know by now, this blog reflects the topics discussed during the radio broadcast of Let's Talk Medical with Doctor Gigi, which can be heard live on WTAN 1340-AM in the St. Petersburg/Tampa/Clearwater area at 1:00 on Fridays. You can also listen live or to the recorded podcasts via: www.SkipShow.com. I welcome phone calls during the live show, & can be reached locally at (727)-441-3000 or toll-free at (866)-TAN-1340. If you prefer, you can always e-mail me via: DoctorGigi@SkipShow.com.
Monday, February 27, 2012
Friday, February 24, 2012
Turf Wars; Cash Practices; Choosing a Professional to Do a Procedure; Pain in Tailbone Area; Inflamation & Chronic Diseases
Once again I begin with an apology for the lateness of this post. No excuses... I've just been very busy this past week! We began Let's Talk Medical with Doctor Gigi on Friday February 17, 2012 with conversation regarding a bit of a turf war. Two different professionals had previously spoken about how each of them would treat a patient with plantar fasciitis, which is a painful inflamation at the heel where the tissue at the bottom of the foot attachs. The Chiropractor had one approach, whereas the Neuromuscular Massage Therapist had another. There were apparently some judgements regarding whose treatment is "right." Well, I proposed that the treatment will vary according to the professional's training. For plantar fasciitis, I generally recommend treatment which differs from either of their approaches: a soft-soled shoe, an arch support, ice stretches, & an anti-inflammatory (such as Ibuprofen). If the patient does not improve, I often recommend Physical Therapy, or perhaps a referral to a Podiatrist (who often gives a steroid injection & possibly fits the patient with an orthotic). As you can see, the treatment depends upon which type of doctor or therapist you see... and no one treatment is right or wrong! It is good to know that there are multiple options, so you can choose the best one for you. Of course, you might have to try several options before you find your best regiment. Though most medical professionals believe that their specialty provides the best treatment, realize that we are limited by our training & often do not even know what other professionals know or do! So, we should all remember that we are complimentary, not competitive, as we should provide the care we know & understand, but welcome other therapies in which we lack training & knowledge... as long as all the treatments help the patient!
Skip stated that it seems that multiple physicians are changing their practices & seeing fewer patients. He expressed a hope that they are getting away from the rat-race of medicine & perhaps doing as I am... abandoning insurance & taking "cash only" so I can actually work for the patient. Reality is that most of the physicians who are changing their practices are not doing this, but instead are incorporating cosmetic procedures for which patients pay cash. Unfortunately, this helps the physician make a better living, but takes a well-trained professional out of the true practice of medicine. Also, since these cosmetic procedures do not involve insurance & thus provide an excellent source of revenue, many professionals are trying to get into the act. As a consumer, you should realize there are many people who will profess to have the appropriate training to do a cosmetic procedure, & in fact they are likely telling you the truth. To be certain however, don't hesitate to ask to see a person's credentials, as that will let you know if they in fact have the proper credentials & exactly what training they have had. And did you know that payment is usually based on the procedure itself, not on the training or expertise of the professional doing the procedure. So... if you want Botox injections, a Plastic Surgeon will likely do it for the same price as a Family Practice doctor or a Nurse Practitioner. But... the Plastic Surgeon has years of training dedicated to cosmetic procedures, whereas the other 2 likely have had only limited training in that or a few cosmetic procedures. When you pay cash, realize that people compete for your dollars, so shop around & ask questions. As they say, "buyer beware," as licensure does not always translate to expertise!
On a different note, Gene sent an e-mail indicating that he occasionally has sharp pain beneath his tailbone when he is in bed. First, I would look for a pilonidal cyst as these are painful cysts which occur at the bottom of the tailbone (at the top of the buttocks crease). However, Gene would likely have redness & swelling in this area, with perhaps some discharge, & the pain would probably occur at any time... not just in bed. It is more likely that the discomfort is due to some musculoskeletal problem as it is positional (occurs when the body is in a particular position). He might consider whether or not he needs a new bed, & he might investigate this by sleeping in a different bed for a while to see if he feels better. If he is a side-sleeper, he might try a small flat pillow to support the tissue between his ribs & his hips, as most of us have an hour-glass shape which allows us to torque at the waist when we lay on our sides. If these simple things do not help, Gene likely needs to see his doctor for an evaluation, which should include a physical examination to look for a pilonidal cyst, as well as for a boney or soft-tissue abnormality. X-rays might be ordered, as they might show arthritis or masses, & if there is no big problem found, perhaps a physical therapy evaluation or chiropractic evaluation might be helpful. I did point out that since Gene said the pain sometimes feels like a gas bubble, it might in fact simply be gas. If that is the case, I would expect that he would be aware that he has pain, then he passes gas, & then he feels better! Lastly, I believe that if Gene continues to have this pain, he should have a rectal exam to evaluate his prostate & rectum, and perhaps even a colonoscopy, as problems in the prostate or rectum might cause pain of this nature.
Colleen posed a question about chronic inflamation & chronic diseases. Certainly "inflamation" is the buzz-word lately, & science is apparently showing that many chronic diseases such as diabetes & heart disease are associated with chronic inflamation. This does not mean however that inflamation is the cause of these disease processes. I propose that the disease process itself leads to inflamation, not vice versa. Thus inflamation does not likely cause diabetes, high cholesterol, or high blood pressure, but rather poor control of diabetes, cholesterol, & blood pressure likely cause an inflamatory reaction in the body which in turn causes damage to blood vessels & other organs in the body. So treatment of inflamation actually requires treatment of the disease process itself, not just an anti-inflamatory medication. So if you are worried about inflamation be sure to control your blood pressure, blood sugar, & cholesterol, and stop smoking. Also, there is a belief that statin medications (such as Zocor, Lipitor, Mevacor, & Pravachol) not only lower cholesterol, but also lower inflamation in blood vessels. Similarly, Ace-inhibitors (such as Lisinopril, Vasotec, & Univasc) or ARB's (such as Cozaar & Benicar) not only lower blood pressure, but also decrease intravascular (=inside the blood vessel) inflamation. Some people with high risk for strokes & heart attacks opt to take a statin & perhaps even a low-dose Ace-inhibitor even if they have normal cholesterol & normal blood pressure... simply to try to decrease inflamation & perhaps keep their blood vessels healthy! Most of us know that Cardiologists recommend aspirin to decrease one's risk of heart attack & stroke. Most strokes and heart attacks are caused by clumps of platelets which lodge in & block blood vessels, leading to a lack of blood flow to the brain (a stroke) or heart (a heart attack). Aspirin is known to stop platelets from clumping, thus aspirin decreases the likelihood of strokes & heart attacks, but perhaps they also help prevent these things simply by virtue of their anti-inflamatory effects, as aspirin is a great inflamation reducer. Lastly, a little known source of chronic inflamation is the mouth. Teeth with "cavities", & gums with "gingivitis" result in chronic inflamation, & there are reports that people with these problems are less healthy & more likely to suffer from cardiovascular disease. So if you want to be healthy, be sure to brush daily, floss often, & see your dentist regularly!
Here's to our health!
Gigi
PS Don't forget to listen to me on Let's Talk Medical with Doctor Gigi at 1:00PM Eastern time on WTAN 1340-AM in the Tampa/St. Pete/Clearwater area, or via www.SkipShow.com where you can listen live or to the recorded podcasts. And please don't hesitate to call or e-mail if you have a medical question or comment: (727)-441-3000 or toll-free at (866)-TAN-1340 or DoctorGigi@SkipShow.com. New blog to follow soon...
Skip stated that it seems that multiple physicians are changing their practices & seeing fewer patients. He expressed a hope that they are getting away from the rat-race of medicine & perhaps doing as I am... abandoning insurance & taking "cash only" so I can actually work for the patient. Reality is that most of the physicians who are changing their practices are not doing this, but instead are incorporating cosmetic procedures for which patients pay cash. Unfortunately, this helps the physician make a better living, but takes a well-trained professional out of the true practice of medicine. Also, since these cosmetic procedures do not involve insurance & thus provide an excellent source of revenue, many professionals are trying to get into the act. As a consumer, you should realize there are many people who will profess to have the appropriate training to do a cosmetic procedure, & in fact they are likely telling you the truth. To be certain however, don't hesitate to ask to see a person's credentials, as that will let you know if they in fact have the proper credentials & exactly what training they have had. And did you know that payment is usually based on the procedure itself, not on the training or expertise of the professional doing the procedure. So... if you want Botox injections, a Plastic Surgeon will likely do it for the same price as a Family Practice doctor or a Nurse Practitioner. But... the Plastic Surgeon has years of training dedicated to cosmetic procedures, whereas the other 2 likely have had only limited training in that or a few cosmetic procedures. When you pay cash, realize that people compete for your dollars, so shop around & ask questions. As they say, "buyer beware," as licensure does not always translate to expertise!
On a different note, Gene sent an e-mail indicating that he occasionally has sharp pain beneath his tailbone when he is in bed. First, I would look for a pilonidal cyst as these are painful cysts which occur at the bottom of the tailbone (at the top of the buttocks crease). However, Gene would likely have redness & swelling in this area, with perhaps some discharge, & the pain would probably occur at any time... not just in bed. It is more likely that the discomfort is due to some musculoskeletal problem as it is positional (occurs when the body is in a particular position). He might consider whether or not he needs a new bed, & he might investigate this by sleeping in a different bed for a while to see if he feels better. If he is a side-sleeper, he might try a small flat pillow to support the tissue between his ribs & his hips, as most of us have an hour-glass shape which allows us to torque at the waist when we lay on our sides. If these simple things do not help, Gene likely needs to see his doctor for an evaluation, which should include a physical examination to look for a pilonidal cyst, as well as for a boney or soft-tissue abnormality. X-rays might be ordered, as they might show arthritis or masses, & if there is no big problem found, perhaps a physical therapy evaluation or chiropractic evaluation might be helpful. I did point out that since Gene said the pain sometimes feels like a gas bubble, it might in fact simply be gas. If that is the case, I would expect that he would be aware that he has pain, then he passes gas, & then he feels better! Lastly, I believe that if Gene continues to have this pain, he should have a rectal exam to evaluate his prostate & rectum, and perhaps even a colonoscopy, as problems in the prostate or rectum might cause pain of this nature.
Colleen posed a question about chronic inflamation & chronic diseases. Certainly "inflamation" is the buzz-word lately, & science is apparently showing that many chronic diseases such as diabetes & heart disease are associated with chronic inflamation. This does not mean however that inflamation is the cause of these disease processes. I propose that the disease process itself leads to inflamation, not vice versa. Thus inflamation does not likely cause diabetes, high cholesterol, or high blood pressure, but rather poor control of diabetes, cholesterol, & blood pressure likely cause an inflamatory reaction in the body which in turn causes damage to blood vessels & other organs in the body. So treatment of inflamation actually requires treatment of the disease process itself, not just an anti-inflamatory medication. So if you are worried about inflamation be sure to control your blood pressure, blood sugar, & cholesterol, and stop smoking. Also, there is a belief that statin medications (such as Zocor, Lipitor, Mevacor, & Pravachol) not only lower cholesterol, but also lower inflamation in blood vessels. Similarly, Ace-inhibitors (such as Lisinopril, Vasotec, & Univasc) or ARB's (such as Cozaar & Benicar) not only lower blood pressure, but also decrease intravascular (=inside the blood vessel) inflamation. Some people with high risk for strokes & heart attacks opt to take a statin & perhaps even a low-dose Ace-inhibitor even if they have normal cholesterol & normal blood pressure... simply to try to decrease inflamation & perhaps keep their blood vessels healthy! Most of us know that Cardiologists recommend aspirin to decrease one's risk of heart attack & stroke. Most strokes and heart attacks are caused by clumps of platelets which lodge in & block blood vessels, leading to a lack of blood flow to the brain (a stroke) or heart (a heart attack). Aspirin is known to stop platelets from clumping, thus aspirin decreases the likelihood of strokes & heart attacks, but perhaps they also help prevent these things simply by virtue of their anti-inflamatory effects, as aspirin is a great inflamation reducer. Lastly, a little known source of chronic inflamation is the mouth. Teeth with "cavities", & gums with "gingivitis" result in chronic inflamation, & there are reports that people with these problems are less healthy & more likely to suffer from cardiovascular disease. So if you want to be healthy, be sure to brush daily, floss often, & see your dentist regularly!
Here's to our health!
Gigi
PS Don't forget to listen to me on Let's Talk Medical with Doctor Gigi at 1:00PM Eastern time on WTAN 1340-AM in the Tampa/St. Pete/Clearwater area, or via www.SkipShow.com where you can listen live or to the recorded podcasts. And please don't hesitate to call or e-mail if you have a medical question or comment: (727)-441-3000 or toll-free at (866)-TAN-1340 or DoctorGigi@SkipShow.com. New blog to follow soon...
Wednesday, February 15, 2012
Maybe You Should Fire Your Doctor; Bad Bugs in Hospital; What's Contagious; National Heart Month, & Heart Info; Get Well Nanci
So first I apologize for the late posting, but we were late getting the Podcast on the website. The radio show of February 10, 2012 touched on many issues. First, Skip sent "Get Well" wishes to The Fabulous Sports Babe (Nanci) who has been ill. Though we did not discuss it, Nanci is also a friend of mine, & I echo his sentiments: Get Well & know that we all care!
I was not feeling well & had left work early, so Skip wanted to know how a person knows that he should not go to work. I indicated that generally VIRAL syndromes are more contagious than bacterial infections when they involve the respiratory tract. Thus a typical "cold" or "flu" is likely much more contagious than bronchitis or pneumonia which often are more likely caused by bacteria. Viruses often spread via coughing & sneezing as the virus particles are very small (bacteria are larger, so less likely to spread via these droplets of fluids). Thus, you are most likely contagious (& thus a danger to your co-workers) when you have a fresh viral upper respiratory tract infection with coughing, sneezing, & fever. Days later you may still have symptoms, but you are likely less contagious, expecially if the fever has resolved. So I would recommend that you stay home when you are first sick, as that is usually the time when you are most infectious. Now, certainly some bacterial infections DO spread from person to person, but these are not usually respiratory infections. MRSA (Methicillin-resistant Staph. aureus) can cause bad skin infections & is very contagious. C. diff causes severe diarrhea, & is very contagious. Meningitis can be viral or bacterial, & both forms are VERY contagious. So it is obvious that a simple answer does not exist, but when in doubt, take off work when you think you have a fresh viral infection... & if in doubt, consult your doctor... or your boss, as many employers would prefer you take a day off as opposed to getting the whole office sick!
Another point was made regarding the fact that people with allergies that affect their eyes & noses often think they have a virus or an infection. Allergies usually do not cause fever, nor do they usually cause colored phlegm. So if you have a clear runny nose & runny eyes, but no fever, it might be wise to try an antihistamine (such as Loratidine or Allegra or Zyrtec which are all over-the-counter) as these "fight" the allergy & just might "cure" you. Also, if you keep feeling like you have a "cold" that just won't go away, that might be an allergy. Due to the warm winter we've had, we are starting to see allergy problems earlier this year than usual... at least in the Florida area.
Someone sent a note that he had a primary care doctor who would not make a "referral" to a specialist, & he wanted to know other options, as without the referral his insurance would not pay for the specialist's opinion. My gut response is that he should get a new doctor! But let's look at the whole picture. First, a "referral" is a form that a doctor completes indicating that he has recommended that the patient see another doctor or get a certain test. Not all insurance companies require a "referral," but if yours does, you will have to get it in order to have guarantee that the insurance will pay for that consult or test. In the old days, primary care doctors were the "gate-keepers" who helped the insurance company conserve finances by only giving referrals which they deemed medically necessary. The problem was that often the doctor got a BONUS if he did not waste the insurance company's money... thus if he withheld medical care he actually made more money! Obviously this is in direct conflict with the doctor-patient relationship, so hopefully few plans incorporate this protocol, but if yours does, I recommend you change insurance plans if at all possible! So let's get back to our friend who needs a referral. Know that if you ask me to send you to a specialist, I as a good physician will want to treat you first... if I think it is appropriate. I don't want my colleagues to think that I am stupid or don't try to take care of you. So, if I ask you to do something or try something, do it. If you don't get better, I will be happy to refer you. Also, know that if the referral or test will not likely change our treatment plan, perhaps you can wait a bit before pursuing it. For instance, if you have back pain (but no neurologic changes) & ask for an MRI of your back, I will likely ask: "if you have a herniated disc, will you go for surgery?" If the answer is "yes," then we get the test. If however you answer that you would more likely choose a trial of physical therapy or medications, then I would suggest that you simply try that first, & only get the MRI if you don't improve. Obviously, good communication with your physician is a must, & if you don't have that, again perhaps you need a new physician. Occasionally a patient has no choice but to work with a certain doctor, & if rapport is a problem, perhaps that patient should go out-of-network & pay a non-insurance doctor for an opinion. In the long-run, this can be more cost effective than paying for the test or specialist visit yourself. Ask the non-insurance doctor to educate you & arm you with the ammunition you will need to "convince" your insurance doctor to do what you want him to do!
Our same friend indicated that he (or she) does some sort of work at several hospitals, & seems to be getting some sort of "bug" from that exposure. Well there certainly are very resistant bacteria in our hospitals, & despite every effort to erradicate them, they live on to infect more people! Trust me, you do not want to be in the hospital if you do not have to be there... & if you must be there, WASH YOUR HANDS & insist that those who care for you do the same! Doctors & nurses are likely guilty of spreading many of these bugs due to poor handwashing... & apparently the computer keyboard is one of the likely culprits! As for our friend, we don't know where he goes in the hospital, nor do we know what he keeps getting, thus it is hard to give much feedback, except... I recommend that he speak with the Infection Control nurse at the hospital, as this person will be able to help evaluate if the hospital really has a problem.
February is American Heart Month! Easy to remember due to Valentine's Day! First, remember that women DO get heart disease, it just starts later in women than in men, & women often don't have classic symptoms. So men get heart disease in their 40's, whereas women usually are in their 50's when they get heart disease. Whereas men often have crushing chest pain with nausea, vomiting, & sweating, women might only have heartburn. So, ladies, you are potentially at risk, & if you have "risk factors" (see below), you should see your doctor for further tests of your heart. When we speak of "cardiovascular" issues, realize that we are really talking about blood vessels. These blood vessels bring blood & thus oxygen to tissues, & if they get blocked, those tissues suffer damage. Thus, diseased or blocked vessels can lead to heart attacks, strokes, kidney problems, & even painful legs when you walk. So cardiovascular risks are the things that cause your blood vessels to block up, & they include: High LDL (Lousy) cholesterol, Low HDL (Healthy) cholesterol, Hypertension (high blood pressure), Diabetes, Cigarette/Cigar use, being a Man or a menopausal Woman, & having a family history of heart disease before 55-60 years of age. Try to control all of your risk factors if you want to decrease your chance of having a heart attack or other vascular event. Basic guidelines are:
1) get your LDL below 100,
2) get your HDL above 40 & preferably above 60 (and know that below 30 is BAD!),
3) get your blood pressure below 130/80 or 130/85, & if you have diabetes, get it below 120/70,
4) get your average blood sugar below 150 (HgbA1c of less than 7.0),
5) stop, or at least limit, smoking, &
6) SORRY, but changing your sex probably won't help, & you just can't change your family genetics!
Lastly, we talked about the different parts of the heart, as not all "heart problems" are the same. The heart obviously has blood vessels which supply it with blood & oxygen, & if these block up, we get the classic heart attack, with part of the heart potentially dying due to lack of oxygen. The heart itself is a big muscle. Part of this muscle can die if it's blood supply gets blocked, but other things (such as alcohol, viral infections, & poorly controlled hypertension) can cause it to get weak & thus to pump inefficiently. There are also heart valves which separate the 4 heart chambers (which hold the blood & pump it around). If a valve is leaky, it allows backwards flow of blood in the heart & can enlarge a chamber. If a valve is stenotic (restricted or pinched to a smaller size) it can cause the heart to have to squeeze harder to pump the blood through that small opening, resulting in an enlarged chamber or a weakened heart muscle. Lastly, there is an electrical wiring system in the heart which conducts the electrical impulse which controls the heart beat. If this electrical system is sick, it can result in abnormal heart beats, some which increase your risk of stroke, & some which are fatal. Sometimes people will say that their family member died due to a heart attack, when in fact they died "sudden death" due to a fatal irregular heart beat rather than a blocked blood vessel. So... try to be specific when describing your or your family member's "heart trouble" to a doctor, as not all heart trouble is the same, & not all heart trouble has a genetic basis.
On that note, I bid you a belated Happy Valentine's Day, & here's to our health... heart & all!
Gigi
PS Please check out the radio show as sometimes hearing this is more effective than reading it. We can be heard live on Fridays at 1PM Eastern time on WTAN 1340-AM in the Tampa/St. Petersburg area, or you can listen live or to the recorded podcasts via the web: www.SkipShow.com. If you have comments, leave them here, or contact me at: DrGigi@SkipShow.com, or call us live during the show via: (727)-441-3000 or toll-free at (866)-TAN-1340.
I was not feeling well & had left work early, so Skip wanted to know how a person knows that he should not go to work. I indicated that generally VIRAL syndromes are more contagious than bacterial infections when they involve the respiratory tract. Thus a typical "cold" or "flu" is likely much more contagious than bronchitis or pneumonia which often are more likely caused by bacteria. Viruses often spread via coughing & sneezing as the virus particles are very small (bacteria are larger, so less likely to spread via these droplets of fluids). Thus, you are most likely contagious (& thus a danger to your co-workers) when you have a fresh viral upper respiratory tract infection with coughing, sneezing, & fever. Days later you may still have symptoms, but you are likely less contagious, expecially if the fever has resolved. So I would recommend that you stay home when you are first sick, as that is usually the time when you are most infectious. Now, certainly some bacterial infections DO spread from person to person, but these are not usually respiratory infections. MRSA (Methicillin-resistant Staph. aureus) can cause bad skin infections & is very contagious. C. diff causes severe diarrhea, & is very contagious. Meningitis can be viral or bacterial, & both forms are VERY contagious. So it is obvious that a simple answer does not exist, but when in doubt, take off work when you think you have a fresh viral infection... & if in doubt, consult your doctor... or your boss, as many employers would prefer you take a day off as opposed to getting the whole office sick!
Another point was made regarding the fact that people with allergies that affect their eyes & noses often think they have a virus or an infection. Allergies usually do not cause fever, nor do they usually cause colored phlegm. So if you have a clear runny nose & runny eyes, but no fever, it might be wise to try an antihistamine (such as Loratidine or Allegra or Zyrtec which are all over-the-counter) as these "fight" the allergy & just might "cure" you. Also, if you keep feeling like you have a "cold" that just won't go away, that might be an allergy. Due to the warm winter we've had, we are starting to see allergy problems earlier this year than usual... at least in the Florida area.
Someone sent a note that he had a primary care doctor who would not make a "referral" to a specialist, & he wanted to know other options, as without the referral his insurance would not pay for the specialist's opinion. My gut response is that he should get a new doctor! But let's look at the whole picture. First, a "referral" is a form that a doctor completes indicating that he has recommended that the patient see another doctor or get a certain test. Not all insurance companies require a "referral," but if yours does, you will have to get it in order to have guarantee that the insurance will pay for that consult or test. In the old days, primary care doctors were the "gate-keepers" who helped the insurance company conserve finances by only giving referrals which they deemed medically necessary. The problem was that often the doctor got a BONUS if he did not waste the insurance company's money... thus if he withheld medical care he actually made more money! Obviously this is in direct conflict with the doctor-patient relationship, so hopefully few plans incorporate this protocol, but if yours does, I recommend you change insurance plans if at all possible! So let's get back to our friend who needs a referral. Know that if you ask me to send you to a specialist, I as a good physician will want to treat you first... if I think it is appropriate. I don't want my colleagues to think that I am stupid or don't try to take care of you. So, if I ask you to do something or try something, do it. If you don't get better, I will be happy to refer you. Also, know that if the referral or test will not likely change our treatment plan, perhaps you can wait a bit before pursuing it. For instance, if you have back pain (but no neurologic changes) & ask for an MRI of your back, I will likely ask: "if you have a herniated disc, will you go for surgery?" If the answer is "yes," then we get the test. If however you answer that you would more likely choose a trial of physical therapy or medications, then I would suggest that you simply try that first, & only get the MRI if you don't improve. Obviously, good communication with your physician is a must, & if you don't have that, again perhaps you need a new physician. Occasionally a patient has no choice but to work with a certain doctor, & if rapport is a problem, perhaps that patient should go out-of-network & pay a non-insurance doctor for an opinion. In the long-run, this can be more cost effective than paying for the test or specialist visit yourself. Ask the non-insurance doctor to educate you & arm you with the ammunition you will need to "convince" your insurance doctor to do what you want him to do!
Our same friend indicated that he (or she) does some sort of work at several hospitals, & seems to be getting some sort of "bug" from that exposure. Well there certainly are very resistant bacteria in our hospitals, & despite every effort to erradicate them, they live on to infect more people! Trust me, you do not want to be in the hospital if you do not have to be there... & if you must be there, WASH YOUR HANDS & insist that those who care for you do the same! Doctors & nurses are likely guilty of spreading many of these bugs due to poor handwashing... & apparently the computer keyboard is one of the likely culprits! As for our friend, we don't know where he goes in the hospital, nor do we know what he keeps getting, thus it is hard to give much feedback, except... I recommend that he speak with the Infection Control nurse at the hospital, as this person will be able to help evaluate if the hospital really has a problem.
February is American Heart Month! Easy to remember due to Valentine's Day! First, remember that women DO get heart disease, it just starts later in women than in men, & women often don't have classic symptoms. So men get heart disease in their 40's, whereas women usually are in their 50's when they get heart disease. Whereas men often have crushing chest pain with nausea, vomiting, & sweating, women might only have heartburn. So, ladies, you are potentially at risk, & if you have "risk factors" (see below), you should see your doctor for further tests of your heart. When we speak of "cardiovascular" issues, realize that we are really talking about blood vessels. These blood vessels bring blood & thus oxygen to tissues, & if they get blocked, those tissues suffer damage. Thus, diseased or blocked vessels can lead to heart attacks, strokes, kidney problems, & even painful legs when you walk. So cardiovascular risks are the things that cause your blood vessels to block up, & they include: High LDL (Lousy) cholesterol, Low HDL (Healthy) cholesterol, Hypertension (high blood pressure), Diabetes, Cigarette/Cigar use, being a Man or a menopausal Woman, & having a family history of heart disease before 55-60 years of age. Try to control all of your risk factors if you want to decrease your chance of having a heart attack or other vascular event. Basic guidelines are:
1) get your LDL below 100,
2) get your HDL above 40 & preferably above 60 (and know that below 30 is BAD!),
3) get your blood pressure below 130/80 or 130/85, & if you have diabetes, get it below 120/70,
4) get your average blood sugar below 150 (HgbA1c of less than 7.0),
5) stop, or at least limit, smoking, &
6) SORRY, but changing your sex probably won't help, & you just can't change your family genetics!
Lastly, we talked about the different parts of the heart, as not all "heart problems" are the same. The heart obviously has blood vessels which supply it with blood & oxygen, & if these block up, we get the classic heart attack, with part of the heart potentially dying due to lack of oxygen. The heart itself is a big muscle. Part of this muscle can die if it's blood supply gets blocked, but other things (such as alcohol, viral infections, & poorly controlled hypertension) can cause it to get weak & thus to pump inefficiently. There are also heart valves which separate the 4 heart chambers (which hold the blood & pump it around). If a valve is leaky, it allows backwards flow of blood in the heart & can enlarge a chamber. If a valve is stenotic (restricted or pinched to a smaller size) it can cause the heart to have to squeeze harder to pump the blood through that small opening, resulting in an enlarged chamber or a weakened heart muscle. Lastly, there is an electrical wiring system in the heart which conducts the electrical impulse which controls the heart beat. If this electrical system is sick, it can result in abnormal heart beats, some which increase your risk of stroke, & some which are fatal. Sometimes people will say that their family member died due to a heart attack, when in fact they died "sudden death" due to a fatal irregular heart beat rather than a blocked blood vessel. So... try to be specific when describing your or your family member's "heart trouble" to a doctor, as not all heart trouble is the same, & not all heart trouble has a genetic basis.
On that note, I bid you a belated Happy Valentine's Day, & here's to our health... heart & all!
Gigi
PS Please check out the radio show as sometimes hearing this is more effective than reading it. We can be heard live on Fridays at 1PM Eastern time on WTAN 1340-AM in the Tampa/St. Petersburg area, or you can listen live or to the recorded podcasts via the web: www.SkipShow.com. If you have comments, leave them here, or contact me at: DrGigi@SkipShow.com, or call us live during the show via: (727)-441-3000 or toll-free at (866)-TAN-1340.
Sunday, February 5, 2012
Dr. Thorpe, Chiropractor; Computers in the Hospital; "Off label" use of meds; Benadryl for sleep; Thyroid Cancer & Mammograms; Emergency Rooms are not for primary care; New time slot is 1:30!!!
First, I must admit that I have been remise in saying "thank you" to my colleague Dr. Lorraine Thorpe. She is a chiropractor, & like myself, she practices in St. Petersburg, FL. Though we approach the patient from different angles due to our different professions, we are very similar in our committment to the patient & his or her health! I respect the care she provides to her patients, & I am honored to be associated with her! Though it may seem strange to some that a Chiropractor and an MD "get along," please realize that they call it complimentary medicine for a reason: the different approaches to the evaluation & treatment of the patient compliment one another & lead to better care in the long run. So again, I thank Dr. Thorpe for her sponsorship of the show, & I am pleased that we are all getting to know more about what she does in her chiropractic clinic!
As you have heard many times, I as well as many in the medical profession (doctors, nurses, physical therapists, hospital administrators, etc.) are totally frustrated with the computerization of medicine. The idea is great, but the implementation is painful, & in my opinion unhealthy! I find that I spend an awful amount of time running interference trying to find computer errors that otherwise could lead to patient harm. In fact, I recently read that there are documented cases of several patients dying due to computer errors. So I would suggest that if you are hospitalized you should pay attention, talk with your medical professionals, & always ask about medicines before you swallow them: what is it, what is it for, & who ordered it! Keep notes if you can, & if at all possible, have a friend or family member stay with you to act as your advocate. It is also a good idea to have a physician who will be your primary care doctor as well as your hospital doctor. He will already be vested in a relationship with you before your hospital stay, & thus will have better rapport with you & your family during the hospitalization.
We had a question regarding the use of medication "off label." When a medication is first invented, it goes through rigorous studies to prove it is safe & that it works for a particular disease process (what we call "efficacy"). These studies are overseen by the Food & Drug Administration, & in the end, they review the data & approve or disapprove the medication. When it is approved, it is "labeled" in regards to how it is used & for what disease processes. When the drug hits the market, the pharmaceutical representatives set about educating the doctors about it & it's use. They are not allowed to speak about anything other than what the studies have "proven," but many times physicians use medications in ways that have not been proven. We do this because we assume that medicines in a similar class will behave similarly. Thus, if a new anti-depressant hits the market, I will likely use it like I would any other anti-depressant. A great example of this is a new medicine called Savella. It is an SNRI (like Effexor), so one would assume that it can be used to treat depression. But... one would be WRONG! Forest Pharmaceuticals owns Savella, & they opted to get it to market as a treatment for fibromyalgia. Thus they did fibromyalgia studies, & ... viola... they proved it helps fibro. pain. Thanks to these studies, we now can prescribe Savella for treatment of fibromyalgia, but since there were no studies to evaluate it as an anti-depressant, we are not supposed to use it for that. I pose the question however: if a person has tried other anti-depressants with poor tolerance or poor response, would you prescribe Savella for him? Remember, it is an anti-depressant, & we know its side-effects, so in certain situations it might be an appropriate treatment. I call this "off label" use of medicine the "art of medicine." It is not always scientifically based, but it is not necessarily quackery or bad medicine. In fact, it helps determine new uses for old drugs. Such is the case with Elavil (an old Tricyclic anti-depressant), which is not indicated for, but is commonly prescribed for treatment of chronic pain, prevention of migraine, & treatment of TMJ (temperomandibular joint) syndrome. If you wonder why we don't do more research to get the label for these disease processes, the answer is simple: MONEY! It is not cost effective to spend millions or billions of dollars to get indication for a rare disease, nor is it effective if the drug will soon lose it's patent & go generic. Doctors have the right to prescribe "off label," but with the ever increasing oversight by insurance companies & the government, as well as the growing legal arena in which we practice, I suspect we will see less of this "art" being practiced in the future!
Irene had called last week regarding Tylenol PM which she took regularly for sleep. We suggested that she stop Tylenol PM (which has Tylenol AND Benadryl) & instead take only Benadryl (=Diphenhydramine). She reported she was sleeping well with Benadryl 25 mg 1 1/2 tabs (which is 37.5 mg total) each night with good results. She wanted reassurance that this is safe to do for years. The maximum dose of Benadryl is 50 mg 4 times per day, so that is a total of 200 mg per day. As you can see, she is well below the daily maximum, & is not even at the max for a single dose (50 mg), so I reassured her that this should be safe... & is certainly safer than the Tylenol PM she used to take. As always, she should be sure to tell her physician that she takes this (& any other over-the-counter meds) so he can help ensure there are no contra-indications with her other meds or medical conditions.
Skip mentioned that Dr. Oz has been speaking about the fact that thyroid cancer is becoming a common cancer in women. One wonders why women, & why not men. Well, the supposition is that mammograms might be causing the thyroid cancer! Though no one knows that for certain (yet), we discussed that there is no harm in asking the x-ray tech who does the mammogram to cover your thyroid with a lead thyroid guard. Though it is apparently not common practice for them to do this as a matter of protocol, again there is no harm in requesting that they do it for you. In fact, when you call to make your mammogram appointment, ask if they will use the thyroid guard. If so, then schedule your mammogram with them. If not, tell them thanks, but schedule with a different x-ray department that will accomodate your request!
We discussed a question posed on the January 29, 2012 blog. It was in reference to a young lady with abdominal pain & back pain, associated with eating. You can refer to the blog for more details, but I did respond that she might have a stomach ulcer, as ulcers can cause pain in the middle of the belly (just below the breast bone) which radiates straight through to the back, & which often gets worse when you eat... as the sick stomach must then try to work to digest your food. I think the teaching point in the story however is not specific to this situation, but rather a general understanding of how Emergency Rooms work. This patient indicates that she had been to the ER where they had "ruled out" several conditions, but had not made a diagnosis. Please understand that the Emergency Room is just that... a place to go when you have an emergency! There the medical staff will evaluate you for deadly conditions, but if they do not find one, they send you home. It is not their job to DIAGNOSE your illness... they just want to make sure you will not DIE from WHATEVER is wrong with you! This patient has been to the ER & had a negative work-up. That does not mean she has nothing wrong, it just means she likely has nothing horrible that is likely to kill her soon! She absolutely must see a primary care doctor to have a proper evaluation including a history, physical exam, & possibly labwork. That doctor will either treat her or refer her to a Gastroenterologist (stomach doctor) for further studies. The point is to not use the ER as your primary care doctor... you will not get the kind of care you need & deserve!
Remember that next week the Skip Show will move to 1:00-2:00 PM Eastern time. Therefore, Let's Talk Medical with Doctor Gigi will be broadcast at 1:30 PM on Fridays, so look for us in our new time slot! And don't forget, if you miss the live show, you can still check out the podcast on www.SkipShow.com, or catch this blog... same place & same time!
Here's to our health!
Gigi
PS Please feel free to comment on these blogs, or e-mail me with questions or concerns via: DrGigi@SkipShow.com. If you are not too shy, call during the live show at: (727)-441-3000 or toll-free at: (866)-TAN-1340.
As you have heard many times, I as well as many in the medical profession (doctors, nurses, physical therapists, hospital administrators, etc.) are totally frustrated with the computerization of medicine. The idea is great, but the implementation is painful, & in my opinion unhealthy! I find that I spend an awful amount of time running interference trying to find computer errors that otherwise could lead to patient harm. In fact, I recently read that there are documented cases of several patients dying due to computer errors. So I would suggest that if you are hospitalized you should pay attention, talk with your medical professionals, & always ask about medicines before you swallow them: what is it, what is it for, & who ordered it! Keep notes if you can, & if at all possible, have a friend or family member stay with you to act as your advocate. It is also a good idea to have a physician who will be your primary care doctor as well as your hospital doctor. He will already be vested in a relationship with you before your hospital stay, & thus will have better rapport with you & your family during the hospitalization.
We had a question regarding the use of medication "off label." When a medication is first invented, it goes through rigorous studies to prove it is safe & that it works for a particular disease process (what we call "efficacy"). These studies are overseen by the Food & Drug Administration, & in the end, they review the data & approve or disapprove the medication. When it is approved, it is "labeled" in regards to how it is used & for what disease processes. When the drug hits the market, the pharmaceutical representatives set about educating the doctors about it & it's use. They are not allowed to speak about anything other than what the studies have "proven," but many times physicians use medications in ways that have not been proven. We do this because we assume that medicines in a similar class will behave similarly. Thus, if a new anti-depressant hits the market, I will likely use it like I would any other anti-depressant. A great example of this is a new medicine called Savella. It is an SNRI (like Effexor), so one would assume that it can be used to treat depression. But... one would be WRONG! Forest Pharmaceuticals owns Savella, & they opted to get it to market as a treatment for fibromyalgia. Thus they did fibromyalgia studies, & ... viola... they proved it helps fibro. pain. Thanks to these studies, we now can prescribe Savella for treatment of fibromyalgia, but since there were no studies to evaluate it as an anti-depressant, we are not supposed to use it for that. I pose the question however: if a person has tried other anti-depressants with poor tolerance or poor response, would you prescribe Savella for him? Remember, it is an anti-depressant, & we know its side-effects, so in certain situations it might be an appropriate treatment. I call this "off label" use of medicine the "art of medicine." It is not always scientifically based, but it is not necessarily quackery or bad medicine. In fact, it helps determine new uses for old drugs. Such is the case with Elavil (an old Tricyclic anti-depressant), which is not indicated for, but is commonly prescribed for treatment of chronic pain, prevention of migraine, & treatment of TMJ (temperomandibular joint) syndrome. If you wonder why we don't do more research to get the label for these disease processes, the answer is simple: MONEY! It is not cost effective to spend millions or billions of dollars to get indication for a rare disease, nor is it effective if the drug will soon lose it's patent & go generic. Doctors have the right to prescribe "off label," but with the ever increasing oversight by insurance companies & the government, as well as the growing legal arena in which we practice, I suspect we will see less of this "art" being practiced in the future!
Irene had called last week regarding Tylenol PM which she took regularly for sleep. We suggested that she stop Tylenol PM (which has Tylenol AND Benadryl) & instead take only Benadryl (=Diphenhydramine). She reported she was sleeping well with Benadryl 25 mg 1 1/2 tabs (which is 37.5 mg total) each night with good results. She wanted reassurance that this is safe to do for years. The maximum dose of Benadryl is 50 mg 4 times per day, so that is a total of 200 mg per day. As you can see, she is well below the daily maximum, & is not even at the max for a single dose (50 mg), so I reassured her that this should be safe... & is certainly safer than the Tylenol PM she used to take. As always, she should be sure to tell her physician that she takes this (& any other over-the-counter meds) so he can help ensure there are no contra-indications with her other meds or medical conditions.
Skip mentioned that Dr. Oz has been speaking about the fact that thyroid cancer is becoming a common cancer in women. One wonders why women, & why not men. Well, the supposition is that mammograms might be causing the thyroid cancer! Though no one knows that for certain (yet), we discussed that there is no harm in asking the x-ray tech who does the mammogram to cover your thyroid with a lead thyroid guard. Though it is apparently not common practice for them to do this as a matter of protocol, again there is no harm in requesting that they do it for you. In fact, when you call to make your mammogram appointment, ask if they will use the thyroid guard. If so, then schedule your mammogram with them. If not, tell them thanks, but schedule with a different x-ray department that will accomodate your request!
We discussed a question posed on the January 29, 2012 blog. It was in reference to a young lady with abdominal pain & back pain, associated with eating. You can refer to the blog for more details, but I did respond that she might have a stomach ulcer, as ulcers can cause pain in the middle of the belly (just below the breast bone) which radiates straight through to the back, & which often gets worse when you eat... as the sick stomach must then try to work to digest your food. I think the teaching point in the story however is not specific to this situation, but rather a general understanding of how Emergency Rooms work. This patient indicates that she had been to the ER where they had "ruled out" several conditions, but had not made a diagnosis. Please understand that the Emergency Room is just that... a place to go when you have an emergency! There the medical staff will evaluate you for deadly conditions, but if they do not find one, they send you home. It is not their job to DIAGNOSE your illness... they just want to make sure you will not DIE from WHATEVER is wrong with you! This patient has been to the ER & had a negative work-up. That does not mean she has nothing wrong, it just means she likely has nothing horrible that is likely to kill her soon! She absolutely must see a primary care doctor to have a proper evaluation including a history, physical exam, & possibly labwork. That doctor will either treat her or refer her to a Gastroenterologist (stomach doctor) for further studies. The point is to not use the ER as your primary care doctor... you will not get the kind of care you need & deserve!
Remember that next week the Skip Show will move to 1:00-2:00 PM Eastern time. Therefore, Let's Talk Medical with Doctor Gigi will be broadcast at 1:30 PM on Fridays, so look for us in our new time slot! And don't forget, if you miss the live show, you can still check out the podcast on www.SkipShow.com, or catch this blog... same place & same time!
Here's to our health!
Gigi
PS Please feel free to comment on these blogs, or e-mail me with questions or concerns via: DrGigi@SkipShow.com. If you are not too shy, call during the live show at: (727)-441-3000 or toll-free at: (866)-TAN-1340.
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