The Grumpy Doc

Grumpy opinions about everything.

Category: Medicine Page 2 of 4

Of course there will be medicine. I am The Grumpy Doc.

Do I Really Need To Go To The Hospital?

By

On November 22, 2024

In Medicine

Introduction

Yes, it’s hard waiting in this room.  I get it, I really do!  After many years as an emergency doc I really understand what it’s like for you to be waiting for treatment for yourself or family members.  It’s particularly stressful during the holiday season when emergency departments are crowded and no one wants to inconvenience family or friends by having to make a trip to the hospital.  I have spent quite a few Christmases in the emergency department, so I’ve seen first hand how difficult it can be for patients and families to try to celebrate their holidays in the hospital. (By the way, that’s me in the white coat.)

If you do need to go to the emergency department, be sure and check in with the triage nurse soon as you get there. Give as detailed a description of your symptoms as possible. The more information you provide, the better job the nurse can do of triaging you. Triage is method that emergency departments use to determine who needs to be seen first. It’s not first come first served.  If at any time your symptoms change during your stay, you need to immediately notify the nurse.

During the holiday season emergency departments are frequently over crowded and under staffed. This can lead to long delays. If at all possible you should have someone with you in case you do start having problems they can immediately notify the nursing staff for you. 

A word of caution. There is a common misconception that taking an ambulance will get you to the head of the line. This is not true. Even if you arrive by ambulance, if your initial assessment does not indicate an emergent condition, you may be triaged to the waiting room. Additionally, your insurance company may refuse to cover the ambulance trip for a non emergent condition.

 Now, here’s the big but…  A lot of people delay seeking medical care during the holiday season with sometimes disastrous results.  Below are 10 reasons that you should seek medical care at any time and particularly during the stressful  holiday season.

1. Chest Pain

  • Symptoms: Pressure, tightness, or discomfort in the chest, which may radiate to the arms, back, neck, or jaw, often accompanied by shortness of breath, excessive sweating, or nausea. Women and diabetics may experience milder symptoms, such as isolated fatigue, dizziness, or nausea, and should maintain a high degree of suspicion.
  • Potential Outcomes If Ignored: Chest pain could signal a heart attack, potentially leading to heart muscle damage, heart failure, or death if not treated promptly.
  • Action: Seek emergency care. Call 911 or visit an emergency department (ED) immediately, as timely intervention can be life-saving. Contact your PCP for chest pain primarily in the chest wall, especially if it worsens with coughing or movement.

2. Severe Shortness of Breath

  • Symptoms: Difficulty breathing, wheezing, gasping for air, or an inability to catch your breath.
  • Potential Outcomes If Ignored: Severe shortness of breath could indicate conditions like asthma, pneumonia, pulmonary embolism, or heart failure. If untreated, it may lead to respiratory failure or sudden death.
  • Action: Seek emergency care immediately. Severe shortness of breath requires prompt evaluation in the ED to determine the cause and provide necessary treatments. Mild shortness of breath with activity or when lying flat should be assessed by your PCP.

3. Sudden Weakness, Numbness, or Difficulty Speaking

  • Symptoms: Sudden loss of strength or sensation, particularly on only one side of the body, difficulty speaking, confusion, or trouble walking or holding objects.
  • Potential Outcomes If Ignored: These symptoms often indicate a stroke. Without prompt treatment, brain damage can occur quickly, leading to permanent disability or death. If the symptoms resolve on their own, it could be a transient ischemic attack (TIA), a warning sign of an impending stroke.
  • Action: Seek emergency care. Call 911 immediately. Early treatment can significantly improve recovery outcomes. Do not ignore TIA symptoms, as a stroke may follow shortly.

4. Severe Abdominal Pain

  • Symptoms: Sharp or intense pain in the stomach area, often accompanied by nausea, vomiting, or fever.
  • Potential Outcomes If Ignored: Severe abdominal pain could indicate appendicitis, bowel obstruction, or gallbladder disease. Untreated, these conditions can lead to infections or organ damage.
  • Action: Seek emergency care for sudden, intense pain. For persistent but less severe pain, contact your PCP for evaluation.

5. High Fever with Severe Symptoms

  • Symptoms: A fever over 103°F (39.4°C), especially if accompanied by confusion, headache, weakness, dizziness, stiff neck, rash, or difficulty breathing.
  • Potential Outcomes If Ignored: High fever with severe symptoms may indicate serious infections like meningitis or sepsis, which can rapidly become life-threatening.
  • Action: Seek emergency care for high fevers with concerning symptoms. For lower but persistent fevers, consult your PCP.

6. Persistent Cough or Coughing Up Blood

  • Symptoms: A cough lasting more than three weeks, wheezing, or producing blood-streaked mucus.
  • Potential Outcomes If Ignored: A chronic cough could be a sign of lung infections like pneumonia, chronic obstructive pulmonary disease (COPD), or even lung cancer. Coughing up blood may indicate a severe infection or pulmonary embolism.
  • Action: Contact your PCP for a persistent cough. Seek emergency care if you are coughing up blood or experiencing severe symptoms like high fever or shortness of breath.

7. Severe Allergic Reaction (Anaphylaxis)

  • Symptoms: Swelling of the throat, lips, or tongue; difficulty breathing; rapid heartbeat; or dizziness following exposure to an allergen.
  • Potential Outcomes If Ignored: Anaphylaxis can be life-threatening if not treated immediately, potentially leading to shock or death.
  • Action: Seek emergency care. Use an epinephrine auto-injector if available and call 911 or go to the ED right away.

8. Sudden, Severe Headache

  • Symptoms: Intense headache that comes on suddenly, often described as the “worst headache of your life”, sometimes accompanied by vomiting or visual changes.
  • Potential Outcomes If Ignored: A sudden, severe headache could indicate a brain aneurysm or stroke. Ignoring these symptoms may result in brain damage or death.
  • Action: Seek emergency care. Immediate attention is necessary, especially if the headache is accompanied by neurological symptoms like weakness or vision changes.

9. Sudden Vision Loss or Changes

  • Symptoms: Sudden blurred vision, double vision, or complete or partial loss of vision in one or both eyes.
  • Potential Outcomes If Ignored: Sudden vision changes may indicate retinal detachment, stroke, or another neurological issue. Without treatment, permanent vision loss or brain damage can occur.
  • Action: Seek emergency care if vision loss is sudden or accompanied by other symptoms like headache or weakness. For gradual vision changes, consult your PCP or an ophthalmologist.

10. Unexplained Weight Loss or Fatigue

  • Symptoms: Significant, unintended weight loss or extreme fatigue persisting without a clear cause.
  • Potential Outcomes If Ignored: Unexplained weight loss or fatigue could signal serious underlying conditions such as cancer, diabetes, thyroid disorders, or depression. Delayed diagnosis and treatment may lead to worsening health.
  • Action: Contact your PCP. While not usually an emergency, a comprehensive evaluation is needed to identify and address the underlying cause.

Conclusion

Recognizing when to seek medical attention can be life-saving. For severe, sudden symptoms like chest pain, shortness of breath, or signs of a stroke, emergency care is essential. For more gradual or less urgent issues, your primary care physician can provide diagnosis, guidance, and treatment. Don’t wait—early intervention often prevents serious complications down the road.

Joint Replacement: A Path to Pain-Free Living

By

On November 16, 2024

In Medicine

Joint replacement surgery is a crucial option for people dealing with severe joint pain and mobility issues. Having undergone a reverse total shoulder replacement myself four weeks ago, this topic is personal to me. Over the years, I’ve treated many patients and seen friends and family members undergo joint replacements. But until it was my turn, I hadn’t fully realized the impact it would have on my life.  Now I’m looking forward to being able to put things on the top shelf of the closet again.

A few years ago, my wife started experiencing pain in her hip. She slowly began to limit many of the activities she enjoyed. She kept thinking she didn’t need surgery because the pain would go away. Eventually when she could hardly leave the house due to the pain she opted for surgery. Now she’s back to walking, riding bicycles, and going to exercise class.  The only drawback is setting off the security alarms in the airports.

As we age or suffer injuries, the cartilage in our joints can deteriorate, leading to pain, stiffness, and reduced quality of life. Falls, in particular, are a significant cause of joint injuries requiring replacement. In my case, a fall resulted in the rupture of three out of four tendons in my left rotator cuff. In this post, we’ll explore three common joint replacements: knee, hip, and shoulder, and discuss the symptoms, surgical procedures, and recovery processes for each.

Knee Replacement

When Is It Needed?

Knee replacement surgery is usually recommended when the knee joint becomes severely damaged, often due to:

  • Osteoarthritis
  • Rheumatoid arthritis
  • Post-traumatic arthritis
  • Severe knee injury

Common symptoms indicating the need for surgery include pain during activity, swelling, loss of mobility, and difficulty walking, climbing stairs, or even standing.

The Surgery

In a total knee replacement, the surgeon removes the damaged cartilage and bone from the femur, tibia, and patella. These are replaced with metal and plastic components designed to mimic the function of a healthy knee joint. Hospital stays typically range from one to three days.

Recovery Process

Recovery usually takes several months. Physical therapy starts soon after surgery to restore mobility and strengthen muscles. Most patients can walk with minimal assistance within 4-6 weeks, but full recovery often takes 6-12 months. Consistent physical therapy is crucial to prevent stiffness and improve the range of motion. Swelling may persist for several months and requires ongoing management.

Hip Replacement

When Is It Needed?

Hip replacement surgery is often considered when pain and joint dysfunction interfere with daily activities. Common reasons for hip replacement include:

  • Osteoarthritis
  • Hip fractures
  • Avascular necrosis (bone death due to loss of blood supply)
  • Rheumatoid arthritis

Patients frequently experience hip, thigh or groin pain, stiffness, and a limp, making walking and standing difficult. When other treatments fail, surgery becomes the best option.

The Surgery

In a total hip replacement, the damaged hip socket and femoral head are replaced with prosthetic components. The new joint typically consists of a metal or ceramic ball fitting into a metal or plastic cup. Hospital stays are generally one to three days.

There are two main surgical approaches:

  • Anterior Approach: This approach may allow for a faster recovery with fewer movement restrictions but requires specialized surgical skill.  It results in less muscle damage as the procedure is performed between the muscles rather than through the muscles.  It does carry a small risk of nerve injury.  This approach is not suitable for obese or very muscular patients.
  • Standard Approach: It is often better suited for patients with complex cases like severe fractures as it allows better visibility of the joint.  This method may have a slightly slower recovery time and a marginally higher risk of post-operative dislocation.  It is suitable for a wider range of body types and is appropriate for almost all patients.

The choice of approach should be made in consultation with your surgeon, who will recommend the best option for your specific condition.

Recovery Process

Rehabilitation begins quickly, often within a day of surgery. Patients typically use a walker or crutches for the first few weeks, gradually transitioning to normal walking. Full recovery generally takes about 3-6 months, although some patients may take longer to regain full strength and mobility.

Shoulder Replacement

When Is It Needed?

Shoulder replacement surgery is less common than knee or hip replacements but is necessary when the shoulder joint is severely damaged. It is typically recommended for:

  • Osteoarthritis
  • Rheumatoid arthritis
  • Rotator cuff tear arthropathy
  • Severe fractures

Patients often report pain, limited range of motion, and difficulty with overhead movements or lifting objects.

The Surgery

In a total shoulder replacement, the damaged parts of the humerus (upper arm bone) and the shoulder blade are replaced with metal and plastic implants. If the rotator cuff is intact, a traditional shoulder replacement is performed. If the rotator cuff is severely damaged, a reverse shoulder replacement may be chosen, relying on the deltoid muscle instead.

The decision on the type of shoulder replacement should be made with your surgeon, based on your specific clinical condition.

Recovery Process

Recovery involves several months of physical therapy to restore strength and mobility. A sling is typically used for the first few weeks. Improvements in pain relief and function are often noticed within weeks, but full recovery can take 3-6 months. Patients undergoing reverse replacements may experience less pain initially, though they might have some limitations in their range of motion.

Potential Complications

Infection

One of the most serious complications of joint replacement surgery is infection. It can occur at the incision site or deep around the artificial joint. Infections can be classified as:

  • Superficial (Incisional) Infections: These typically involve only the skin and soft tissue around the incision site. They may be managed with antibiotics and local wound care.
  • Deep Joint Infections: Infections that involve the joint itself are more severe. They may require surgical intervention, such as a procedure to clean the joint (debridement) or, in extreme cases, complete removal of the prosthesis.

Prevention: Surgeons take precautions like administering antibiotics before and during surgery, and follow strict sterile techniques to reduce this risk.

2. Blood Clots (Deep Vein Thrombosis and Pulmonary Embolism)

Blood clots can occur after joint replacement surgeries, particularly for hip and knee replacements. Blood clots can form in the deep veins of the legs (deep vein thrombosis, or DVT) and, if dislodged, travel to the lungs, causing a life-threatening condition known as a pulmonary embolism.

Symptoms:

  • Swelling, redness, and pain in the leg (DVT)
  • Sudden shortness of breath, chest pain, or coughing up blood (pulmonary embolism)

Prevention:

  • Blood-thinning medications (anticoagulants)
  • Compression stockings
  • Early mobilization and physical therapy
  • Use of pneumatic compression devices

Early diagnosis and treatment are critical to preventing serious complications.

3. Dislocation

Dislocation of the new joint is a concern, especially with hip and shoulder replacements. It occurs when the ball of the artificial joint comes out of its socket. This complication is more common in the early stages of recovery when tissues are still healing.

Prevention:

  • Following postoperative movement restrictions (e.g., avoiding certain hip positions)
  • Strengthening surrounding muscles through physical therapy
  • Wearing a brace or sling as directed

Dislocations often require a visit to the emergency room for reduction, where the joint is put back into place. In some cases, additional surgery may be needed.

4. Nerve and Blood Vessel Damage

During joint replacement surgery, nerves and blood vessels surrounding the joint can be damaged. This can lead to numbness, weakness, or changes in sensation.

Symptoms:

  • Tingling or numbness near the surgical site
  • Loss of muscle control or strength

While minor nerve injuries often resolve on their own, more severe damage might require additional treatment or surgical repair.

7. Leg Length Discrepancy

This complication primarily occurs with hip replacement surgery. After surgery, patients may feel that one leg is longer or shorter than the other. This can lead to issues with balance and gait.

Causes:

  • Changes in the alignment of the hip joint
  • Muscle contractures
  • Surgical technique

Prevention and Management:

  • Careful surgical planning and technique
  • Postoperative exercises and physical therapy to improve muscle balance
  • Shoe inserts or orthotics may help in severe cases.

7. Allergic Reactions

Some patients may have an allergic reaction to the materials used in the prosthesis, such as nickel, cobalt, or chromium. This is rare but can cause pain and inflammation.

Symptoms:

  • Persistent joint pain without an obvious cause
  • Swelling or redness

8. Chronic Pain

While joint replacement surgeries are intended to relieve pain, some patients may continue to experience chronic pain after the procedure. This may be due to:

  • Nerve damage
  • Infection
  • Prosthesis issues (e.g., loosening or malalignment)
  • Inflammatory or autoimmune conditions

Conclusion

If you want to learn more about either the surgery itself or the rehabilitation process, there are many useful videos on YouTube. I have watched a number of videos about shoulder replacement and rehabilition and found them to be very informative. A word of caution though. Be sure the videos you choose were done either by an orthopedic surgeon or a licensed physical therapist. You don’t want the latest installment of Fred and Mary Jane’s all-purpose YouTube channel.

Whether it’s the knee, hip, or shoulder, these surgeries often provide a new lease on life, freeing patients from chronic pain they may have endured for years.

 War and Medicine

By

On November 12, 2024

In History, Medicine

The Evolution of the Army Medical Corps

The history of military medicine in the United States during the 18th and 19th centuries is essentially the history of the Army Medical Corps. There is no surprise that the Army Medical Corps played a significant role in advances in battlefield medicine. However, many people do not appreciate that the Army Medical Corps also played a significant role in the treatment of infectious diseases and improvements in general sanitation.  For example, one of the first public health inoculation efforts was ordered by General George Washington in the Continental Army to protect troops against smallpox. Walter Reed led an Army Medical Corps team that proved that the transmission of yellow fever was by mosquitoes. The Army Medical Corps developed the first effective typhoid vaccine during the Spanish American War and in World War II the Army Medical Corps led research to develop anti-malarial drugs.

Revolutionary War and the Founding of the Army Medical Corps

The formal beginnings of military medical organization in the United States trace back to 1775, with the establishment of a Medical Department for the Continental Army. On July 27, 1775, the Continental Congress created the Army Medical Service to care for wounded soldiers. Dr. Benjamin Church was appointed as the first “Director General and Chief Physician” of the Medical Service, equivalent to today’s Surgeon General. However, Church’s tenure was brief and marred by scandal: he was proved to be a British spy, passing secrets to the enemy.

Church’s arrest in 1775 created a leadership vacuum, and the fledgling medical service had to reorganize quickly under Dr. John Morgan, who became the second Director General. Morgan sought to professionalize the medical corps, emphasizing proper record-keeping and standards of care. However, the Revolutionary War medical system struggled with limited resources, inadequate supplies, poor funding and an overworked staff. The lack of an effective supply chain for medicine, bandages, and surgical instruments was a significant issue throughout the conflict.

Early Challenges in Battlefield Medicine

During the Revolutionary War, military medical practices were rudimentary. Medical knowledge and understanding of disease processes had advanced little since the days of ancient Greece. Medical training was inconsistent and was principally by the apprentice method. In 1775 there were only two small medical schools in all of the 13 colonies. One of those closed with the onset of the revolution.

Field surgeons primarily treated gunshot wounds, fractures, and infections. Most treatments were painful and often involved amputation, as this was one of the few ways to prevent infections from spreading in an era without antibiotics. Battlefield medicine was further hampered by the fact that surgeons often had to work without proper sanitation or anesthesia.

One of the most significant health challenges faced by the Continental Army was disease, including smallpox, typhoid, dysentery, and typhus. In fact, more soldiers died from disease than from combat injuries. Recognizing the threat of smallpox, General George Washington made the controversial but strategic decision in 1777, to inoculate his troops against smallpox, significantly reducing mortality and helping to preserve the fighting force. At Valley Forge almost half of the continental troops were unfit for duty due to scabies infestation and approximately 1700 to 2000 soldiers died of the complications of typhoid and diarrhea.

It’s estimated that there were approximately 25,000 deaths among American soldiers both continental and militia in the American Revolution.  An estimated 7000 died from battlefield wounds. An additional 17,000 to 18,000 died from disease and infection. This loss of soldiers to non-combat deaths has been one of the biggest challenges faced by the Army Medical Corps through much of its history.

Post-Revolution: Developing a Medical Framework (1783-1812)

After the Revolutionary War, the United States Army Medical Department went through a period of instability. There were ongoing debates about the structure and necessity of a standing army and medical service in peacetime. However, the need for an organized military medical service became apparent during the War of 1812. The war underscored the importance of medical organization, especially in terms of logistics and transportation of the wounded.

The Army Medical Department grew, and by 1818, the government established the position of Surgeon General. Joseph Lovell became the first to officially hold the title of Surgeon General of the United States Army. Lovell introduced improvements to record-keeping and hospital management and laid the groundwork for future medical advances, though the department remained small and under-resourced.

Advancements in Military Medicine: The Mexican-American War (1846-1848)

The Mexican-American War provided an opportunity for the Army Medical Corps to refine its practices. Field hospitals were more structured, and new surgical techniques were tested. However, disease continued to be a significant challenge, yellow fever and dysentery plagued American troops. The war also underscored the importance of sanitation in camps, though knowledge about disease transmission was still limited.

The aftermath of the Mexican-American War saw the construction of permanent military hospitals and better organization of medical personnel, setting the stage for the much larger and more complex demands of the Civil War.

Civil War: The Birth of Modern Battlefield Medicine (1861-1865)

The Civil War represented a turning point in military medicine, with significant advances in both battlefield care and medical logistics. By the start of the war, the Army Medical Corps was better organized than during previous conflicts, though it still faced many challenges. Jonathan Letterman, the Medical Director of the Army of the Potomac, revolutionized battlefield medicine by creating the Letterman System, which included:

  1. Field Dressing Stations: Located near the front lines to provide immediate care.
  2. Ambulance System: Trained ambulance drivers transported wounded soldiers from the battlefield to hospitals.
  3. Field Hospitals and General Hospitals: These provided surgical care and longer-term treatment.

The Civil War saw the introduction of anesthesia (chloroform and ether), which reduced the suffering of wounded soldiers and made more complex surgeries possible. However, infection remained a major problem, as antiseptic techniques were not yet widely practiced and germ theory as a source for disease and infection was poorly understood. Surgeons worked in unsanitary conditions, often reusing instruments without sterilization and frequently doing little more than rinsing the blood off of their hands between patients.

Sanitation and Public Health Measures

One of the most critical lessons of the Civil War was the importance of camp sanitation and disease prevention. Dr. William Hammond, appointed Surgeon General in 1862, emphasized the need for hygiene and camp inspections. Under his leadership, new regulations improved the quality of food and water supplies. Though disease still claimed many lives, these efforts marked the beginning of a more systematic approach to military public health.

Additionally, the United States Sanitary Commission (USSC)was established in 1861. It was a civilian organization that was created to support the union army by promoting sanitary practices and improving medical care for soldiers with the objectives of improving camp sanitation, providing medical supplies, promoting hygiene and preventive care, supporting wounded soldiers and advocating for soldiers welfare.

Hammond also promoted the use of the Army Medical Museum to collect specimens and study diseases, fostering a more scientific approach to military medicine. Though he faced resistance from some military leaders, his reforms laid the foundation for modern military medical practices.

Conclusion

The evolution of the Army Medical Corps from the Revolutionary War to the Civil War reflects a gradual shift from rudimentary care to more organized, systematic medical practices. Early efforts were hindered by leadership issues, such as the betrayal by Benjamin Church, and by the challenges of disease and limited resources. However, over the decades, the Army Medical Department improved its structure, introduced innovations like inoculation and anesthesia, and laid the groundwork for advances in battlefield care. The Civil War, in particular, was pivotal in transforming military medicine, with lessons in logistics, sanitation, and surgical care that would shape the future of military and civilian medical systems.

For further reading, the following sources provide excellent insights:

  • Office of Medical History – U.S. Army
  • “Gangrene and Glory: Medical Care during the American Civil War” by Frank R. Freemon

The Harmful Grip of Cigarette Smoking

By

On October 24, 2024

In Commentary, Medicine

Addiction, Health Risks, and the Benefits of Quitting

Cigarette smoking remains one of the leading causes of preventable death worldwide.  In the more than 65 years since the US Surgeon General first required health warnings to be placed on cigarette packs, significant progress has been made in reducing the rates of smoking. In 1965 about 45% of US adults were smokers and today fewer than 12% smoke on a regular basis. Youth smoking rates have also declined dramatically. In recent years fewer than 5% of high school students report smoking on a regular basis. In my high school class (1966) the smoking rate was probably closer to 30%. As encouraging as these numbers are, there is no acceptable rate of smoking, and I hope those of you who don’t smoke will pass this article on to family or friends who do. 

The Power of Nicotine Addiction

Nicotine, the primary addictive substance in cigarettes, is remarkably potent. When inhaled, it travels to the brain within seconds, where it stimulates the release of dopamine, a neurotransmitter that creates a feeling of pleasure and relaxation. Over time, the brain rewires itself, craving nicotine to maintain these pleasurable effects, leading to dependency.

The addictive nature of nicotine makes quitting extremely difficult, as withdrawal symptoms, including irritability, anxiety, difficulty concentrating, and intense cravings, can deter many smokers from quitting. Nicotine also increases heart rate and blood pressure, contributing to the stress-relief paradox: although many smokers feel cigarettes help them relax, the substance actually exacerbates stress on the cardiovascular system.

Smoking can be tied to our daily routines. Some people have commonly have a cigarette with morning coffee or after meals. Other people reach for a cigarette when they’re on the telephone. Social settings and peer influence can make quitting difficult. Attending social gatherings where smoking is common can reignite cravings. A smoker who decides to quit can feel surrounded by the temptations to resume smoking.

There are a number of other factors also that make it difficult to quit smoking. There’s a lack of immediate health benefits noted.  Improvements like better lung function, reduced cancer risk or long terms outcomes are not noted right away. Some smokers fear weight gain more than they fear the effects of smoking and will delay any attempts at cessation because of that. Some smokers also feel frustration because after a few days without a cigarette they think “I don’t feel any better, what’s the point?”

Health Risks: Nicotine and Smoke by-products

Cigarette smoke contains over 7,000 chemicals, many of which are toxic. Among these are tar, carbon monoxide, formaldehyde, and heavy metals like cadmium and lead. Some chemicals are carcinogens, contributing to the development of cancer, while others damage tissues and organs in less visible but no less harmful ways.

  • Cardiovascular disease: Smoking increases the risk of heart attacks, strokes, and peripheral artery disease. It contributes to the buildup of plaque in arteries, restricting blood flow and forcing the heart to work harder. Among smokers greater than age 40, more than 50% develop cardiovascular disease and they’re more than twice as likely to die from cardiovascular events compared to non-smokers.
  • Congestive heart failure: Nicotine triggers release of adrenaline which increases both heart rate and blood pressure, putting more strain on the heart. Carbon monoxide from cigarettes binds to hemoglobin reducing the oxygen carrying capacity of the blood. Plaque buildup from coronary artery disease as well as myocardial fibrosis, scarring in the heart tissue, both lead to impaired cardiac function. Quitting smoking can significantly lower the risk of death from heart failure related complications.
  • Chronic obstructive pulmonary disease (COPD): Smoking damages the lungs, leading to chronic conditions such as emphysema and chronic bronchitis. Over time, lung capacity declines, making breathing progressively more difficult.  Even with smoking cessation, lost lung function cannot be fully recovered. It is vitally important that anyone with pulmonary disease quit smoking as soon as possible.
  • Cancer: Tobacco use is responsible for roughly 80% of lung cancer cases. It is also linked to cancers of the mouth, throat, esophagus, pancreas, bladder, and cervix, among others.
  • Diabetes: Smoking increases the risk of type 2 diabetes by around 30 to 40%. Smokers with diabetes are much more likely to experience complications such as heart disease and kidney failure.
  • Reproductive health issues: Smoking affects fertility in both men and women. Pregnant smokers are at higher risk for miscarriage, preterm delivery, and having low-birth-weight infants.

The Benefits of Quitting Smoking

It’s never too late to quit smoking, and the benefits begin almost immediately after quitting.

  • Within 20 minutes: Blood pressure and heart rate start to normalize.
  • Within 12 hours: Carbon monoxide levels in the blood drop to normal, improving oxygen flow.
  • Within weeks: Lung function improves, and circulation begins to return to normal.
  • Within months to a year: Coughing and shortness of breath decrease, and the risk of heart disease drops significantly.
  • Within five years: Stroke risk drops to that of a non-smoker, and the risk of certain cancers is cut in half.
  • After ten years or more: The risk of lung cancer is about half of what it would have been had the person continued to smoke.

The Deceptive Appeal of Vaping

Unfortunately, the rise of e-cigarettes, also known as vaping, has emerged as an alternative to smoking among many people. E-cigarettes deliver nicotine through vapor rather than smoke. While they eliminate some of the harmful byproducts like tar and carbon monoxide, vaping is not without risks. Some vaping products contain toxic materials not contained in tobacco. Especially custom or self-blended cartridges for vape pens that may have carcinogenic or otherwise harmful additives not readily obvious to the user. Unfortunately, many adolescents and young adults who have never smoked cigarettes have developed a nicotine addiction through e-cigarette use.

Conclusion

There is no safe level of use of tobacco or other forms of nicotine.  Quitting smoking improves quality of life, reducing the frequency of respiratory infections and improving overall energy levels. For long-time smokers, the prospect of reversing years of damage may seem daunting, but research consistently shows that health outcomes improve at any point, even decades after quitting.  If I could give my smoking patients only one piece of medical advice it would be: “Quit smoking and quit now”.  And I know how hard it is. I quit smoking 53 years ago and for many years afterwards it remained a daily struggle. But eventually, with the help and support of my family I was able to get past my tobacco cravings.

Vaccinations for Older Adults

By

On October 14, 2024

In Medicine

 What You Need to Know

As we age, our immune systems naturally weaken, making us more susceptible to infections and illness. For senior citizens, staying healthy can sometimes be a challenge, but one of the most effective ways to protect yourself is through vaccinations. In this article, we’ll explore the key vaccines that are especially important for older adults and discuss why staying up to date with them can have a significant impact on your health and quality of life.

Why Vaccines Matter for Seniors

Vaccines are not just for children. In fact, as we get older, some vaccines lose their effectiveness, and the risks of certain diseases increase. Conditions such as pneumonia, shingles, and flu can become more severe in older adults, leading to complications like hospitalization or even death.

Additionally, some seniors may have underlying health conditions like diabetes, heart disease, or chronic lung disease, which further increase the risks associated with preventable infections. Vaccinations help reduce these risks by boosting your immune system and offering protection against specific diseases.

Key Vaccines for Senior Citizens

  1. Influenza (Flu) Vaccine: The flu is not just an inconvenience, it can be dangerous, particularly for people over 65. Every year, the flu leads to serious complications in seniors, including pneumonia. The CDC recommends that everyone 65 and older get a high-dose flu vaccine annually, as it is formulated to better stimulate the aging immune system. Even if the flu vaccine doesn’t entirely prevent infection, it often reduces the severity of the illness. Remember, the Spanish Flu pandemic of 1918-1920 was one of the deadliest of all time with estimates of death ranging from 17 to 50 million with some estimates as high as 100 million.
  2. Pneumococcal Vaccine: Pneumococcal diseases, such as pneumonia, meningitis, and bloodstream infections, are significant threats to older adults. The CDC recommends two types of pneumococcal vaccines for those 65 and older:
    1. PCV20 or PPSV23: Typically given once, offering broad protection against the most common strains of pneumococcus.  If you have never been vaccinated, the PCV20 is the main recommendation.
    1. PPSV23: If PCV15 was given initially, a dose of PPSV23 should be given at least one year later.  If you had the older PCV13 (but not PCV15), your physician may recommend the PCV20 for additional coverage. The combinations of pneumococcal vaccines can be confusing, so check with your physician.
  3. Shingles Vaccine (Herpes Zoster): Shingles is caused by the reactivation of the chickenpox virus (varicella-zoster) and is more common and severe in older adults. The shingles vaccine, Shingrix, is recommended for adults over 50 and is given in two doses. Shingrix provides strong protection against shingles and its most serious complication, postherpetic neuralgia (PHN), a painful condition that can last for months or even years after the rash disappears.
  4. Tetanus, Diphtheria, and Pertussis (Tdap): Every adult should receive a Tdap booster, which protects against tetanus, diphtheria, and whooping cough (pertussis). For seniors, a Td booster is recommended every 10 years to maintain protection. Tetanus can enter the body through cuts or scrapes.  Both pertussis, which is increasing in incidence, and diphtheria, which is extremely rare, can be serious, or fatal, for older adults.
  5. COVID-19 Vaccines and Boosters: While the pandemic has become more manageable, COVID-19 still poses a threat, especially to older adults. COVID vaccines and boosters have significantly reduced severe illness and hospitalization. Unvaccinated patients are 2.5 times more likely to die from a COVID-19 infection than are the vaccinated.  The discrepancy is even higher among older patients. The CDC continues to update its guidelines for boosters, so it’s important for seniors to stay current with recommendations, especially if they have underlying   conditions. 
  6. Respiratory Syncytial Virus (RSV) Vaccine: RSV is a common virus that can cause severe respiratory illness in older adults.  It is recommended for most adults beginning at age 60.  Consideration should be given to vaccinating younger adults with chronic heart or lung disease, diabetes, or a weakened immune system due to cancer or chronic immunosuppressant medications.  

The Benefits of Staying Up to Date

Vaccinations for seniors are about more than just preventing illness. They help reduce the severity of disease, prevent complications, and decrease the likelihood of hospitalization. Staying current with vaccines also has a community benefit.  By protecting yourself, you help limit the spread of contagious diseases to more vulnerable populations, including those with weakened immune systems.

Talk to Your Healthcare Provider

As always, it’s essential to consult with your healthcare provider before getting vaccinated, especially if you have underlying health conditions. Your doctor can help you determine which vaccines are most appropriate for you based on your age, medical history, and lifestyle.

Conclusion

Vaccinations are a critical part of staying healthy as we age. By keeping your vaccines up to date, you not only protect yourself but also contribute to the overall health of your community. If you’re unsure about which vaccines you need, schedule an appointment with your healthcare provider to discuss a vaccination plan that will keep you protected for years to come. Remember: Prevention is the best medicine, and vaccines are a simple, safe, and effective way to reduce the risk of serious illness as we get older.

Understanding Vitamins, Supplements, Herbal Preparations, Patent Medicines, and Homeopathic Medications

By

On October 4, 2024

In Commentary, Medicine

What you should know.

The cost of prescription medications is almost constantly in the news. It has even become a topic of debate in the current presidential elections. Americans spend over $500 billion annually on prescription medications. This includes drugs covered by insurance, and out of pocket costs and specialty drugs for chronic conditions.

But this is not the only expense Americans have for drug related health care items. Almost $90 billion a year is spent on nonprescription preparations.

The shelves of pharmacies, health food stores and convenience stores are lined with a vast array of vitamins, supplements, patent medicines, herbal preparations, and homeopathic medications. They are also available from hundreds of online sources, both reputable and of questionable origin.

 Many people turn to these products in the hope of improving their health, boosting their immune systems, or addressing specific ailments. However, the development, testing, approval processes, and regulation of these products can be confusing, even for the most educated consumer. We will delve into each of these classes of health products, exploring how they are developed, tested, and regulated, and highlighting some potential drawbacks of which you should be aware.

Vitamins and Dietary Supplements

Development and Testing

Vitamins and dietary supplements include a broad range of products such as vitamins, minerals, amino acids, and other nutritional components. These products are typically developed through a combination of scientific research and commercial interest. Manufacturers may isolate nutrients from food sources or create them synthetically. Testing often involves ensuring that the products contain the stated ingredients in the correct amounts. However, unlike pharmaceuticals, these products are not usually subject to rigorous clinical trials to prove efficacy and safety before they are marketed.

Approval Process

In the United States, vitamins and dietary supplements are regulated by the Food and Drug Administration (FDA) under the Dietary Supplement Health and Education Act (DSHEA) of 1994. Under DSHEA, manufacturers are responsible for ensuring the safety and labeling of their products before they reach the market. However, the FDA does not approve dietary supplements before they are sold. Instead, the FDA can take action against any supplement that is found to be unsafe once it is on the market.

Drawbacks

One of the primary drawbacks of dietary supplements is the lack of pre-market approval, which means that the burden of proving safety is often on the consumer or the FDA post-market. This can lead to situations where unsafe or ineffective products remain on the market until sufficient adverse events are reported. Additionally, the quality of supplements can vary widely between manufacturers, and contamination with other substances is a known risk. Although, given the competitive nature of these products and the number of distributors, questionable products are usually forced out of the market early.

Herbal Preparations

Development and Testing

Herbal preparations include products made from plants or plant parts, used for their supposed medicinal or therapeutic properties. The development of these products is often rooted in traditional medicine practices, although modern herbal preparations may undergo some degree of scientific research. Testing for herbal preparations can vary widely; some are backed by clinical studies, while others rely on anecdotal evidence or traditional use.

Approval Process

The FDA considers herbal supplements as foods, not medicines. So, they are not subject to the same testing, manufacturing, and labeling standards and regulations as medicines.

This means they do not require pre-market approval by the FDA. However, in other parts of the world, such as Europe, herbal products may undergo more rigorous testing and regulation.   All herbal products that display an intended use must be accompanied by a box warning stating: “These statements have not been evaluated by the Food and Drug Administration.  This product is not intended to diagnosis, treat, cure or prevent any disease.”

Drawbacks

 The primary concerns with herbal preparations are the variability in potency and the potential for contamination or adulteration with other substances. Additionally, the lack of standardization in the preparation of herbal products can lead to inconsistent effects. Herbal supplements, unlike medicines, do not need to be standardized to make sure of batch-to-batch consistency.  Some herbs can also interact with prescription medications, leading to adverse effects.

Homeopathic Medications

Development and Testing

Homeopathic medications are based on the principle of “like cures like,” where substances that cause symptoms in a healthy person are believed to cure similar symptoms in a sick person when taken in highly diluted forms. The development of homeopathic remedies typically involves diluting a substance repeatedly until little to no trace of the original substance remains.

While counterintuitive, homeopaths believe that a homeopathic medicine is more powerful the more times the active ingredients have been diluted.    A 6X potency indicates that the drug has been diluted at a ratio of 1 to 10 for a total of six times.   A C potency means the dilution ratio is 1 to 100.  The higher the numeral, the lower the concentration of active ingredients in the medicine. 

Testing in homeopathy is controversial, as traditional scientific methods, such as randomized controlled trials, often find no evidence that homeopathic remedies are more effective than a placebo.  Some supporters claim that homeopathic remedies are developed for a specific patient making general testing irrelevant.

Approval Process

 In the U.S., homeopathic medications are subject to regulation by the FDA under a different framework compared to dietary supplements. Historically, these products were allowed to be sold without pre-market approval as long as they were prepared according to the guidelines of the Homeopathic Pharmacopeia of the United States (HPUS) and the FDA’s Good Manufacturing Practices.  All products are required to be clearly marked as “homeopathic”.  In recent years, the FDA has increased scrutiny of homeopathic products, particularly those marketed for serious conditions, or containing potentially harmful ingredients, as well as those for eye conditions, and all homeopathic injectables.

Drawbacks

The major drawback of homeopathic medications is the lack of scientific evidence supporting their efficacy. Most scientific reviews and clinical trials have found that homeopathic remedies do not perform better than placebos. Moreover, because homeopathic products are so highly diluted, they are generally considered safe, but they may delay patients from seeking effective medical treatments for serious conditions.

Patent Medicines

History and Evolution

Patent medicines have a colorful history. They began in the 19th century and were popular into the early 20th century before evolving into the over-the-counter industry that we now know. This class includes many modern over the counter medications produced by reputable drugs companies and also medications of dubious quality and effectiveness produced in garages and basements.

In the late 19th and early 20th centuries, medicine wagons and medicine shows became popular vehicles for the promotion and sale of patent medicines. These traveling shows often combined entertainment with health claims, featuring acts such as music, magic tricks, and even wild west performances. At the center of the spectacle, a charismatic “doctor” or salesman would tout the benefits of their patent medicine—a proprietary formula claimed to cure a wide range of ailments.

Patent medicines of this era were largely unregulated, and their ingredients were often a secret. Some contained alcohol, opium, or other stimulants, which provided temporary relief or a placebo effect. Because there were few laws governing their production and sale, these concoctions could be marketed without scientific proof of their efficacy or safety.

Medicine shows traveled to rural and urban areas alike,  attracting customers who had little access to conventional medicine, particularly those in remote regions. Unfortunately, these products were often ineffective or even dangerous. The rise of the Pure Food and Drug Act of 1906, which required the labeling of ingredients and restricted misleading claims, signaled the decline of these shows and the broader patent medicine industry.

A few of the original patent medicines stayed on the market until the late 20th century. The most famous of these was Carter’s Little Liver Pills which was touted for curing headaches, constipation, dyspepsia and biliousness. Lydia Pinkham’s Vegetable Compound which was sold for “female complaints “, is still on the market though it has been significantly reformulated. A number of medications on the market now could be considered as the descendants of early patent medicines, perhaps the best known of these is Geritol

Approval Process

Modern patent medicines fall into the category of over the counter (OTC) drugs.  Preparation of these medicines must either follow a monograph established by the FDA (essentially a recipe book) or undergo New Drug Application (NDA) process.   All patent medicines must comply with strict labeling standards and include accurate ingredient lists, dosage instructions, and warnings. Any health claims must be supported by scientific evidence.

Drawbacks

There are several drawbacks to over the counter (patent) medications. There’s a significant risk that people may intentionally take more than the recommended doses. This is particularly dangerous with some medications such as Tylenol which can lead to liver damage. People may use medications for a longer than the recommended period.  They may also be used in an attempt to treat conditions for which they are not intended. They may mask symptoms of a more serious condition leading to a delay in seeking appropriate medical care.

Conclusion

Vitamins, supplements, herbal preparations, patent medicines and homeopathic medications each occupy a unique space in the health and wellness industry. While they offer consumers more choices in managing their health, the differences in how these products are developed, tested, and regulated are significant. As a consumer, it’s essential to be informed about these differences to make safe and effective choices.

I’d like to thank my friend Steve Kaplan, a Registered Pharmacist, who is also my coauthor for this post.

A Simple Guide to Understanding Common Blood Tests

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On September 21, 2024

In Medicine

Introduction

Blood tests are a common part of both health maintenance and diagnostic visits.  Doctors order blood tests to assess and monitor various aspects of a patient’s health. Blood tests can help detect illnesses, confirm a diagnosis, or monitor ongoing health conditions. For example, a complete blood count (CBC) checks for conditions like anemia or infection, while a lipid panel measures cholesterol levels to aid in assessing heart disease risk. Blood tests can also monitor organ function, such as the liver and kidneys, ensuring they are working properly. They are used to track how well treatments, like medications, are working, or to detect side effects that might not be immediately apparent. Additionally, blood tests provide crucial information about electrolyte levels, hormone balances, and metabolic activity, helping doctors make informed treatment decisions. Overall, these tests give doctors a detailed look at the body’s internal functions, often identifying potential issues before they become more serious or even apparent.

Understanding Normal Ranges

Before discussing the individual tests, let’s look at how you should go about understanding the results that are being presented. Blood tests are reported quantitatively, that is the results are shown as numbers. Along with the value for your individual test you will find the reference range. This is the range of normal values from low to high established by the lab. It can vary slightly from lab to lab. Values from one lab are not always directly comparable to those of another.  Individual labs may also change their reference range from time to time.

How are these normal ranges established? They are established through population studies that consider large samples of healthy individuals and look at factors like sex, age and ethnicity. The standard normal values are developed using a bell-shaped curve. “Normal” is usually defined as those test results that fall within two standard deviations of the mean, that includes about 95% of all results. This leaves about 5% of the normal healthy population with test results that will be slightly outside the normal range presented. That’s why it’s important to discuss your individual results with your doctor to get a better understanding of where you fit in the normal range and whether a minimally abnormal result is of true clinical significance.

Commonly ordered blood tests

1. Complete Blood Count (CBC)

A CBC measures the different components of your blood, which includes:

  • Red Blood Cells (RBCs): These carry oxygen from your lungs to the rest of your body. Low levels could indicate anemia.  There are also several conditions that can cause elevated levels.
  • White Blood Cells (WBCs): These help fight infections. If they’re too high, it might mean an infection, inflammation, or other conditions such as leukemia.
  • Hemoglobin: This is the protein in red blood cells that carries oxygen. Low hemoglobin often points to anemia which can be caused by several underlying problems.
  • Hematocrit: This is the percentage of red blood cells in your blood. It helps to diagnose anemia or dehydration.
  • Platelets: These help your blood clot. Abnormal levels can lead to excessive bleeding if levels are low or excessive clotting problems if levels are high.

Why it’s important: CBC is a key test to diagnose infections, anemia, or clotting issues.

2. Comprehensive Metabolic Panel (CMP)

A CMP checks the body’s metabolism and organ function. It includes:

  • Electrolytes: Sodium, potassium, and chloride are vital for nerve and muscle function. Abnormalities can cause weakness or heart arrhythmias.
  • Blood Urea Nitrogen (BUN) and Creatinine: These measure kidney function. High levels may indicate kidney disease.
  • Glucose: Blood sugar levels; important for diagnosing diabetes.
  • Liver Enzymes (ALT, AST): Elevated levels can indicate liver damage.
  • Albumin: A protein made by the liver; low levels may be associated with liver or kidney disease or other metabolic disorders.

Why it’s important: The CMP gives a broad view of how your liver, kidneys, and metabolism are functioning.

3. Thyroid Panel

The thyroid panel includes:

  • Thyroid-Stimulating Hormone (TSH): Signals the thyroid to produce hormones. High TSH often means low thyroid activity (hypothyroidism), while low TSH can indicate overactivity (hyperthyroidism).
  • T3 and T4: These hormones regulate metabolism. Abnormal levels can affect energy, weight, and mood.

Why it’s important: Thyroid issues can cause fatigue, weight changes, and mood disturbances; this panel helps evaluate the cause of those conditions.

4. Hemoglobin A1C

This test measures your average blood sugar levels over the past 2-3 months. It’s used to:

  • Diagnose diabetes: An A1C of 6.5% or higher from most reference labs indicates diabetes.
  • Monitor diabetes: For people with diabetes, it helps gauge how well blood sugar is being controlled.

Why it’s important: A1C is crucial for diagnosing and managing diabetes, as it provides a long-term view of blood sugar control.  A1C will be discussed in more detail in a future article on diabetes.

5. Vitamin D Levels

Vitamin D helps regulate calcium and phosphate, which are important for bone health. Low levels are common and can lead to:

  • Bone weakness: This can cause conditions like osteoporosis.
  • Fatigue and muscle pain.

Why it’s important: Many people are deficient in vitamin D, and low levels can increase the risk of bone fractures and other health issues.

6. Vitamin B12 Levels

Vitamin B12 is essential for nerve function and producing red blood cells. A deficiency can cause:

  • Fatigue and weakness: Low B12 can lead to anemia.
  • Nerve damage: Tingling, numbness, or memory problems may occur with long-term deficiency.

Why it’s important: Identifying B12 deficiency is key, especially in older adults, as it can prevent neurological and cognitive problems.

7. Prostate-Specific Antigen (PSA)

PSA is a protein produced by the prostate gland. High levels of PSA can indicate:

  • Prostate cancer.
  • Benign prostatic hyperplasia (BPH): An enlarged prostate, which is common as men age.
  • Prostatitis: Inflammation or infection of the prostate.

Why it’s important: PSA is used primarily for early detection of prostate cancer, especially in men over 50.  PSA will be discussed further in a future article on prostate cancer.

8. Cholesterol Panel (Lipid Panel)

This test measures fats in the blood, including:

  • Total Cholesterol: High levels indicate increased risk of heart disease.
  • Low-Density Lipoprotein (LDL): Often called “bad” cholesterol, high LDL can lead to plaque buildup in arteries.
  • High-Density Lipoprotein (HDL): Known as “good” cholesterol, HDL helps remove LDL from the arteries.
  • Triglycerides: Another type of fat that, when elevated, raises the risk of heart disease.

Why it’s important: Monitoring cholesterol is crucial for heart health, as high cholesterol is a major risk factor for heart disease and stroke.

Significance of Abnormal Results

Abnormal test results don’t always mean something immediately serious, but they can be early warning signs. For example:

  • High glucose or A1C: Could indicate diabetes or prediabetes.
  • Low red blood cells or hemoglobin: Suggests anemia, possibly from iron deficiency or chronic disease.
  • High liver enzymes: May indicate liver inflammation or damage, possibly from alcohol use or infections like hepatitis or overuse of medications such as acetaminophen.
  • High PSA: Could be a sign of prostate cancer, but it could also result from less serious conditions like an enlarged prostate or a prostate infection.

Review your blood tests with your doctor. The better you understand your individual results, the better you can participate in your own health management. This knowledge can be empowering when choosing the health care plan that is best for you.

The Grumpy Doc says see your doctor and ask questions. Your doctor should never be offended by questions; they will be glad you are taking an active interet in your health care. Take a written list of your concerns with you so you don’t forget what you wanted to ask. Even The Grumpy Doc occasionally forgets things (as difficult as that may be to believe).

Dr. Google Will See You Now (Revised)

By

On September 3, 2024

In Commentary, Medicine

There are few words that cause more trepidation among doctors than having a patient start off a visit by saying, “I was reading on the internet”. It’s not that we don’t want our patients to be well informed; a knowledgeable patient is an important part of successful health care.  It is what we call the therapeutic alliance.

What we worry about is what they may have been reading on the Internet. There is a lot of good information available, and I always encourage my patients to learn as much as they can about their own health issues. There are many professionally researched and peer reviewed medical websites. They include such commercial sites as Medscape and WebMD. They also include patient advocacy sites such as the American Diabetes Association and the American Heart Association. And, of course, there are the government sites such as the Centers for Disease Control and the National Institutes of Health. All these present the best available science and benefit from rigorous research and review.

That is not to say that they won’t change. Science evolves and knowledge improves. What is our best knowledge now may at some point in the future be proven wrong.  However, your best chance of getting solid information is on these well documented sites.

What I worry about are the undocumented or unverified websites that provide what can best be called rumor or conspiracy.   Any time a patient tells me,” I was reading on the Facebook page “The Truth About….,” I cringe.  Any Facebook page entitled “The Truth About…” is unlikely to contain much truth.   

False information takes on a life of its own on the internet. The big lie almost always buries the truth. Long after the article that was the basis for a false claim linking the MMR vaccine with autism was withdrawn by the British medical journal The Lancet, and long after the physician who wrote the article was found by the British General Medical Council to have falsified the data and long after he lost his medical license, the study is still quoted by many anti-vaccine people as being a fundamental truth.

Even when the authors of such false information repudiate it, people still believe it. It becomes part of the legend that “they” forced the author to remove it. No one ever explains who “they” are or why “they” want to keep the public in ignorance. Of course, there is never any source documentation or research reference.

The websites espousing false medical information may be second in number only to those espousing false political information. At times it seems that the more outlandish the claim the more readily their adherents will believe it.  It doesn’t even seem to matter that this type of information is frequently published anonymously. You would think the readers would wonder why a person in possession of such great knowledge would refuse to take credit for it. They will frequently require you to make a purchase or enter a credit card number before you’re allowed in on the secret. Clear references from reliable sources are almost always absent. If they do refer to reliable sources, check and make sure their claims are actually backed up on the site they reference.

How do you evaluate reliable medical websites?  First, they should have clear authorship; the site should identify the author(s) and their credentials. There should be frequent updates. Health information should be current. You should look for a publication or review date. There should be clear citations as reliable sites will provide references for their information. The site should be objective in tone; the content should be balanced and should not be focused on selling you something. And finally, reputable sites will have clear privacy policies on how they handle user data.

In summary, I want all my patients to be well informed and take an active interest in their health care. I encourage you to Google any medical questions you have. Just be sure that what you are reading is accurate and verified and scientifically based. Are the authors, their qualifications, and their affiliations clearly identified? Are reliable references cited?  Has the article been peer reviewed by experts in the field? Is the article little more than a cleverly prepared sales pitch?  Don’t allow conspiracy theories and “crackpot science” to have a detrimental effect on your health.

If in doubt, ask your doctor. If you don’t trust your doctor to give you factual information and prefer to consult with anonymous pseudo medical websites, then perhaps it’s time to find a new doctor.  But please, think twice before disregarding the advice of someone whose entire professional life is dedicated to your good health.

Understanding Medical Care Guidelines

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On August 7, 2024

In Commentary, Medicine

An important discussion to have with your physician.

Trivia question: What are medical guidelines?  Are they rules we must follow or are they simply suggestions or are they something in between?

As we get older and have more frequent visits to the doctor, we are bound to hear one of them say, “according to the guidelines”.   To understand how the guidelines apply to you, it is important to know how and why they are developed.   You also need to know if there are ever times when you shouldn’t follow them.

At the end of this article, I’ll tell you about my experience with one specific guideline, and how strictly following it possibly could have led to a bad outcome for me. But first, let’s learn a little more about medical guidelines.

Medical care guidelines, also called clinical guidelines, come in two general classes. There are guidelines for preventative care and guidelines for the management of disease processes.

Guidelines have several goals. They are intended to improve public health by recommending evidence-based preventive and treatment measures to help reduce the incidence and severity of disease and improve overall public wellbeing. They’re designed to optimize resource utilization by preventing unnecessary treatment and screening tests. They are also intended to reduce health care disparities by ensuring that all recommended treatments are widely available and are based on the most up-to-date evidence so that health care across the nation is at a uniformly high level of quality.

Sources of Guidelines

Preventative care guidelines have to do with such things as cancer screening, cardiovascular health, vaccinations and immunizations, and lifestyle improvement such as diet and exercise recommendations. Disease management guidelines are developed to ensure the best possible treatment for diseases such as hypertension, diabetes and pulmonary disease.

Guidelines are developed by physician groups such as the American College of Physicians and the American Academy of Pediatrics. They are also developed by advocacy groups such as the American Cancer Society and the American Diabetes Association. Government organizations such as the Centers for Disease Control and Prevention and the National Institutes of Health also develop and promulgate medical care guidelines.

The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in prevention and evidence-based medicine. They issue recommendations on a wide range of preventive services including screenings, counseling and preventative medications. The USPSTF rates medical care recommendations from Grade A, those with a high certainty of substantial benefits, all the way to Grade D, those services that are not recommended due to having no benefit or having harm that outweighs benefits.  Their recommendations can be viewed at www.uspreventiveservicestaskforce.org.

Preventative care guidelines

 Preventive care guidelines are designed to help identify and mitigate potential health issues before they become significant problems.   They help to ensure adequate screening for significant disease processes. They are also designed to help avoid unnecessary screening which may lead to unnecessary treatment and cost.

Preventative care guidelines include such things as mammogram recommendations, colonoscopy recommendations, blood pressure and cholesterol screening, and prostate cancer screening.  Preventative care guidelines also include recommendations for vaccinations both for children and adults. Recommendations on diet and the use of vitamins and supplements are one area where the guidelines seem to change frequently.

Treatment guidelines

Treatment guidelines provide a roadmap for managing specific medical conditions. These recommendations encompass diagnostic procedures, therapeutic interventions, and follow-up care to ensure optimal patient outcomes.

Treatment guidelines include recommendations for such things as initiation of blood pressure management and diabetes management.  They provide recommendations for diagnostic modalities and specific medications and dosages.

For example, treatment guidelines include blood pressure levels at which medication should be started, the goal of treatment and specific medication, depending on what other medical conditions the patient may have.  Similarly, there are blood glucose management recommendations for diabetics that are tailored to specific patient populations.  The use of bronchodilators and pulmonary rehabilitation and oxygen therapy for lung diseases are also the subject of a series of guidelines.  Treatment guidelines continually evolve as new medications are developed and our understanding of disease processes improves.

Understanding the variability in guidelines.

While the guidelines developed by the various organizations share a common goal of improving patient care, their methodologies and focus areas can differ, reflecting diverse perspectives and priorities within the medical community. There’s not a single set of guidelines that are fixed across all specialties. While the various guidelines are generally in agreement, some may have slightly different recommendations for such things as the onset and aggressiveness in treating hypertension or diabetes. There may be variations in the guidelines for diagnostic testing such as mammograms or colonoscopies.  For example, the USPSTF recommends biennial mammograms for women aged 50 to 74, whereas the American College of Surgeons advises annual mammograms starting at age 45 and transitioning to biennial screening at 55. The discrepancy lies in differing interpretations of the balance between benefits and harms of more frequent screenings.

Some guidelines may also become outdated, not reflecting new medications or new treatment plans.  Even where there are variations, all guidelines strive to be evidence based, patient centered, and up to date.

Additionally, guidelines need to be individualized to meet the needs of each patient. The overall guidelines are based on the most effective health care for the population as a whole. Some patients may require specialized screening or treatment. For example, women who have a family history of early onset of breast cancer or of genetic mutations may require screening at an earlier age or more frequent screening. Men with a family history of prostate cancer at a young age or of a particularly aggressive prostate cancer may require earlier screening including biopsies or may need screening beyond the age that general guidelines recommend screening is no longer necessary.

My Experience

Several years ago, I received a diagnosis no one wants to hear. Cancer!  Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for five years.

But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.

It starts with the PSA, the prostate specific antigen.  This is something every man over 40 should know about and every man over 50 should consider getting checked.

So, what is the PSA? It is a protein that is produced by both cancerous and normal cells of the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test your family doctor can order as part of your annual work up.

What are the recommendations for the PSA? The USPSTF has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer.  Please note the phrase “consideration of screening”.  This is not a firm recommendation.

 A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer.  Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the prostate. It is possible, though unusual, that a cancer could be missed in the biopsy process

Additionally, most prostate cancer is very slow growing. Most men who have prostate cancer later in life will generally die of something else before they would die of prostate cancer.  However, a small percentage of men will have a high-grade prostate cancer that can progress rapidly and cause their death.

I’m going to use my personal experience as a way of explaining why it is important to have a discussion with your physician about guidelines.  The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a set of blood tests that we draw for people annually for their physical exam.  I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.

My PSA came back slightly elevated. Since it was a very minor elevation, I followed the guidelines and waited six months and repeated it. At that time, it increased only a small amount. The guidelines suggested repeating it again in six months. I have to admit though, I have never been a wait-and-see kind of guy. I scheduled an appointment with a urologist.

The urologist and I discussed the options. He told me that the elevation was slight, and we could wait and repeat it in 6 months or if I wished we could do a biopsy. I decided on a biopsy and then after receiving the biopsy results and having further discussions, I eventually decided on surgery.  It was my decision, as it should be, made in consultation with my physician and my family.

The post-operative pathology report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had extended beyond the capsule of the prostate. Fortunately for me it had not metastasized and had not spread to the lymph nodes, nor had it extended beyond the fat layer surrounding the prostate. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the outcome may have been different.

What’s the bottom line?

 Does my experience mean that the guidelines should be ignored?  Far from it, I made an informed decision, in conjunction with my physician, on what was best for me. Additionally, I have followed the guidelines in the management of my hypertension and high cholesterol.

Healthcare guidelines are essential in promoting preventive care and effective treatment and in helping clinicians provide high-quality, evidence-based care. But the guidelines are just that, guidelines they are not “set in stone” rules for healthcare. It’s important for you to discuss your health care with your physician.   Be an informed health care consumer. Ask how the guidelines are being used to manage your health care and how they may be affected by your family history or personal history. You and your physician should be involved in joint decision making. Your individual plan will generally follow the guidelines while having some variation based on what is the best care for you.  And that’s what the guidelines are all about, making sure we are able to provide the best possible health care for all of our citizens.

Stand Strong: Protect Yourself From Falls

By

On May 11, 2024

In Commentary, Medicine

Not too long ago I decided to spend my lunch break from the clinic by taking a walk around downtown. It was a beautiful day. It was warm, the sun was shining, and the sky was bright blue. I just started my walk when I thought I heard tires squealing behind me. I looked over my shoulder and as soon as I did, I felt my foot catch on a piece of broken concrete, and I went down hard. Fortunately, I fell right in front of my office and even more fortunately I work for the ambulance authority. Within minutes I was surrounded by paramedics and a nurse practitioner who made sure I was well taken care of. My CELLULAR watch also helped save the day. I’ll talk more about my experience later in this post but now I’d like to talk about falling in general.

Those of us of a certain age have gotten used to having every visit to any type of medical appointment include the question: “Have you fallen recently?” Even though I know the reason for this, it still annoys me. They always assume older folks are going to fall. (I think I’ve told you before, I preferred to use the term older folks or even old geezers for that matter but, I refused to be labeled as elderly.)

It’s been estimated that over 25% of older adults fall each year but probably less than half of those will report the incident to their health care provider. Once you’ve fallen your risk doubles that you will fall again. As we advance in age, falls become the leading cause of both fatal and non-fatal injuries.

Chronic medical conditions such as diabetes and heart disease can increase our risk of falling by affecting our blood pressure and causing dizziness. Some of the medications we take can have the same side effects. Also, older folks are less likely to eat or drink adequately leaving them more susceptible to dehydration and fainting. If these things are happening to you, it’s important to let your doctor know so together you come up with a plan to protect yourself.

Environmental factors also play a critical role in falls. Common hazards include loose rugs, wet floors, uneven surfaces, curbs, icy sidewalks, and dropped objects. As I found out, what would have been a simple stumble with a quick recovery when I was younger became a hard fall.

So why is that? As we age arthritis can cause stiffness in our joints which slows our reaction time. Loss of muscle mass and with it decreased core strength make it harder for us to maintain and regain our balance. Changing eyesight makes it difficult to tell where objects are in relationship to one another. As we get older, we tend to shuffle or drag our feet when we walk making us more susceptible to the uneven surfaces. I know that’s one of my major problems.

There are many resources people can use to reduce their risk of falling. I’m sure you all know about them: strength exercises, flexibility and balance classes, and regular stretching can be very helpful. There are many websites that tell you how to fall-proof your home and workspace. And of course, everyone should get a regular checkup to make sure that they don’t have undiagnosed health problems.

Now, I want to tell you about the one thing that I thought was very important for me in my fall. I’ve always been a gadget guy. A few years ago, I decided to get an Apple Watch. I like the idea of being able to get a weather report, check my e-mail, check my texts, check my calendar, and answer the phone all from my wrist. And, because I am a gadget guy, I got the one with cellular capability. I never really expected to make use of it, I just thought it seemed neat.

As competitive as the smart watch market is, I’m sure they all have similar capabilities. I’m not an expert on any of the others, but I do know about the Apple Watch, and I’d like to tell you about it. The watch comes with a fall alert and SOS system. If you fall like I did, you immediately get a notice on your phone that says it looks like you’ve had a hard fall, to which you can either respond “yes send help”, or “no I’m fine”. If you respond yes, it sends your GPS coordinates to 911. If you respond no, it asks if you’re sure, to which you again respond that you are sure and then that’s the end of it. If you do not respond at all or the watch detects you aren’t moving, it waits a few seconds and then sends your GPS coordinates to 911. I know a lot of people are concerned about technology tracking them. Well, I’m glad it does.

And now back to being a gadget guy. This is where the cellular option paid off for me. The SOS fall protection system only works when your phone and watch are in range of one another. You can only make calls from your watch when they were in range as well. Unless, you have a cellular capable watch which works independently.

I know most people think they won’t go anywhere with their watch without their phone. Well, that’s what I thought. But that day, I inadvertently left my phone on my desk. And when I fell, I couldn’t get up. I told my watch not to send my information to 911 because I was right in front of the ambulance authority. I called into the office and very quickly had all the help I could ever want. But if I had not had a cellular capable watch I would either have had to crawl into the office or lay there on the sidewalk until somebody stopped to help me. Which someone did almost immediately. So, there are Good Samaritans in Charleston.

So, my bottom-line recommendation to you is to get a smart watch, whatever type you prefer, and make sure it has cellular capability. Don’t do anything including housework, yard work, or even taking a walk at lunch that may have any risk of a fall without having your smart watch with you. As I found out, the risk of falling is greater than you think. I wish I were getting compensation for pitching this technology.

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