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Latest Posts

The Truth About Vitamins And Supplements: How To Protect Yourself

Prepared Patient Publication Logo Vitamins, herbs and other dietary supplements are sold as natural alternatives to pharmaceuticals and many people turn to them in an attempt to improve their health. Others seek supplements to lose weight or after hearing that they can help with serious medical conditions. These products are now used at least monthly by more than half of all Americans—and their production, marketing and sales have become a $23.7 billion industry, according to the Nutrition Business Journal.

What Are Dietary Supplements and How Are They Regulated?
98-year-old Bob Stewart, a retired podiatrist and senior Olympian, credits his use of supplements for his healthy aging. Writer Betsy McMillan, a mother of two now adult children, however, nearly suffered permanent liver damage due to a supplement that contained potentially fatal levels of niacin.

Unlike pharmaceuticals—which must be FDA-approved as safe and effective before they can be marketed—supplements are considered as foods by regulators and assumed to be safe until proven otherwise. Although pharmaceutical manufacturers face inspections to ensure that the right dose is in the right pill without dangerous contaminants, supplements do not undergo such intense government scrutiny.

Despite many reports of health problems, Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Treating The Common Cold

For the last week I have had a cold. I usually get one each winter. I have two kids in school and they bring home a lot of viruses. I also work in a hospital, which tends (for some reason) to have lots of sick people. Although this year I think I caught my cold while traveling.  I’m almost over it now, but it’s certainly a miserable interlude to my normal routine.

One thing we can say for certain about the common cold — it’s common. It is therefore no surprise that there are lots of cold remedies, folk remedies, pharmaceuticals, and “alternative” treatments. Finding a “cure for the common cold” has also become a journalistic cliche — reporters will jump on any chance to claim that some new research may one day lead to a cure for the common cold. Just about any research into viruses, no matter how basic or preliminary, seems to get tagged with this headline. (It’s right up there with every fossil being a “missing link.”)

But despite the commonality of the cold, the overall success of modern medicine, and the many attempts to treat or prevent the cold — there are very few treatments that are actually of any benefit. The only certain treatment is tincture of time. Most colds will get better on their own in about a week. This also creates the impression that any treatment works — no matter what you do, your symptoms are likely to improve. It is also very common to get a mild cold that lasts just a day or so. Many people my feel a cold “coming on” but then it never manifests. This is likely because there was already some partial immunity, so the infection was wiped out quickly by the immune system. But this can also create the impression that whatever treatment was taken at the onset of symptoms worked really well, and even prevented the cold altogether.

What Works

There is a short list of treatments that do seem to have some benefit. Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen, and naproxen, can reduce many of the symptoms of a cold – sore throat, inflamed mucosa, aches, and fever. Acetaminophen may help with the pain and fever, but it is not anti-inflammatory and so will not work as well. NSAIDs basically take the edge off, and may make it easier to sleep. Read more »

*This blog post was originally published at Science-Based Medicine*

McDonald’s Vs. DASH: Two Days, Two Diets

This week I’ve been trying to eat according to the DASH guidelines for lowering blood pressure. It actually hasn’t been too difficult — partly because I’m not following their strictest guidelines, which call for just 1,300 milligrams of sodium and 16 grams of saturated fat a day. I’ve been shooting for 2,300 milligrams of sodium and 22 grams of saturated fat.

In 2003, I tried a somewhat different “diet,” which in some ways was more difficult to follow, even though it only lasted one day. My son Jim (then age 11) and I ate every meal at McDonald’s for an entire day (yes, this was before Super Size Me). We recorded the experience on the Web. I thought it would be interesting to compare my day at McDonald’s to a typical day on DASH. Read more »

*This blog post was originally published at The Daily Monthly*

Gout Prevention And Vitamin C

This past month, I saw a couple of patients in the emergency department who suffered from gout. When I was a medical student at Duke in the early 1970s, we commonly encountered patients with this disease, because of epidemiological factors that clustered in the southeastern U.S. Today on the west coast, we don’t encounter it as commonly. However, for those persons who suffer from gout, it’s a big deal. An acute attack of gout, caused by uric acid crystal formation and the attendant inflammation and pain, can ruin a few days of activity, or even cause a trip to be terminated.

There are a few approaches to treating a person with an acute flare of gout. The current mainstays are administration of nonsteroidal antiinflammatory drugs (NSAIDs), such as naproxyn, or antiinflammatory drugs in the form of corticosteroids. Colchicine is less commonly used.

How does a person prevent gout? The basic tenet is to minimize uric acid production in the body, and/or to prevent its precipitation into crystals within the body’s tissues and fluids. There are risk factors associated with suffering from gout, so doing one’s best to mitigate these is the proper approach. Here are some of the commonly accepted risk factors:

1. Being obese or overweight
2. Eating purine-rich foods, although there is some controversy about this, since some researchers have identified certain purine-rich foods that, in their assessment, did not seem to be associated with an increased propensity to gout.
3. Drinking excessive quantities of alcohol. This has been recognized for centuries.
4. Elevated blood pressure
5. Lead poisoning. This is one of the reasons that we saw a certain form of gout, known as saturnine gout, when I was a medical student. Persons in the North Carolina region who manufactured moonshine whiskey using an apparatus (still) that included leaded radiators from cars suffered from gouty attacks.
6. Genetics – not much you can do about selecting your parents…
7. Kidney insufficiency or failure
8. Medication use that promotes increased uric acid in the bloodstream
9. Certain blood disorders, such as leukemia or lymphoma
10. Low thyroid function

There was recently a very interesting article that appeared in the Archives of Internal Medicine, entitled “Vitamin C Intake and the Risk of Gout in Men. A Prospective Study,” authored by Hyon K. Choi and colleagues (Arch Intern Med 2009;169(5):502-507). They sought to determine whether or not higher vitamin C intake significantly reduces serum uric acid levels, and therefore the risk of suffering from gout.

Adapted from the abstract to the article: We prospectively examined, from 1986 through 2006, the relation between vitamin C intake and risk of incidents of gout in 46,994 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain the American College of Rheumatology criteria for gout. Vitamin C intake was assessed every 4 years through validated questionnaires. During the 20 years of follow-up, we documented 1317 confirmed incident cases of gout. Compared with men with vitamin C intake less than 250 milligrams per day (mg/d), the multivariate relative risk (RR) of gout was 0.83 for total vitamin C intake of 500 to 999 mg/d, 0.66 for 1000 to 1499 mg/d, and 0.55 for 1500 mg/d or greater.

The conclusion is that higher vitamin C intake is independently associated with a lower risk of gout. Supplemental vitamin C intake may be beneficial in the prevention of gout. This is, of course, only a single analysis, so warrants further investigation by others before the assumption can be completely made that this will bear out across a larger population. Vitamin C may not really do anything to prevent a “cold,” but perhaps it is useful to prevent gout.

This post, Gout Prevention And Vitamin C, was originally published on Healthine.com by Paul Auerbach, M.D..

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.

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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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