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Are Heartburn Medicines Safe?

Almost everyday in the clinic patients ask for my take on recent studies raising concerns about Proton Pump Inhibitors (PPIs) such as Prilosec, Prevacid, and Nexium. I wrote a short article on the topic you can access through the link here

Heartburn article

 

 
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Posted by on June 4, 2016 in Uncategorized

 

Fasting Labs

Is it necessary to be fasting when you have labs drawn? The dogmatic answer has long been yes, creating an uncomfortable, inconvenient situation for patients.  They either have to return to the clinic a second time for labs or else uncomfortably fast until their doctor’s appointment. But a recent study published in JAMA Internal Medicine suggests that fasting likely isn’t necessary after all.

The study’s author looked at 3 meta-analyses (or collection of studies) and found the following:

-There wasn’t a significant difference in the cholesterol levels whether people fasted or not.

-Fasting and non-fasting lipid levels had the same predictive power for whether people would have an adverse cardiac event such as a heart attack.

For these reasons, clinical practice guidelines have changed to endorse non-fasting labs in most circumstances. The main situation when a person needs to do a fasting test is when the level of triglycerides (a type of bad cholesterol) is above 400. In this unusual circumstance, the lab should be repeated on a fasting basis.

This study’s conclusion, that people don’t need to usually fast for their labs, fits my practice. It’s news many patients will be glad to hear.

The study’s conclusions are linked here:

Article

 

 
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Posted by on May 17, 2016 in Uncategorized

 

The History and Future of Hypertension

In an interesting essay, Dr. Marvin Moser writes that “as late as the 1950s, elevated blood pressure was considered by many experts to be necessary for adequate perfusion of vital organs.”[1] The eminent American cardiologist Paul Dudley White suggested in 1937 that “hypertension may be an important compensatory mechanism that we should not tamper with even if we were certain we could control it.”

 

In 1937, 54 year old Franklin Roosevelt’s blood pressure was 162/98. But in accordance with medical opinion of the time, his personal physician did not prescribe medication to lower it. By 1941, a reading of 188/105 was recorded and finally a barbiturate and massages were prescribed. In 1944, a cardiologist examined Roosevelt and was appalled at what he found. Many of the now well-understood results of untreated high blood pressure were present. A chest x-ray showed fluid in his lungs and an enlarged heart from congestive heart failure. His urine showed protein due to kidney damage. The cardiologist recommended digitalis (a medication to treat heart failure) and a low salt diet. By the time Roosevelt attended the Yalta conference his blood pressure was recorded at 260/150. Seeing Roosevelt at the conference, Winston Churchill’s physician Lord Moran noted that “Roosevelt looked straight ahead with his mouth open as if he were not taking things in.” In 1945, while sitting for a portrait, Roosevelt complained of a headache and suddenly lost consciousness. His blood pressure was measured at over 300/190 and he was later found to have a cerebral hemorrhage.

 

In the late 1950s, thiazide diuretics were identified as the first well tolerated and effective medication for treating high blood pressure (hypertension). In the 1960s and 1970s, new blood pressure medications became available and a consensus on the importance of treating hypertension solidified.

 

It is now clear that treating hypertension early can prevent heart attacks and strokes, as well as heart and kidney failure. But until recently, there has been debate about how low we should aim to get the pressure. In November of this year, a landmark study called SPRINT (Systolic Pressure Intervention Trial) offered tremendous insight into this issue. The study took people 50 years and older with hypertension and randomized them to aim for a systolic blood pressure of either a) less than 140 or b) less than 120. The study was stopped earlier after 3.3 years when it became clear that the people with tighter blood pressure control were experiencing clear benefits. There were significantly less bad outcomes such as heart attacks, congestive heart failure, strokes, and death in the group with the lower blood pressure.

 

My takeaway from this study is to aim for a systolic blood pressure closer to 120 in patients I treat for hypertension. The trial provides firm evidence that doing so lowers the risk of having a heart attack, stroke, and congestive heart failure. Nonetheless, a person’s individual situation must be taken into account. As people age, the ability to compensate when standing up can be compromised, making them prone to fall if blood pressure is lowered too aggressively. In addition, decreasing blood pressure below a certain level in some people can cause fatigue and a poor quality of life. It takes more medications to achieve a lower blood pressure and these can sometimes have side effects. So patients and their doctors should work together to find a combination of medications and behaviors (such as exercise and diet) that fits their unique situations.

[1] Historical Perspectives on the Management of Hypertension

 
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Posted by on December 9, 2015 in Uncategorized

 

Boxing and Parkinson’s Disease

Although I’m not a neurologist, I’ve seen firsthand how devastating Parkinson’s Disease can be.  Parkinson’s does not just consist in tremors. It is a progressive neurological disorder than can ultimately take away essential capacities such as walking, writing, and swallowing.  Research into Parkinson’s has yielded impressive therapeutic interventions such as deep brain stimulation.  Nonetheless, the human brain is the most complicated structure in the known universe, so that our current understanding and treatment of Parkinson’s is limited.

I am moved by the courage people with Parkinson’s, as well as their loved ones, display in living with this disease.  CBS Sunday Morning recently had a segment that was particularly inspiring.  CBS correspond Leslie Stahl reports on how her husband and other people with Parkinson’s have found some hope and healing in an exercise program that uses boxing techniques.  In the segment, a researcher says a  study of the program showed it offers people with Parkinson’s genuine clinical benefit.  I highly recommend watching the segment  linked below (it starts with an advertisement that quickly passes).  Whatever challenges you face might seem less daunting after witnessing such bravery.

 
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Posted by on November 25, 2015 in Uncategorized

 

The Nuclear Option

Here’s an article I wrote on a reproductive method that uses DNA from three different people to prevent mitochondrial diseases. The technique raises challenging ethical questions.

http://www.worldmag.com/2015/10/the_nuclear_option

 
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Posted by on October 27, 2015 in Uncategorized

 

A Higher Vision

While I feel privileged to practice medicine, from time to time I find myself becoming burned out and discouraged. Spending the time needed to care for a person at their clinic appointment without falling behind in the day’s schedule, angry calls from patients about their insurance no longer covering the medications they’ve been on for years, the sheer volume of labs to respond to and paperwork to review–all of this can leave a physician feeling like Sisyphus pushing the boulder up the endless mountain.  When I feel this way, the writing of Daniel Sulmasy helps me to regain perspective. Sulmasy is an internist, palliative care physician, bioethicist, philosopher, and former Franciscan friar who serves on the Presidential Commission for the Study of Bioethical Issues.  I had the chance to meet and talk with Sulmasy for a while at a conference a few years ago and found him to be kind, gracious, and humble.

Here are a couple of passages from his book The Healer’s Calling. It should be noted that Sulmasy is a Christian and these passages reflect his spiritual tradition:

“For the health care professional, love for one’s patients alone will not ultimately satisfy. Patients can be very fickle. They can bring frivolous lawsuits against those who did their best in love to help them, and this can be deeply hurtful. Patients can be demanding at times. The relationship to the patient will not be a full healing relationship if one cannot see it in the context of one’s relationship with God–one’s spirituality.  If a health care professional is not careful to cultivate a spiritual life, he or she will quickly end up becoming cynical about patients. No physician or nurse will last very long in health care looking to patients themselves for personal satisfaction. Patients can only be the point of departure. They are not the source of satisfaction, but signposts that point the way to satisfaction. Physicians and nurses are really doing their jobs when they see each patient as a precious being swept up into the mystery of God’s love. . . No matter how sophisticated the technology of healing gets, true healing will involve three very simple human elements: compassion, touch, and conversation.”

Sulmasy’s words are lofty and well beyond what I achieve except in my very best moments. Nonetheless, he offers a noble vision of medicine that calls health professionals to strive toward something higher amid the daily stress and frustrations of clinical practice.

 
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Posted by on October 22, 2015 in Uncategorized

 

Advice for Aspiring Physicians

Tonight I spoke with UT’s Plan II Pre-Medical Society, answering their questions about what it’s like to become and be a doctor. Here’s some of the advice this old man shared with the youngsters.

Embrace Your Gifts and Passions

Early in his career, the late physician and author Oliver Sacks badly wanted to be a neuroscientist. The only trouble was he just wasn’t very good at it. After a number of mishaps in his attempts to do research, his supervisors firmly told him his future was not in the lab. Instead, he was sent to work with patients with severe degenerative neurological diseases living in a long-term care facility. While his contemporaries saw this kind of work as a dead-end, Sacks found it very much to his liking. At the nursing home, he was able to spend long hours with patients learning their stories.  Out of this experience, he discovered his gift for writing about what it’s like to live with a serious neurological condition. Sacks’ books and articles have evoked empathy and interest in people who would otherwise be overlooked. He has drawn medicine’s attention to the patient’s experience of illness, rather than simply studying and addressing disease. As Nobel Prize-winning scientist Eric Kandel wrote, Sacks “transformed the view of the mind for millions of people in a way that is both insightful and entertaining.” Imagine how much the world would have missed if Oliver Sacks had insisted on being a neuroscientist instead of embracing his gift for hearing and writing patients’ stories.

Be Curious

I recently saw a patient with symptoms I simply could not make sense of.  As I asked her questions about what she was feeling, more and more interesting details about her life came forth. I followed my curiosity and soon we were discussing changes in her most important relationships and transitions that were taking place. And then the cause of her symptoms became clear. Just by following my curiosity, rather than directly trying to figure out what was wrong.

It is also important to be curious about systems, customs, and institutions. Medical students should embrace the naivete they bring to their work. Medicine’s pedagogical method of apprenticeship leads it to honor tradition and hierarchy. It is slow to embrace change and question itself. While students are learning the culture and methods of medicine, I encourage them to also respectfully question why things are the way they are.  This is how breakthroughs and innovation happen. The disciplines of hospice and palliative care emerged when people looked at how patients were spending the end of their lives and asked if there could be a better way.  Was it really necessary to die in an intensive care unit connected to tubes and wires, surrounded by strangers and beeping machines? Or might it be much better to die at home in your own bed with family at our your side?

Seek Balance

There is more to life than medicine Keep up your relationships with your friends and family. Exercise. Take time to do what recharges your battery–music, books, writing, sports, travel, being outdoors. What good is it if you become a doctor, but in the process are transformed into a miserable, boring person?

Anyway. I hope the students gained something out of our time together. I enjoyed being with them and sharing what I’ve learned.

 

 

Seek Balance

 
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Posted by on October 15, 2015 in Uncategorized

 
 
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