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How Much Vitamin D Does Your Child Need?

Tanya Altmann, MD

It’s been a little while since I had a “blonde moment” during an expert interview, but this one was pretty funny. I was in the middle of a podcast with Dr. Tanya Altmann, media personality and spokesperson for the American Academy of Pediatrics, about vitamin D – when I thought I heard her say that there were now special formulas of vitamin D for incense.

I knew that Dr. Altmann practiced medicine in Southern California, so I wasn’t terribly surprised about this new method of vitamin delivery. However, I hadn’t heard about vitamin D inhalation previously, so I asked her to explain how this new incense formula worked.

She paused to gather her thoughts and then corrected me: “No, I was saying that there’s a new formula for INFANTS…”

Oh. My bad.

So here’s the rest of our delightful interview. You may want to listen to the podcast, though I did edit out the awkward “incense” section so as not to start a new cult. One doesn’t want to give others too many ideas on the Internet! I hope that Dr. Tanya won’t think less of me for that misunderstanding.

Dr. Val: What is vitamin D, and why do we need it?

Dr. Tanya: Vitamin D is an essential nutrient for your entire body. Although it’s called a vitamin it actually functions as more of a hormone, playing an important role in the immune system. Vitamin D can help to protect people against illness, diabetes, and even cancer, though its role in helping to build strong bones (and protect infants from rickets) is probably its best known attribute.

Dr. Val: Tell me about the new AAP guidelines for infants, children and adolescents. Why did they change?

Dr. Tanya: Based on data collected in several recent research studies, the American Academy of Pediatrics issued new guidelines last month which essentially doubled the recommended daily amount of vitamin D (from 200 to 400 IUs) for infants, children, and adolescents. Historically people were able to get sufficient amounts of vitamin D through sun exposure (the body can create vitamin D when the skin is exposed to sunlight), but now that we need to protect kids from sun’s harmful rays due to future skin cancer risk, vitamin D levels have dropped significantly. Sunscreen, of course, blocks the sun from stimulating the creation of vitamin D in the skin. Read more »

Joan Lunden Loves Personal Health Records

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Joan Lunden

Former Good Morning America host, Joan Lunden, is getting behind the personal health record industry. As the daughter of a physician, Joan grew up believing that she’d become a doctor one day. She told me that all that came to a screeching halt when she “realized that she didn’t like blood or stitches.” But Joan has always kept women and children’s health advocacy initiatives close to her heart.  She will soon be starring in a new Lifetime TV show called Health Corner. I caught up with her about her recent work with PassportMD.


Listen to the podcast here, or read a summary of our discussion below.

Dr. Val: Tell me about your experiences in taking care of your mom, and what led you to become involved with a PHR company.

Lunden: I lost my brother to type 2 diabetes a little over a year ago. As it happens, he had been managing my mom’s medical care, and so with his loss I needed to step in and take it over. Of course she lives on one coast and I live on the other. I’ve got 4 little kids (two sets of twins) and three young adult children. It becomes really daunting to keep track of everyone’s medical care. Around that time I met some folks from PassportMD, and when they showed me how easy it could be to keep everyone’s records in one place, I said, “this is exactly what I need.”

I think I’m really typical of a lot of women out there in what we call “the sandwich generation.” Today a high percentage of women with small children are working outside of the home. It’s really a lot to juggle – a career, raising a family, and getting everyone to the doctor on time – forget about getting YOU to the doctor on time. As good as we women are at nurturing others, we tend to be at the bottom of our own to-do lists.

What I really love about PassportMD is not just the organization (I can immediately see all my kids’ vaccination schedules for example) but the fact that I’m building a family medical history. It’s so important to know your family history so that you can engage in appropriate screening tests and take preventive health measures. This PHR even sends you reminders when its time for immunizations, mammograms, or other appropriate screening tests.

Dr. Val: As a doctor I’ve encountered resistance to PHRs from patients because they don’t want to have to enter all the data themselves. They’d like it to be auto-populated with their medical record data so that they don’t have to start from scratch. Has the PassportMD tool solved that problem?

Read more »

Unexpected Consequences: Wyeth Law Suit Could Limit Patient Access To Medications

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Bert Rein

On November 3, 2008 the US Supreme Court will hear opening arguments in the Wyeth vs. Levine case. This highly publicized lawsuit has been discussed by the New York Times and the Journal of the American Medical Association and will likely be the most important case during the upcoming Supreme Court term. However, neither source has fully explained the unexpected consequences to the consumer if Wyeth loses.

To get to the bottom of the issue, I interviewed Bert Rein, attorney for Wyeth. Bert has conducted interviews with NPR and the three major TV news networks. Please enjoy this exclusive podcast interview here at Getting Better with Dr. Val, or read my summary of our conversation below.

Dr.Val: Bert, please summarize for our listeners what has happened so far in the Wyeth vs. Levine case.

Rein: Ms. Levine is a guitarist who suffers from migraine headaches and associated nausea. One day she sought pain management therapy at a clinic in northeast Vermont – the same clinic where she regularly received care.  They elected to treat her with a combination of demerol (for pain) and phenergan (for nausea). They delivered the drugs intramuscularly, but several hours later Ms. Levine returned, complaining of an unrelieved migraine headache.

The clinic’s physician realized that the drugs would be more potent if they were injected intra-venously so he asked the PA (physician assistant) to give another dose of the drugs through Ms. Levine’s vein. Unfortunately, the PA inserted a butterfly needle (rather than the usual heplock for an IV) into what she thought was Ms. Levine’s vein, and delivered the phenergan into or near a punctured artery. Phenergan’s label clearly states that the drug can cause tissue necrosis if it comes in contact with arterial blood. Ms. Levine experienced a necrotic reaction to the medication which resulted in the eventual amputation of her arm. She sued the clinic for negligence and was awarded $700,000 dollars in a cash settlement.

Ms. Levine then brought a separate lawsuit against Wyeth, claiming that the phenergan label did not offer sufficient instructions about how to administer it safely, though the risks of necrosis from arterial blood exposure to phenergan are well known and labeled in capital letters as a warning on the drug’s label. Read more »

No One Really Knows What Most Genetic Tests Mean

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Dr. Armstrong

Genetic testing is all the rage. Thousands of tests are now available over the Internet, costing people anything from $60 to $3000 per test. While some DNA sequences are fairly well understood (like the BrCA gene or the chromosomal anomaly that causes Down’s Syndrome), most of them are only loosely associated with specific diseases and health outcomes. Experts agree that one day we’ll have a better understanding of the complex interplay of multiple gene sequences, but that day is still far off.

A recent post at GigaOM (h/t to KevinMD ) was critical of genetic testing in general, noting its potentially prohibitively expensive consequences:

Somewhere between 10 and 50 percent of autopsies reveal diseases other than the one that killed the patient. If consumers test themselves, then tell their doctors, the medical system could wind up treating 50 percent more diseases than it does today — even those that wouldn’t have killed the patient.

I interviewed Dr. Joanne Armstrong, senior medical director for Aetna, and assistant professor of obstetrics and gynecology at Baylor College of Medicine in Houston, Texas, about the current state of genetic testing. To listen to the full conversation, please click here.

Dr. Val: First of all, could you tell me a little bit about your work, and what got you interested in genetics in the first place?

Dr. Armstrong: I am the head of the Women’s Health division of Aetna, and about 8 years ago when BrCA testing (the test for predisposition to breast and ovarian cancer) became widely available, I began thinking about the educational initiatives that needed to support this testing. I knew that it would become part of mainstream medical practice and wanted to make sure that patients understood the tests and what to do about them.

Dr. Val: In your view, what are some legitimate and appropriate genetic tests?

Dr. Armstrong: There are about 1200 genetic tests available now, and most of them are not medically appropriate or clinically valid. Read more »

Actor Ben Vereen Speaks Out About His DiabetesVer

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Ben Vereen

I had the pleasure of speaking with Tony-award winning actor and Broadway star, Ben Vereen about his recent diagnosis of diabetes. Ben has had an extremely accomplished career, including recent guest appearances on NBC’s Law and Order, and ABC’s Grey’s Anatomy. He’ll appear in an upcoming Fox feature with Patti Labelle called, “Mama, I Want To Sing” so don’t miss it.

To listen to a podcast of our interview, please click here.


Dr. Val: Ben, how exactly were you first diagnosed with diabetes?


Vereen
: Unfortunately, prior to my diagnosis I didn’t recognize the signs of diabetes and didn’t understand what was causing my symptoms. I had dry mouth, frequent urination, severe thirst, sugar cravings and fainting episodes and didn’t realize they were all caused by diabetes. One day my daughter saw me pass out and she took me to the hospital. It didn’t take them long to figure out that my blood sugar was out of control. They kept me overnight and told me the next day that I had diabetes. I was shocked because I thought I was exercising regularly and eating well – it never occurred to me that I could have diabetes.

Looking back I realize that I had been told once (about 8 years ago) that I had “a touch of diabetes” but I thought it had gone away because of my good eating habits and exercise. I wish I had thought to follow up on that diagnosis and ask my primary care physician to check my blood sugar regularly.

Read more »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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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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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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