Archive for Medicine

Why are so many people on chronic medications?

Posted in Medicine, Uncategorized with tags , , , , on May 16, 2008 by Dr. CJ

A recent report revealed that over half of all Americans are on at least one medication on a chronic basis.  This analysis includes children and adults.

The article cites that medications for blood pressure and cholesterol are the most common.  Note that these problems are core features of the Metabolic Syndrome which is already at epidemic levels and steadily worsening.

Best line of the article:

"Honestly, a lot of it is related to obesity," he said. "We've 
become a couch potato culture (and) it's a lot easier to pop a 
pill" than to exercise regularly or diet. 

Another epidemic problem is the overdiagnosis of and over-prescribing of medications for so-called ADHD.  That calls for a separate post, if I dare, but no one can argue that so many children need medication to get through a school day.  That’s flat-out ridiculous and more an indicator of a parent’s ability to teach discipline and maturity than a “disorder” of the child. 

Certainly, there is also an influence from public education.  For example, I frequently see people who have either learned about their risk for certain medical conditions or about medications that are being advertised for these conditions, and this bit of awareness prompts them to initiate a discussion about it. 

There’s room for a long, complicated discussion about the necessity and ethics of pharmaceutical products being used on this scale.  As mentioned previously, I encourage patients to minimize their use of medications by addressing the important health factors

People want quick fixes, and especially easy fixes.  It still amazes me, yes, but people are far more willing to pay $30-100 / month and subject themselves to risk of liver disease, muscle injury, electrolyte depletion, and other side effects than to devote themselves to a regimen of healthy eating and regular physical activity to achieve the same results.

This report also begs the question: why are the doctors prescribing so much medication?  Aside from the obvious increase in chronic medical conditions like hypertension, hyperlipidemia, and diabetes; the philosophy of the physician is put to the test when confronted with these patients, as in drug vs. fitness.

Another good reason to have pets – Pets can detect cancer

Posted in Pets, Uncategorized with tags , , , , on May 14, 2008 by Dr. CJ

My wife and I are big-time lovers of dogs.  We have a couple cats, too, but the dogs are our passion.  They are basically our kids for the time being, and they certainly demand that kind of treatment. 

I’ve often wondered what it would be like without them, but that image seems so boring to me.  As much as a handful they can be, there are innumerable moments of bliss as a dog-owner. 

I’m often reminded of a bumper sticker I once saw:

The more people I meet, the more I love my dog.

Here’s another bonus of being a pet-owner.  Just in the last several years, some anecdotes about dogs detecting cancers in their owners have surfaced and have actually prompted some research studies.  The article describes a study for bladder cancers, in which the dogs were trained to sniff the urine and were 3x more successful at detecting presence of cancer than chance alone (41% vs. 14%). 

My favorite part of that study is that one of the so-called “normals”, a healthy control subject was consistently identified by the dogs as having cancer.  Further investigation led to the discovery of a kidney cancer.

Another study demonstrated that dogs were 99 percent accurate in their identification of lung cancer  and 88 percent accurate in identifying breast cancer by breath samples.  Pretty amazing results.  They note, however, that the control subjects were all healthy, and thus it would be important to verify that the dogs could distinguish cancer from some other condition, e.g. infection.

This could be an interesting area of research, particularly if an abnormality can be identified and consistently measured in a laboratory setting. 

Lifestyle recommendations to lower your risk of cancer

Posted in Preventive Medicine with tags , , on April 20, 2008 by Dr. CJ

For what it’s worth, here is a summary of an updated report issued jointly by the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR), titled Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective

  1. Be as lean as possible within the normal range of body weight.
  2. Be physically active.
  3. Avoid sugary drinks and limit consumption of energy-dense foods.
  4. Eat mostly foods of plant origin.
  5. Limit red meat and avoid processed meat.
  6. Limit alcohol drinks.
  7. Limit consumption of salt.
  8. Aim to meet nutritional needs through diet alone.
  9. Exclusively breastfeed infacts (no other liquids) for up to six months.
  10. Cancer survivors should follow the recommendation for cancer prevention.

Being overweight or obese was found to impose a much higher risk of cancer compared to lean individuals.

I offer #11: Pick your parents wisely – family history is a big factor.

The Dalai Lama goes to Mayo

Posted in Preventive Medicine, Rants and Raves with tags , , , , on April 16, 2008 by Dr. CJ

Here’s the type of news piece that gives me a good, long laugh – another worldly figure travels across the world to get an annual physical exam at the Mayo Clinic

No doubt, the Mayo Clinic is capable of doing great things – they have specialists so specialized that they have forgotten how to treat a common cold.  Who wouldn’t want an “expert” to manage an unusual condition?  Few people have unusual conditions, though.

I’ve seen patients in my clinic who go there for their annual exam.  For some reason, they feel that getting a clean bill of health from Mayo is some kind of blessing for eternal wellness.  Mayo is, in fact, good at coordinating a ridiculous number of labs, imaging, diagnostic tests, and doctor visits into a comprehensive day-long physical exam.  They are masters at communication and planning, apparently.  However, is there any benefit to this kind of overwhelmingly thorough evaluation?

This shotgun approach to an annual health exam is a dangerous venture for a few reasons. 

  1. It’s expensive.  I’d hate to be your insurance company staring at a list of charges you rack up on that one day.
  2. It cultivates a sense of urgency to “do everything” all the time.  People love to feel pampered – talk to your insurance company or whoever is actually paying for those charges.
  3. It leads to unnecessary follow-up testing.  Not all “abnormal” results are necessarily abnormal.  But, if you go fishing for everything when there’s no focus on a particular problem, you’re going to find a lot of junk, and you won’t know how to interpret it.
  4. It’s a poor use of resources.  Common things being common, most people don’t have “rare” diagnoses that require an expert on minutiae.  In an ideal world, we could find a way to maximize the efforts of the highly-specialized physicians who really don’t need to be dealing with routine conditions that could be managed by any other competent physician.  Do you need a world expert on obesity and metabolism to tell you that you need to eat better and exercise more? 

I don’t question their value in managing rare or difficult-to-treat conditions, but for the average individual it’s a complete waste of time and money.  It’s all about perspective – the things that are going to kill you are staring you in the face every day and are simple to manage.  There’s nothing glamorous about searching high and low to come up with weird explanations for common problems. 

Then again, I don’t know Buddha’s take on health.

Reduce risk of heart disease with the Polypill

Posted in Heart Disease, Medicine with tags , , , on April 2, 2008 by Dr. CJ

This paper published in the British Medical Journal ranks among my favorite, but there’s an even better sequel to it that I will review next.

The concept of a Polypill was introduced in 2003 by Wald and Law as a combination of medications and vitamins that would significantly reduce the risk of heart disease in a population.  Obviously, medications are no substitute for a healthy lifestyle, as there is inherent risk to taking any exogenous substance.  Their approach, however, was a theoretical look at combining the pharmaceutical agents and vitamins that have the best evidence for lowering cardiovascular disease risk.

They focused on the following cardiovascular risk factors:

  • Hypertension (elevated blood pressure)
  • Homocysteine
  • Platelet function

Evidence of cardiovascular disease risk reduction was based on analysis of previously published results. 

  • LDL cholesterol would be treated with a statin.
  • Hypertension would be treated with a 3-drug combination of the 5 main classes of blood pressure medications (thiazide diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, and calcium channel blockers).
  • Homocysteine would be reduced with folic acid supplementation.
  • Platelet function would be addressed with aspirin.

Without going into detail about the numbers, let’s just take a look at the final analysis.  Wald and Law estimated that the cumulative risk reduction of treating all 4 of these factors by the Polypill would reduce risk of ischemic heart disease (e.g. heart attacks) by 88% and risk of stroke by 80%.

Previous studies have demonstrated that treating one risk factor has the same proportional effect (same percentage reduction) on risk irregardless of the other risk factors, so treating each risk factor does contribute an additive effect on risk reduction.

On average, they predict that this approach could result in a gain of 11-12 years of like free from heart attack or stroke for each person taking such a regimen.

Side effects from a component of this drug combination were estimated to affect 8-15% of individuals, most concerning of which would be bleeding from aspirin.

Heart disease is still the #1 cause of death in the US, and not everyone wants to take medications indefinitely to reduce their risk of heart disease.  So, who would be a candidate for this Polypill?  For individuals at relatively low risk for cardiovascular disease, there is no known significant benefit to an approach like this.  Oftentimes, the risk of side effects will outweigh benefits.  For people at high risk of heart disease, however, there may be some credence to such an approach, particularly older individuals or those with history of vascular disease.

Again, remember that this is purely a theroretical approach to reducing heart disease based on previously published studies demonstrating risk reductions of the various components of the drug combination.  In a health system that recognizes the importance of preventive medicine, this Polypill may one day become a reality.

Inhaled insulin was doomed from the start

Posted in Diabetes, Rants and Raves with tags , , on March 8, 2008 by Dr. CJ

This recent news blip about a new inhaled insulin failing caught my attention, months after the big flop of Exubera, Pfizer’s inhaled insulin product. It was meant as an alternative delivery method of insulin for individuals with diabetes mellitus who were resistant to the use of injections. Interesting idea, in theory, but in practice is a mess.

I had the delightful opportunity (read sarcasm) to discuss this product with some Pfizer pharmaceutical reps who of course were pushing it as the latest, greatest insulin product. Not to pat myself on the back, but I told them it wouldn’t catch on like they were hoping . . . for a few reasons.

  • The apparatus was apparently difficult to use. It was a clumsy-looking handheld canister, into which packets of inhalable insulin were dispersed, and then the contents of that chamber were inhaled. Dosing was very limited due to the sizes of the insulin packets, which would then require multiple inhalations to receive one “dose”. How’s that any easier?!?
  • My biggest grudge with it was that insulin is not meant to be dispensed into the lungs and thus posed grave danger. Insulin is a tumor growth factor [note: “tumor” not necessarily being a malignant process]. An example of this function in action is the deposit of tissue beneath the skin where frequent injections are performed. Why would anyone put that product in their lungs, with potential for decreased lung function and inappropriate tissue growth? * Part of my duty to my patients is to protect them from these marketing blunders. Last thing I want is a surge in lung cancer cases.

I hope my intellectual assaults on the Exubera reps played a little role in hurrying Exubera off the market. There are a few other new drugs I’ve recently heard about that should also provide me good fodder to toy with the pharmaceutical reps.

* “Growth for the sake of growth is the ideology of the cancer cell.” – Edward Abbey

Off to my physical exam

Posted in Preventive Medicine with tags , , on February 27, 2008 by Dr. CJ

You’ve probably heard the saying about how healthcare personnel (doctors/nurses, etc.) are the worst patients – rarely seek attention, rarely do the preventative exams that they encourage to patients, ignore advice when given to them.

It’s true . . . to some extent. I’ve encountered hundreds of much worse layperson patients, but there is some truth to that saying.

Well, I’ve decided to make use of the ol’ insurance coverage by scheduling a physical exam, really just to get my cholesterol rechecked. My “bad” (LDL) cholesterol has always been borderline okay, but my “good” (HDL) has definitely been low.
Now that I’ve busted my butt on diet and exercise, I’m expecting to see a significant improvement in both my HDL and LDL cholesterols. I’m expecting that all my lipid values will be in range now, including the TC/HDL ratio.

We’ll see if my advice to myself was any good.

I’m hungry . . . I always eat breakfast.

Another interesting article on doctors and their family members as patients.