Archive for the 'Medicine' category

Is simvastatin the next Baycol?

Jun 09 2011 Published by under Medicine

As the connection between elevated cholesterol and heart disease became clear, researchers looked for ways to lower cholesterol levels in humans.  A set of compounds known as HMG-CoA reductase inhibitors ("statins") were found to lower cholesterol quite effectively, although some early drugs (i.e. cerivastatin/Baycol) were found to have some disturbing side effects.  Especially when combined with other cholesterol medicines, cerivastatin had a high incidence of  serious muscle damage, much higher than other statins (along with allegations that unfavorable safety data may have been buried by Bayer).  Other cholesterol medications can also cause muscle damage but none to the extent of cerivastatin.  Still, in prescribing statins, physicians monitor patients for signs and symptoms of muscle damage.

Physicians were initially reluctant to prescribe statins, and drug companies such as Merck were quite anxious to sell them.  A lingering problem was lack of data showing that statins could prevent heart attacks and death.  The data showed that higher cholesterol levels put people at higher risk, but before 1994 there weren't good data showing a direct benefit of statins.

In 1994 The Lancet published the Scandinavian Simvastatin Survival Study (usually called "4S").  It was sponsored by Merck, the maker of simvastatin (Zocor), and is considered one of the best and most important statin studies.  Four thousand four hundred forty four patients with heart disease, high cholesterol, and being treated with a cholesterol-lowering diet were randomized to receive either simvastatin or placebo.  The results were dramatic.  They showed significantly reduced deaths in the simvastatin group, and decreased need for invasive heart procedures.  There were few safety problems.

Later studies confirmed many of the findings of 4S, and statins have become an important tool in preventing heart attacks in people with heart disease.   Other benefits have been found as well, and statins seem to have beneficial vascular effects beyond simply lowering cholesterol, but measured levels of cholesterol are still the most commonly used marker to judge the effectiveness of statins.

With all statins, a higher dose produces lower cholesterol levels, an effect that tends to taper off at higher levels (for example increasing simvastatin from 40 mg to 80 mg gives an additional drop in LDL cholesterol of about 6%).  The risk of unwanted effects such as muscle damage may also increase with higher doses, so doctors try to balance the need for lowering cholesterol with the risk of side effects.   Some of the newer statins such as rosuvastatin (Crestor) have increased potency at lower doses and appear to have a lower incidence of side effects at effective doses, but rosuvastatin is a very expensive medication.  Most other statins are available as generics for about 4-10 USD monthly.  Insurance companies have made a very strong push to encourage the use of generics, so doctors and patients are often forced to decide between paying more money, or pushing up the dose---and perhaps the side effects---of older drugs.

Today the FDA announced restrictions (consumer version) on the use of very high dose simvastatin (80 mg). Especially in combination with certain medications and in some patients, the high dose can lead to a higher risk of muscle damage.  They specifically recommended that this dose should be avoided, unless a patient has been taking it for at least a year without problems (the risk is highest during the first year of treatment).  If cholesterol cannot be controlled at lower doses, they recommend changing drugs.

This is going to cause (has already, actually) an avalanche of calls to doctors' offices.  This risk to any individual isn't terribly high, and most patients shouldn't abruptly stop their medications, but people taking 80 mg of simvastatin should ask their doctor whether it is best to keep going or to make a change.

The take home message is that statins are inexpensive, safe, and effective for the prevention of heart attacks and other serious illnesses in many groups of patients, and that it often takes years to sort out the safest approach to therapy.  If you are on a lower dose of simvastatin you should not increase it to 80 mg.  If you have taken 80 mg of simvastatin safely for over a year to control your cholesterol effectively, there is no need to abruptly stop it.  For any patient concerned about their therapy, there are many safe and effective alternatives.

(Full disclosure: I've been taking simvastatin safely for years and have no plans to change any time soon.)

6 responses so far

Old time rock and roll

Jun 08 2011 Published by under Fatherhood, Medicine

"Daddy, is that an electric guitar?"

"Yes dear, it is."

"It's cool! Is it rock and roll?"

"Absolutely."

"Daddy," she said quietly, almost conspiratorially, "don't tell anyone but I like Bob Seger more than Taylor Swift."

We drove toward her swim class, and Radio Disney was thankfully unavailable.  I put my MP3 player on shuffle, and for once, PalKid didn't freak out.  Van Morrison, The Beatles, Carole King, Elvis Costello, Daniel Lanois, Los Lobos, Miles Davis---all sorts of music poured into the car.  She didn't like it all, but she asked all the right questions.

"Is this jazz?  It sounds like jazz."

"Well, jazz and rock and roll, they're sort of cousins."

"I like the girl singers. Who's this one?"

"Her name is Norah Jones."

"She sings so pretty, Daddy."

******

We finally made it to the pool.  She was, as has been her habit lately, very clingy. A broad-shouldered swim instructor with a whistle hanging from her lips like a cigarette peeled her off of me and tossed her to the young men in the water.  As I walked away, she began to swim a damned good front crawl, breathing and all.  I haven't taken her to swimming in a long time.  The crowd of mostly young parents was dressed in everything from t-shirts to shalwar kameez and all the kids were cute, but not as cute as my kiddo.  I promised her if she comported herself well (no whining!) we would go to our favorite frozen custard place.

Thank god she did.  There's nothing like real frozen custard on a 95 degree evening, letting my daughter sit in the front seat (in park) and spin the tunes.

At home, it was time to make the beds, set up the IV, tuck in the kiddo, and that's really about all I remember until MrsPal woke me from PalKid's bed to flush the IV.

******

And medicine keeps happening.  I'm finding that in general, my patients tend to listen to me more than to quacks.  Daily, they offer me clippings or printouts of the latest miracle cures, asking if it's too good to be true.  Thanks to the research I do for my writing, and to the writing of others such as the crew at Science-Based Medicine (from which I've been sadly absent of late), I can tell them not only that it's bunk, but exactly what kind of bunk and why.  The preliminaries dealt with, we can move on to the real business of preventing and treating disease, a job that gets more fun by the day.

 

5 responses so far

Another day...

Jun 02 2011 Published by under Medical Musings, Medicine

My poor, poor blog.  So neglected.  So much quackery left un-busted.  It turns out that real life can sometimes be more consuming than other interests.  After a significantly disruptive illness, life rarely snaps back to it's previous shape, but slowly takes on new forms and habits.  I no longer have to bathe MrsPal and pack her wounds daily, but I still have to give her IV fluids and help her with medications.  I no longer have to cancel patient time to pick up PalKid or get to the hospital to visit my wife, but she's still a needly little thing (the Kid, that is), clinging to me like one of those stuffed monkeys with the Velcro hands and feet.

And of course, the needs of my patients don't change at all.  An abnormal chest x-ray is just as important no matter what else is happening in my life.  Patients have a doctor, not a team, at least not usually, and that doctor is responsible for gathering and communicating data, facilitating testing and consultations, and all sorts of other time-sensitive work.  Many jobs are like that I suppose, but from my biased viewpoint, doctoring is different.

I'm currently  having an ethical discussion with myself (not aloud) about whether I can make up a bottle of Placebo for PalKid.  At night as attention starts to focus away from her, her throat hurts, or her lip, or some other boo-boo and she wants medicine.  It seems foolish to pump her full of ibuprofen, but she sees me giving Mommy medicine and helping her feel better.  I'll probably never make up that bottle, probably never give her as much attention as she wants, but she'll probably get as much as she needs.

20 responses so far

Real outreach

May 24 2011 Published by under Medicine

It's no secret that doctors don't often look like their patients.  This simplistic observation hides a more complex set of effects: in addition to the economic problems faced by minorities seeking medical care, there is a quieter, dirtier history, one of forced sterilization, institutionalization, research abuse (and, one might argue, murder).  It should then be no surprise that when it comes to getting proper health care, minorities are often at a economic and cultural disadvantage, and have valid reasons not to trust the health care system.

For many minorities, the emergency department is the landing zone when preventable illness finally becomes impossible to ignore.  Internists like me see case after case of advanced heart disease, kidney failure, and stroke that could have been prevented with good primary care.

As a recent study has shown, when suffering signs of a catastrophic illness such as stroke, African Americans may reach out to friends before calling 911.  This is one of the many good reasons for looking into ways to bring prevention directly into trusted minority community institutions rather than waiting for minorities to seek out care that may be unavailable or alienating.

Hypertension is a potent risk for heart attack, stroke, and kidney failure, common ailments among African Americans. Investigators went to Dallas County, TX to see what effect if any outreach at black-owned barbershops might have on patrons' blood pressure.  Shops received one of two interventions: either standard pressure pamphlets, or an intervention group where patrons were screened with their haircuts and offered peer-based intervention, and encouraged to get medical follow up.

The results were both frightening and encouraging.  Forty-five percent of men screened had hypertension, and of those, only 38% had their disease under good control.  Both groups in the study had improved blood pressure control, with the more intensive intervention group experiencing a slightly greater increase in blood pressure control.

This study shows the great potential of community-based interventions for important health conditions, especially in communities with less access to standard health care.  It is important that programs like this continue to be studied for validity and strength of effect, and if widely implemented, that they remain science-based, and do not become a profit opportunity for more charlatans to prey on the poor and on minorities.

 

References

Hsia, A., Castle, A., Wing, J., Edwards, D., Brown, N., Higgins, T., Wallace, J., Koslosky, S., Gibbons, M., Sanchez, B., Fokar, A., Shara, N., Morgenstern, L., & Kidwell, C. (2011). Understanding Reasons for Delay in Seeking Acute Stroke Care in an Underserved Urban Population Stroke DOI: 10.1161/STROKEAHA.110.604736

Victor, R., Ravenell, J., Freeman, A., Leonard, D., Bhat, D., Shafiq, M., Knowles, P., Storm, J., Adhikari, E., Bibbins-Domingo, K., Coxson, P., Pletcher, M., Hannan, P., & Haley, R. (2010). Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men: The BARBER-1 Study: A Cluster Randomized Trial Archives of Internal Medicine, 171 (4), 342-350 DOI: 10.1001/archinternmed.2010.390

3 responses so far

To pee, or not to pee

May 21 2011 Published by under Medicine

Folks, I am so tired of not writing every day.  I knew with the new job I'd be cutting back quite a bit, but then with MrsPal's illness, all my writing time has gone right into the Foley bag.

By the way, a Foley catheter is not something one should try to remove on their own.  Many men and some women have had the pleasure of hosting a Foley catheter because there are times in a person's life when they may not be able to pee for themselves. This is particularly true of males.

Men are more frequently invaded by urinary catheters because of an anatomic accident, but women have their own anatomic annoyance, the urinary tract infection (UTI).  To understand how people's sexy bits can become so un-sexy, we need to learn a little anatomy (and this is about to get clinically graphic so I'm putting in a page break.  You've been warned). Continue Reading »

8 responses so far

Lessons

May 14 2011 Published by under Medical education, Medical Musings, Medicine

One of my early lessons in medicine was "listen to the nurses".  This isn't to say that nurses know everything and doctors nothing.  But we have very different knowledge sets, and it would be easy for a young medical student to simply dismiss anything told them by a "mere nurse" (in this case, "mere nurse" meaning someone who they think---often erroneously---cannot affect their grade).  Not only do nurses spend more time with the patients, but the have skills that med students need to learn.  Some of the essential skills taught to young physicians by nurses include how to draw blood and place IVs, how to turn patients, how to lift people safely.  At many hospitals special teams take care of IVs and blood draws, but many of us trained at hospitals where we were often responsible for these tasks.  During emergencies, it helps to know how to do everything---if someone's heart has stopped, waiting for the IV team would be a pretty bad idea.

In addition to the nurses, at least a dozen pregnant women taught me to place IVs.  Pregnant women often have nice, plump veins, making it easy for the novice to slip in a needle.  Getting in the needle and catheter is only a small part of it though;  you have to learn the preparation and the dance.  You have to learn how to tear the tape you need ahead of time, how to secure the IV and flush it, and all the other bits of knowledge that surround getting the needle into the vein.  Most important, you have to remember that the vein is attached to a human being, one who may be frightened and in pain, and needs your confidence, your ear, and all of your empathy and compassion.

I made it my business to learn as many of these lessons as I could.  I volunteered to start IVs and get blood from the most difficult "sticks".  I wanted to be the one people would call if they couldn't get the job done themselves.  While I rarely use these skills anymore (an excuse often tossed out by young docs who don't want to bother to learn them) I still value them, and especially now I need to send out a "thank you" to all of the doctors, nurses, techs, and patients who taught me.

This morning I hung a bag of IV fluids for my wife.  It seemed familiar.  It took me a second, but the understanding, the comfort with the process came back to me quickly.  Because of this, we can sit together at home instead of at the hospital.  This is worth every night I spent on call alone and tired, surrounded by other people's loved ones.

14 responses so far

How much would you pay to see your doctor?

May 01 2011 Published by under Medicine, Uncategorized

We pay far too much for health care in this country, spending ridiculous amounts and getting outcomes no better than countries that spend a fraction of what we do.  But most efforts at reforming the system have been aimed not toward better, more cost-effective care.

The last twenty years have seen all sorts of experiments arise in how to fund health care in the US.  One thing many of these models---such as HMOs---have in common is being loathed by patients and doctors alike.  It seems as if each new incarnation of private health insurance is designed solely to maximize insurance company profits rather than to deliver safe, timely, evidence-based care for which doctors are fairly compensated.

One of the experiments of the last ten years is so-called "boutique" or "concierge" medicine.  In this model, patients pay their doctor a retainer and in return, the doctor takes on fewer patients and uses the reduced patient load to make herself more available to her patients.  In addition to collecting the retainer, the doctor can still charge for individual visits and she or the patient can send the bill on to the insurance company.

Something about this model has always rubbed me wrong, but in truth, there appear to be few ethical problems with this model, at least in theory.  However, the model requires a pool of patients willing to put out a retainer for their care.  Is the care actually any better?  To my knowledge, this hasn't been well-studied, but I would make an educated guess that patients are in general more satisfied, but that there is no reason to expect better medical outcomes.  My diabetic patient with proteinuria should be on an ACE inhibitor whether or not I see five patients a day or twenty.

It certainly can work out well for the physician.  It is much more satisfying to care for a fewer number of patients and to make money from the choice (e.g. 250 patients paying a $1500 retainer each, plus insurance reimbursement).  But in the present economy, it can be difficult to recruit enough patients willing to shell out the bucks for this sort of care.  Some doctors have prosed a hybrid model, in which some patients are part of the concierge patients, others standard fee-for-service or HMO patients.

This model seems fraught with ethical dangers.  To have a practice where patients are inherently unequal, where a few bucks insures better treatment for some will inevitably lead to poorer care for both groups.  Concierge patients may not have the access they expect (although presumably this is set out in some sort of contract), and more important "regular" patients may end up at the bottom of the to do list, having less access to their doctor, less of their time.

In a free market, a patient unsatisfied with this arrangement can walk away.  But in reality, it is not always easy to find a primary care physician, and insurance and geography may place significant restraints on choice.

Given the failing model we currently have, where primary care doctors are reimbursed poorly and are forced to see increasing volumes, hybrid practices and other questionable models will keep popping up, and our already inequitable health care system will continue to divide us into haves and have-nots, with both groups encountering sub-standard outcomes and excessive costs.

References

Lucier, D., Frisch, N., Cohen, B., Wagner, M., Salem, D., & Fairchild, D. (2010). Academic Retainer Medicine: An Innovative Business Model for Cross-Subsidizing Primary Care Academic Medicine, 85 (6), 959-964 DOI: 10.1097/ACM.0b013e3181dbe19e

Alexander GC, Kurlander J, & Wynia MK (2005). Physicians in retainer ("concierge") practice. A national survey of physician, patient, and practice characteristics. Journal of general internal medicine, 20 (12), 1079-83 PMID: 16423094

13 responses so far

Alternative medicine: same thing, different words?

Apr 30 2011 Published by under Absurd medical claims, Medicine

When discussing the absurdity of religious disagreements, peacemakers often make the point that all religions believe in one underlying Truth or Deity, that all religions are guided by the idea that we should be excellent to each other.  I don't believe this, but it serves as a useful analogy.

In medicine, those trying to bring together science-based practitioners and alternative practitioners (or more honestly, alternative docs trying to justify their practices) often argue that we are simply using different words for the same concepts, that one person's chi is another one's "life force", "energy", or some such thing.

In religious arguments, no one can be proven wrong about who's god is the real one, but it can be pretty well determined whether or not religions "believe in" the same underlying principles.    One question deals with the unanswerable, the other with written texts and observable practices---in other words, data.  The same is true for medicine.

The idea that there is some sort of animating force travelling through channels or meridians in the body is an old one.  Sometimes the language is explicitly mystical, and sometimes it is couched in science-y words.  Chiropractors speak of "subluxations" blocking the flow of something-or-other and causing disease.  Whether such a phenomenon exists (it doesn't) is easily discovered.

Lay people very often buy in to vitalist ideas about human health. It goes well with our propensity to believe in mind-body dualism, with religious ideas of soul. People like to believe things, like to find patterns to organize their world based on their own observations, even if these observations are based on false premises.  This is why we have professionals.  We don't let anyone design a bridge, but someone who understands the physics involved.  And we shouldn't let people practice medicine if they have a fundamental misunderstanding of how the body works.

All this is in support of the premise that Dr. Oz is no longer a real doctor, but more of a mystic.  Currently his website is hosting a series on "Fighting Fat with Ayurveda".  Ayurveda is a form of pre-scientific medicine from the Indian subcontinent.  It is based on thousands of years of tradition, but has been largely abandoned by those who can afford real medicine.  It shares with other traditional systems vitalist ideas of unmeasurable life-forces.

As I read the first part of the series I am struck by two patterns.  First, it shows a supposedly real doctor (Oz) implicitly supporting disproved ideas about health and failing to give the real data. Just as disturbing is the "carnival barker" tone of the series:

Over the next several weeks, I will be sharing some of the most powerful ayurvedic secrets for removing amafrom your body and helping you achieve your weight loss resolution.

This idea that there is some secret out there for fat people, diabetics, people with cancer, or whomever, a secret so powerful yet simple, is patently absurd, yet alluring.   But what follows could have been lifted from any internet quack site.  It is a list of symptoms that supposedly tells you if you have excessive "toxins" in your body.  The whole idea of "toxins" being the cause of disease is also old, and also not based on reality.  It's not that toxic substances aren't important, it's that the word is not used the same by real doctors and quacks.

But the language!  Vey's mir, it could have been lifted from any Morgellons, chronic Lyme disease, or other fake disease websites.

The first step is to determine if you have an excessive amount of toxins in your body. If you answer “yes” to the majority of the statements below, you have an excessive accumulation of ama:

1.  I tend to feel obstruction/blockages in my body—constipation, congestion/heaviness in the head area, blocked nose, or a general feeling of non-clarity.

2.  When I wake up in the morning, I do not feel clear; it takes me quite some time to feel really awake.

3.  I tend to feel tired or exhausted mentally and physically.

4.  I get common colds or similar ailments several times a year.

5.  I tend to feel heaviness in the body.

6.  I tend to feel that something is not functioning properly in the body – breathing, digestion, elimination or other.

7.  I tend to feel lazy (i.e., the capacity to work is there, but there is no inclination).

8.  I often suffer from indigestion.

9.  I tend to spit repeatedly or have a bad taste in my mouth.

10.  Often, I have no taste for food and no real appetite.

11.  My tongue is often coated with a thick film, especially in the morning.

Everyone has some or many of these complaints at one time or another, and many of these are normal.  Most people get several colds a year.  Most people get indigestion.  These vague statements are usually designed, in my opinion, to show how "common" an imaginary problem is by making all readers victims of this excess of ama.  And on many websites, such lists, in my opinion, are simply used to draw in pigeons for the fleecing.

Believers in alternative medicine and real doctors are most certainly not talking about the same concepts using different words.  We physicians are talking about real, measurable, testable concepts; things that can be seen, touched, altered.  They are talking about imaginary energies and toxins that cannot be demonstrated to even exist, much less be manipulated to improve health.

There is a long history of real medicine, flaws and all, saving lives and improving health.  All the rest is based on dreams and greed.

16 responses so far

Brief update

Apr 28 2011 Published by under Fatherhood, Medicine, Narcissistic self-involvement

When MrsPal was young she babysat for a local doctor's family. One of her charges is now a resident at my hospital, another a successful business woman, another a teacher if I recall correctly. The father is the head of my state medical specialty society and is one of the finest doctors I know. His wife, with whom my wife shares a unique closeness, has been at the bedside nearly as much as my mother-in-law, helping with everything from showering to answering emails to keeping the flowers fresh. And my mom-in-law has spent hours every day at the bedside, keeping her daughter company, watching over her recovery.

MrsPal is still hanging out in the hospital, and I'm still learning how much work she puts into getting PalKid where she needs to be from moment to moment. If it weren't for the help of friends and family---and a very loving and loyal babysitter---I have no idea how we'd do this. My wife seems to inspire a closeness in her friends, who are in and out of her room visiting, and are constantly calling, texting, emailing, and calling me with offers of babysitting.

I had a close call today: on my way from office to hospital, PalKid's teacher called---Daisy Scouts was cancelled, and she and PalKid were hanging out doing homework. I turned the car around, grabbed the kiddo, and went to my folk's place, where we were fed and watered and generally spoiled for a while. This required missing yet another hospital shift, but my little pal is requiring a lot of love and attention at the moment.

After a good shower, I removed her nail polish (yeah, yeah...) and I'm letting her try to trim her nails for the first time. She's actually not bad at it, and doesn't need reading glasses. If I can get her to fall asleep by eleven, I'll count myself lucky. If we don't get any more thunder tonight, I'll count myself luckier.

7 responses so far

Thunder and lightning

I'd be asleep right now if a loud clap of thunder hadn't sent me bolt upright.  Fortunately, my daughter's only reaction was to mutter senselessly, turn over, and snore peacefully. She's slept with me nearly every night since her mother has been in the hospital.   She's done remarkably well with unexpected changes, even sleeping at a friend's house.  At night she mentions missing mommy, but generally she's her usual charming self.  Last night she realized she'd left her favorite pillow at her friend's house, and that broke her.  She sobbed uncontrollably for her pillow until finally, at nearly midnight, my friend came by in her PJs and dropped it off.

We stopped by another friend's house last night.  It turns out that when there's a crisis, friends are a good thing to have.  She played with the other kids and I ate sushi with the adults, two of whom she refused to believe were married because "girls don't marry girls"---except of course when they do.  She'll figure that one out eventually.

Despite her sticking to me like glue, she's getting pretty tired of a boring old adult, so I just dropped her at another friend's house to play and paint Easter eggs, so for a while at least I get a break from single parenthood.  At least it's a temporary single parenthood.  I was chatting with a colleague yesterday who recently lost his wife.  I am also even more amazed that MrsPal gets done everything she needs to in a day.  I've bent my work schedule nearly to the breaking point and it still takes all the help I can get just to get PalKid where she needs to be from moment to moment.

I don't really know yet how PalKid is processing this whole thing, except that I have a little bedfellow every night, one that despite her diminutive stature can turn a king sized bed into a small palate.

Hopefully she'll enjoy the whole Easter egg thing and come home nice and tired.  Daddy needs some sack time.

16 responses so far

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