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Cardiovascular Problems? Stay Out Of The Heat

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The brutal heat wave gripping much of the country this week is unpleasant for healthy folks. For people with cardiovascular trouble, hazy, hot, humid days can be downright dangerous.

Your body shouldn’t get too hot (or too cold). If your temperature rises too far, the proteins that build your body and run virtually all of its chemical processes can stop working. The human body sheds extra heat in two ways, both of which stress the heart:

Radiation. Like water flowing downhill, heat naturally moves from warm areas to cooler ones. As long as the air around you is cooler than your body, you radiate heat to the air. But this transfer stops when the air temperature approaches body temperature.

Radiation requires rerouting blood flow so more of it goes to the skin. This makes the heart beat faster and pump harder. On a hot day, it may circulate two to four times as much blood each minute as it does on a cool day.

Evaporation. Read more »

*This blog post was originally published at Harvard Health Blog*

Beware Of Potatoes: They May Cause You To Pack On Pounds

Chips

Without meaning to, you’ve gained a few pounds over the last few years. How did that happen? Certain foods, especially the humble potato, may be partly to blame.

In a fascinating study of 120,000 healthy, non-obese women and men taking part in long-term studies of diet and health, the participants gained an average of 3.3 pounds every four years over a 13-year period. When the researchers tallied up the foods that contributed most to this weight gain, potatoes topped the list—twice:

  • potato chips
  • potatoes
  • sugar-sweetened beverages
  • red meat
  • processed meats

Other contributors to weight gain included sleeping less than six hours a night or more than eight hours, drinking alcohol, and watching television. The results were just published in The New England Journal of Medicine.

The study offered some good news and tips for losing weight, too. Foods and lifestyle choices associated with losing weight included Read more »

*This blog post was originally published at Harvard Health Blog*

The Benefits Of Participating In Clinical Trials

For several years I’ve been preaching in the pages of the Harvard Heart Letter about the importance of taking part in clinical trials. Why? Because I believe they improve medical care, telling us what works and what doesn’t. Figuring it was time to put up or shut up, I volunteered for a clinical trial. I’m glad I did—I learned a lot, received excellent care, and saw first-hand the effort it takes.

The trial was called Targeting Inflammation Using Salsalate in Type 2 Diabetes, or TINSAL-T2D for short. It was being conducted at 16 centers, including the Joslin Diabetes Center in Boston, a short walk from my office. Its aim was to see if an old drug called salsalate (a cousin of aspirin) could arrest low-grade inflammation that may—emphasis on may—make muscles resistant to the effects of insulin and eventually tip the body into type 2 diabetes.

I responded to an ad for TINSAL-T2D and, after undergoing a few preliminary tests, was accepted to take part in it. I was given a bottle of blue pills and asked to take several of them every day. No one—not lead investigator Dr. Allison Goldfine, not study nurse Kathleen Foster, and certainly not me—knew if the pills were the real thing or a placebo. I was also asked to check my blood sugar every morning, and to show up monthly for blood tests and questions galore.

I just finished my year-long stint, still not knowing whether I was taking salsalate or a placebo. I really don’t care, though I’m keen to know if salsalate worked as hoped, something I’ll learn when the results are published.

Why bother?

Read more »

*This blog post was originally published at Harvard Health Blog*

Cell Phones And Brain Cancer: Evidence Of A Link Is Limited

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If the recent announcement by the International Agency for Research on Cancer (IARC) that cell phones may cause brain cancer has you worried, you might want to wait a bit before trashing your mobile phone and going back to a land line.

Last week, the IARC convened experts from around the world to assess what, if any, cancer threat cell phones pose to the 5 billion or so people who use them. After reviewing hundreds of studies, the IARC panel concluded that cell phone use may be connected to two types of brain cancer, glioma and acoustic neuroma.

That sounds mighty scary. But the IARC said the evidence for this conclusion was “limited.” Most studies have shown no connection between cell phone use and brain cancer. In the relatively small number of studies that have observed a connection between the two, the positive result could be due to chance, bias, or confounding.

The decision puts cell phones in IARC’s Group 2B category of agents that definitely or might cause cancer. Group 1 are things like asbestos, cigarette smoke, and ultraviolet radiation. Things in Group 2B are “possibly carcinogenic to humans.” Other denizens of this group include coffee, pickled vegetables, bracken ferns, and talcum powder.

I think the IARC decision puts cell phones on notice—a formal “we’ve got our eyes on you” warning—more than it fingers phones as a cause of brain cancer. For one thing, the evidence so far is pretty weak. Writing on the Cancer Research UK Web site, blogger Ed Yong offers a peak at the data through 2009, taken from a review by Swedish researchers. A graph from the paper shows that only one of 28 studies shows a statistically significant association between cell phone use and cancer. We’ll know more about the strength or weakness of the evidence when the panel publishes its report online later this week and in the July 1 issue of The Lancet Oncology.

For now, I’m far more concerned about being rammed by someone talking on his or her cell phone while driving than I am about getting brain cancer from a phone. If you think the IARC report warrants action, the FDA offers suggestions for reducing your exposure to radiofrequency energy from a cell phone, like using the phone less, texting instead of talking, and using speaker mode or a headset to place more distance between your head and the cell phone.

*This blog post was originally published at Harvard Health Blog*

MyPlate: Spiffy New Nutritional Guidelines For Americans

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The crumbling Food Pyramid and its hip successor (MyPyramid) fell into oblivion yesterday, eroded by the stinging winds of science. Their replacement? A quartered plate called—wait for it—MyPlate that was designed to visually convey the elements of healthy eating to Americans of all ages.

The new icon consists of a white plate divided into four segments: green for vegetables, red for fruits, orange for grains, and purple for protein. Dairy has a prominent place, sitting where a glass of water should be. The hope is that the plate will nudge Americans away from meals dominated by meat and starch and towards meals made up mostly of plant-based foods.

The original Food Guide Pyramid debuted in 1992. It was built on shaky scientific ground. Over the next few years, research from around the world chipped away at the healthy eating message in the pyramid’s base (refined carbohydrates), the middle (meat and milk), and the tip (fats).

The Pyramid got an extreme makeover in 2005. Read more »

*This blog post was originally published at Harvard Health Blog*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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