The Daily Dose with Dr. Spence

March Madness and medicine

2010-03-24T14:24:00.001-07:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Anyone who knows me intimately, and many of those who don’t, are aware that I am a basketball junkie. I have followed college hoops for longer than I can remember and have been a fan of the Duke Blue Devils for longer than that. March Madness marks the one time of year in my life where everything else takes a back-seat. Akin to a religious zealot, I watch games with a frenzied passion rivaled only by the face-painted lunacy of the Cameron Crazies. As the first round of the NCAA Men’s Basketball has come to a close, one thing is certain. Uncertainty. Witness the ascension of teams like St.Mary’s, Cornell, and Northern Iowa to the Sweet 16. There is predictability in the unpredictability of the tournament. An astute reader at this point (perhaps bored to tears) may ask, what does this have to with medicine. You are a physician, not a sports journalist!

The comparisons between March Madness and medicine are blatantly obvious and unnerving. Regardless of what we think it going on with a patient, regardless of what a lab may tell us – there is always a degree of inherent uncertainty that exists in medicine. The ever changing medical landscape never ceases to amaze me. For example, a recent journal article suggested that vitamin D supplementation may actually be DETRIMENTAL as it may cause increased calcium deposits in blood vessels. The same journal reported that lowering blood sugars in diabetics to less than 165 on average resulted in increased mortality. This was a reputable journal, by the way, not just some wayward information I pulled off wikipedia. This is counterintuitive to everything we recognize to be true! Is there any validity to these studies? Only time will tell.

A professor and mentor of mine once stated that 50% of what he had learned in medical school and residency was obsolete only 15 years later. Now, I hold him in high regard as a scholar, and it has nothing to do with the fact he graduated from Duke University School of Medicine. His jump shot may be horrific, but he knows medicine. This is a scary proposition – perhaps a large part of what we are doing academically is flawed. I can relate the stories of dozens and dozens of patients who either defied the odds, beat the statistics, or had remarkable, miraculous recoveries where none were expected. What does this tell me? There is always uncertainty. This is certain. Sound familiar?

There is predictability in the unpredictability of life, medicine and the NCAA basketball tourney. In medicine, we use trends, clinical experience, education, and clinical research to dictate our treatment plans. Sometimes we “go with our gut”. We generally do a good job, but there is always that potential margin of error that must be accounted for. The same is true in hoops. I don’t care how many games you watch, how many statistics you analyze or how much of an inside scoop you think you may have.

No one in their right mind could have predicted that Northern Iowa would beat Kansas. If you did, there are only one of two explanations. You know nothing about college hoops or you live in Northern Iowa. Which is why I picked Kansas!

Do you have any medical questions or concerns that you would like addresses? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Imma Akin

2010-03-12T13:52:00.001-08:00

Dear Dr. Spence,

I have been unable to tolerate any of the statin medications like lipitor or zocor due to muscle pain. Is there any alternative? My bad cholesterol is through the roof.

Signed,

Imma Akin

Dear Imma,

A recent study performed at the University of Pennsylvania has shown that red yeast rice therapy performs similarly to pravastatin (pravachol) in head to head trials. They randomized 43 patients who had previously been unable to take statins due to muscle pain, to either red yeast rice or pravastatin. The lowering of LDL (bad cholesterol) was 27% in the statin group and 30% in the red yeast rice group proving that the alternative therapy was just as effective. Though muscle pain was still a possibility, it was half of what was seen with the pravastatin.

Red yeast rice is made by fermenting polished rice with strains of a particular yeast. It has been a staple of Asian culture and medicine for centuries. Its actions are similar to prescription drugs in that they lower cholesterol by inhibiting a key step in cholesterol production in the liver. Not all practitioners have adopted the use of red yeast rice due to lack of knowledge about the product and the general lack of FDA regulation of the various preparations.

A Chinese analysis from 2006 examined 93 separate trials that involved nearly 10,000 patients. It showed that not only can red yeast rice lower LDL cholesterol as effectively as some statins, it also appeared to increase HDL (good cholesterol) and improve triglycerides. Most importantly, red yeast rice seemed to be extremely well tolerated.

Given that so many people suffer muscle pain as a result of being given statin medication, it seems only natural to look for alternative sources of cholesterol lowering. Red yeast rice is a low cost option for those in need of additional help. The remaining question is – does it provide any true protection against heart attack, stroke, or death? This, unfortunately, is less clear. Medications like zetia have fallen out of favor despite their ability to lower LDL, as they have not proven to decrease death rates. Future studies may elucidate the positive effect that red yeast rice has. Until that time, we have to simply rely on the data at hand.

In your case, I think that red yeast rice would be a great option. Other options include fish oil, flaxseed oil, red wine, and garlic (among others). They all work to a lesser degree but they may be more tolerable. Remember! According to statistics, a decrease of 2 mg/dl in LDL represents a 1% risk reduction in heart disease, so every little bit counts.

Do you have any medical questions or concerns that you would like addresses? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Mediterranean diet

2010-02-24T13:42:00.001-08:00

The Daily Dose
I have frequently been known to extol the virtues of the Mediterranean diet, not just for its potential weight loss effects, but also due to its inherent abilities to slow or prevent the progression of cardiovascular disease. What makes the diet so beneficial? Obviously, the diet is rich in vegetables, fruits, whole grains, fish, wine and lean meats. We presumed that it was the abundance of omega-3 fatty acids that reduced heart risk. Newer research, however, points to one of the diets major components – olive oil; specifically olive oil compounds known collectively as olive oil polyphenols. Further, combinations of olive oil polyphenols, omega-3 fatty acids and resveratrol (found in red wine) may reduce the incidence of neurological disease, age-related bone disorders, and even cancer.

Most notable is the cardiovascular benefits derived from the olive oil polyphenols. They are all capable of increasing the HDL (good cholesterol) while lowering triglycerides and LDL values (bad cholesterol). One study demonstrated significant drops in these numbers with use of only 0.84 fluid ounces per day for three weeks. In combination with the omega-3 fatty acids found in fish, there was dramatic decrease in inflammation within blood vessels, thus theoretically decreasing overall cardiovascular disease. Another study (granted, it was done in filthy rats!) revealed a decrease in plaque formation at the aorta by 54%. Not bad even for vermin.

There is mounting evidence that olive oil polyphenols may work as well as aspirin for those at risk of heart attack or stroke. It has anti-clotting and anti-inflammatory properties similar to that of aspirin without the same potential to burn a hole in your stomach. According to the British Journal of Nutrition, hydroxytyrosol acetate from olive oil inhibits the synthesis of the body’s natural clotting factors.

There is ample data to suggest that the Mediterranean diet can help confer some benefit against certain cancers. It is felt that the mechanism revolves around the suppression of fatty acid synthase, an enzyme responsible for converting carbohydrates into fat in the body. Compounds like olive oil that block this enzyme have been shown to induce anti-cancer effects. Olive oil polyphenols may also inhibit the growth of cancer cells, especially in colorectal cancers, a leading cause of cancer death in this country.

Can something so simple and easy to purchase be this beneficial? It would appear so. Olive oils, while rich in heart-healthy monounsaturated fats, also provide valuable polyphenols which may be the true reason for the successes of the Mediterranean diet. When combined with the other components of the diet, it is hard to argue for a more complete regimen. After all, we truly are what we eat.

Do you have any medical questions or concerns that you would like addresses? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Mammography Arguments

2010-01-13T15:10:00.001-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Mammography Arguments

Another new year is upon us and like so many times before, controversy rears its ugly head. The most recent head scratcher involves the changes in mammogram screening recommendations as proposed by the United States Preventative Services Task Force (USPTF). This panel of doctors and scientists recently concluded that most women in their 40’s do not need mammograms and should wait until their 50’s to get one on a biannual basis. Furthermore, they suggest that breast self-exams are not effective. This is in staunch opposition to the recommendations enforced by the American Cancer Society which has set the standard for screenings – mammogram every year after age 40 and possibly a baseline for those deemed “high risk”. So where does this leave us, outside of confused?

The logic behind the newer recommendations is based on data suggesting that mammography more often than not leads to false positives and unnecessary biopsies without much improvement in women’s survival. False positives are a substantial source of anxiety for affected women. But what about those who have found lumps and subsequently have been treated for breast cancer? Most of these women stand by the previous recommendations and are less likely to be swayed.

Based on pure numbers, roughly 1300 women in their 50’s would have to be screened to prevent one death as opposed to 1900 women in their 40’s. What the USPTF is telling us is that mammography does save lives, but not enough of them. It stands to reason that they believe that screening is a burden to the healthcare system and additional screening is inherently too costly.

I have had women within my own practice that have found a suspicious lump through their own monthly self-checks. They underwent eventual biopsy and surgical intervention at an early stage. I believe that their diligence in monitoring may have saved them from a more aggressive, undetected cancer at a later stage. Tell that same woman that self-exams are useless and see what kind of response you’ll get. I can assure you that it won’t be pretty.

Regardless of which side of the fence you lay on, we may see a trend towards reduced insurance coverage for mammograms in 40 year old females. I will not let the USPTF guidelines change my approach at this time. I still think there is good science behind mammogram screenings. At this time, we do not have a better, more cost effective means to detect breast cancer. Until we do, I’ll be quite happy doing what I’m doing!

Cranking Up Metabolism To Lose Weight

2009-12-10T13:41:00.000-08:00

I am truly amazed at the sheer number of patients I see that ask about weight loss. Most are interested in advice on diet, but a growing number turn to prescription medications in order to achieve their desired results. Over 400,000 deaths per year are attributable to obesity. With obesity overtaking smoking as the number one cause of death in this country, our focus has shifted to greater reliance on preventative medicine.

Traditional weight loss programs tend to suffer the same eventual fate – lack of sustainability. Multiple studies have demonstrated their ultimate failure at three to five years out. Most of these diets are difficult to adhere to for the long term as well; just ask anyone who has ever tried the Adkins diet. Diet pills like adipex or bontril have potential inherent risks, from elevations in blood pressure and pulse to overt valvular heart disease. Weight loss is not as simply as eating less and exercising more as there are huge variations in hormonal and genetic influences. At the core, however, is an overall reduction in caloric intake.

What then are we to do? Our office has embraced a new weight loss program that may offer patients an opportunity to lose weight safely and efficiently without the use of potential harmful medications. The program, called HealthPointe 2.0, has been used in over 25,000 patients in California with impressive results. Typical patients have lost an average of 1-3 pounds per week, or 18-30 pounds in a six week period. Many patients with diabetes or hypertension have been able to decrease, or in some cases, discontinue, many of their medications.

Weight loss is achieved through a fine balance of ensuring three meals a day with the addition of frequent protein based snacks that effectively rev up an individual’s metabolism. Uniquely, it is the snacks that allow a decrease in hunger and allow the body’s metabolism to return to a more normal state. Overweight patients often skip meals in order to decrease total intake, but then snack inappropriately with the wrong foods. In essence, they are actually slowing their metabolism – storing more fat and burning up their body’s protein stores. This results in continued weight gain and fatigue.

Since its inception in our clinic, we have seen quite impressive weight loss. While we readily admit that this diet may not be effective for everyone, it has little risk. After six weeks, patients can gradually add foods (and the amount of those foods) to their diet. The rationale is that once the metabolism has increased, a patient can then begin to eat more normally.

With New Year’s around the corner, there is no better time to work towards a healthier future. Without exception, weight loss is the cornerstone to better health and self-confidence. Diet pills are not the answer and are a potential risk down the line. We need to get more pro-active and get active! Weight loss takes a concerted effort; nothing ventured, nothing gained.

If you have any questions about the HealthPointe system or are interested in taking the Healthpointe challenge, feel free to contact me at 209-2996.

Medical Myths

2009-11-12T13:27:00.001-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Dear Dr. Spence,

Q: Is there any validity to the recommendations to drink eight glasses of water per day to maintain health and hydration status?

A: Another valid question. Much of what we do as practitioners revolves around tradition. Physicians before us did things a certain way, and they in turn passed those methods to the younger generations. “It’s always been done that way” has been the adage used for nearly a century. But with a push towards evidence based medicine, many of the old traditions have been scrutinized ,and ultimately, debunked. The above question is no exception. We have always been led to believe that healthy adults should drink eight glasses of water per day. In 2002, a physician at Dartmouth attempted to track down the source of this recommendation. Not only could he not find a source, he could not find any evidence in the literature supporting it. In 2008, the University of Pennsylvania went so far as to say that, though well-intentioned, drinking eight glasses of water per day provided no increased health benefits. There was no weight loss, no elimination of toxins, no improvement in skin tone nor cure for constipation.

Q: How does one tell if they are dehydrated?

A: Typically, thirst dictates hydration status. Some have speculated that by the time you are thirsty, you are well past the point of dehydration. In actuality, thirst kicks in when you are still within the normal limits of hydration. Signs of dehydration may include, dry mouth, morning headaches or dark colored urine. Many people think darker urine is a sign of infection, but in most instances it is a consequence of hydration status only. Drinking too much water can actually be harmful in that it may cause dangerously low levels of sodium in the blood. Low sodium can cause anything from cramps and fatigue, to seizures and coma.

Q: Is it true that caffeine and alcohol are horribly dehydrating?

A: Research suggests that these have very little dehydrating effect though both act as diuretics. It is felt that the water in both beverages (coffee or alcohol) makes up for any potential losses. The most common issue resulting in dehydration is diarrhea as it may lead to rapid dehydration. This is one of the most common causes of mortality worldwide; death secondary from dehydration as a result of a severe gastrointestinal illness. Of course, exercise is a major contributor to dehydration. The American College of Sports Medication recommends consuming ½ to one cup of water for every twenty minutes of exercise. If you have lost weight from vigorous exercise, then one should drink two to three cups for every pound of weight lost.

All in all, increasing daily water consumption by a cup or two per day is not a bad idea, but overdoing it can be detrimental. As all things, there appears to be a delicate balance between too much and not enough.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

“Sweet” or “Bittersweet”?

2009-10-04T14:09:00.001-07:00

A swirling controversy is amongst us – specifically the taxation of soft drinks and sugared beverages. Its supporters argue that soda and the like are paving the way towards obesity and heart disease. Taxation of these goods may, therefore, improve general health while at the same time dramatically increase state and federal revenue. Detractors maintain the obesity crisis will not be solved through increased taxation and only serves to punish those who consume small amounts of sugared beverages.
Statistically, our consumption of sugared beverages has sky-rocketed in the last quarter century. Since 1977, the per capita intake of caloric drinks has doubled in the United States. The average daily caloric intake is estimated at approximately 172-175 calories per adult and child. Unfortunately, patients recognition that sugared beverages constitute “empty calories” and contributes to weight gain has been less than impressive.

Multiple studies have evaluated the effect of soft drink consumption on obesity and cardiovascular health. In particular, a two year study involving middle school students showed a 60% increased risk of obesity for every additional serving of sugared beverages per day. Another eight year study involving women showed that by increasing consumption of sugared beverages over the study’s final four years, a woman could expect a 17.6 pound weight gain versus 6.2 pounds in the groups that did not increase their consumption.

The massive Nurses Health Study evaluated 91,249 women over eight years and revealed a two fold increase in diabetes mellitus among women who consumed one or more sugared beverage per day. Half the risk appeared to be attributable to greater body weight. Heart disease was increased 23% and jumped to 35% with consumption of two or more servings per day.

Health risks are felt to be secondary to a variety of causes, from elevated triglyceride levels and blood pressures, to decreased HDL (good cholesterol) and an increase in insulin resistance. Medical costs for obese patients are estimated at 147 billion dollars per year – nearly 10% of all U.S health care costs!

Suggested taxation is one cent per ounce of beverage. This would increase the cost of a 20 ounce bottle by about 20% or so. In turn, it is estimated that this would raise 14.9 billion dollars in federal revenue with 928 million dollars raised in Florida alone. Taxes would be levied on the companies themselves, which would then be passed on to the retailer. Consumers would then become aware of the cost increase at the point of sale which may discourage them from their purchase. If a typical consumer changed to a no-calorie substitute, he would shave nearly 175 calories from his diet per day (as noted above). This could decrease total caloric intake by 63,875 per year, or 18.25 pounds!

The backlash from corporate America has been strong. Pepsi threatened to move their headquarters from New York after an 18% tax on sugared beverages was proposed. The beverage industry has created an American Against Food Taxes group to fight the potential governmental taxations. It would appear that their efforts confirm their belief that taxation of sugared beverages will dramatically reduce consumption. Of course, reduced consumption equals reduced profits.

It is clear that a simple reduction in calories may have a huge impact on general health in this country. The question is whether or not taxation of these goods is the best way of achieving these gains.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Increasing Hair Loss

2009-10-04T12:48:00.000-07:00

Dear Dr. Spence,

I am a 52 year old female who has been having increasing hair loss. I’m afraid if I don’t do something at once, I’ll soon be completely bald. Help! What do you suggest I do?
Signed,
Imma Shining

-- Dear Imma,
There are many causes of hair loss. It is important to understand the principles of hair growth before one can understand the principles of hair loss. Hair grows in cycles of two to six years with an average growth of one centimeter per month during each cycle. It is normal to lose approximately 100 hairs per day which can be disconcerting for some people that are not aware of this. This, in part, may explain why hair growth can recuperate after a period of apparent loss.

As noted, there are numerous causes of hair loss, or alopecia. The most common is known as telogen effluvium (doctors always need fancy words to explain common conditions!). In telogen effluvium, an increased number of hairs enter the telogen, or resting phase and these hairs eventually fall out approximately three months later. The normal hair loss of 100 per day dramatically increases and may cause a loss of up to 30-50% of total body hair. Telogen effluvium is typically precipitated by some form of stressful event three months prior to the complaint. Stressful events may include surgery, childbirth, illness, injury or even severe psychologic stress. Other possible causes include thryoid disease (overactive or underactive) and iron deficiency. Medications may be the culprit and can include antiepileptics, hormones, blood thinners and some blood pressure medications.

Alopecia areata causes hair loss in circular patches and is typically a result of chronic illness like diabetes mellitus, thyroid disease or lupus. It can happen at any age and treatment usually consists of treating the underlying disease process. Other causes of hair loss include nutritional deficiencies, syphilis, medications and repeated trauma to the hair though braids, perms, use of hair curlers or twisting.

For physicians, the general evaluation revolves around a thorough history and physical. In some cases, bloodwork may be of some value and often includes thyroid testing as well as evaluation of iron stores and hormone levels (testosterone etc.). As noted, most cases are secondary to telogen effluvium and will resolve over time once the stressor has passed.

Finally, once all is said and done, many women are simply suffering from female pattern hair loss which is characterized by thinning over the central area of the scalp with widening of the midline part. Nearly 50% of women will experience female pattern hair loss in their lifetime. Treatment consists of over the counter minoxidil. It may take three to six months to see results. The higher concentration solutions (5%) do not offer any clear benefit and may be more likely to cause dryness, itching and possible skin irritation. I recommend the 2% solution.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

N- acetylcysteine

2009-08-31T07:53:00.001-07:00

I read with interest a recent article discussing the potential benefits of N- acetylcysteine, an amino acid that has been used in treatment primarily of tylenol toxicity. The effects are based on its ability to act as a potent antioxidant which may support the body’s ability to fight infections or stress. It appears to protect cells from toxins by detoxification of various toxic substances.
The most interesting clinical application is in the treatment and prevention of influenza. With more and more threat of the pandemic H1/N1 swine flu, N-acetylcysteine may be a useful adjunct to current therapy. Compared to placebo pills, N-acetylcysteine users were less likely to have clinical influenza (or at least symptoms of it). Secondly, when those patients actually did develop influenza, it was a much less severe case. It appeared that immunity at a cellular level improved significantly. Though not part of any official CDC recommendations, it may be an option for those who are at higher risk of developing the H1/N1 strain, or any influenza strain for that matter.
A second use of N-acetylcysteine is for patients with chronic lung disease (COPD or emphysema). A study of over 1300 patients found there was a reduction in cough severity and amount of phlegm produced. Those same patients had less likelihood of developing shortness of breath and associated heart failure. Furthermore, based on actual lung testing, they had improvement in their overall lung function. It was shown that in the N-acetylcysteine group, there was nearly 50% less loss of lung function when compared to those not on the supplement. This may be exciting news for patients with chronic lung disease. Many of the available inhaled treatments do not provide total relief. Addition of N-acetylcysteine may be useful in preventing future attacks of acute bronchitis.
Dosing is generally 1200 mg twice per day. Generally at lower doses, the drug is well-tolerated. Side effects may include nausea, vomiting, diarrhea, skin rash, flushing and abdominal pain. Larger doses are used to treat acetaminophen toxicity (tylenol poisoning). At these doses, side effects may include headache, itching, fever and severe allergic reactions. Any patient on nitroglycerin for heart disease should use caution as this combination may result in significant drops in blood pressure. N-acetylcysteine is available over the counter in doses of 600 mg. As noted, standard dosing is two capsules twice per day.
In short, N-acetylcysteine, by acting as a potent antioxidant, may improve symptoms of chronic lung disease and may also be a useful adjunctive medication in the prevention and treatment of viral influenza. It may also protect against kidney damage when given prior to certain imaging procedures (i.e. CT scans that use intravenous contrast). I did not expand on this fact in a deliberate attempt to not bore my readers to tears. There you have it.

Polypill on the Horizon?

2009-08-31T07:47:00.001-07:00

At the recent American College of Cardiology meeting, phase 2 results of the Indian Polycap Study (TIPS) were presented. Within this landmark trial, investigators have been evaluating the positive effects of a polypill that contains three blood pressure lowering agents, a cholesterol reducer (statin) and an aspirin. It has been estimated that use of the polypill could reduce coronary heart disease by 62% and stroke by 48%. The polypill represents one of three strategies in development by the World Health Organization to reduce cardiovascular disease, the other two being weight loss and smoking cessation.
TIPS took 2053 patients and placed them in one of eight study groups and evaluated them over the course of 12 weeks. The other groups included aspirin alone, aspirin plus statin, and combinations with all blood pressure agents. All were Indian patients with an average blood pressure of 134/85 and bad cholesterol (LDL) of 117, both of which are quite good by most standards. Results were impressive with most patients having substantial blood pressure drops and cholesterol lowering. The big question is whether high-risk individuals should be on this combination as a preventative measure. One also wonders if all patients should consider medications like this for health maintenance. It may be years before all the data is back, but it is certainly thought provoking.

Honey for Cough?

Controversy surrounds the use of over the counter cough and cold medications, especially in children. There is no convincing evidence that any of them provide benefit, and, in fact, they may be harmful secondary to side effects and the potential for overdose. It has been estimated that more than 7000 emergency room visits occur annually due to adverse drug events related to the use of children’s cough and cold medications. One third of these are associated with simple dosing errors. Once again, the World Health Organization has stepped in and recommended the use of honey to soothe cough in children older than one year. No formal study has evaluated honey versus standard medicines like dextromethorphan, though it appears better than no treatment. Given the relative safety of honey consumption, its potential use in treating upper respiratory infections is certainly intriguing. I would certainly recommend giving it a try before resorting to OTC purchases. At a minimum, parents should be educated on these issues. We all believe that there medicine can cure anything, but the reality is that they all have the potential to do more harm than good.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Insomnia Part 2

2009-08-17T12:35:00.001-07:00

Dear Dr. Spence,
Why can’t I seem to get a good night sleep? What can I do other than pop pills every night?
Signed,
Sleepless in Marianna

In my last writing I had been discussing some of the causes and implications of insomnia. The solution to improving sleep hygiene, however, is more complex. There are many options available to patients. Some are by prescription, some are over the counter remedies and some are just plain common sense. First and foremost, of course, is fixing any problem that may have led to the insomnia originally. If a patient is depressed for example, proper therapy may be an antidepressant as opposed to a sleep aide.
Changing sleep habits is a simple and occasionally effective way of combating the problem. Maintaining regular sleep and wake times are crucial at helping regulate the body’s natural circadian rhythms. Many people incorporate behavioral therapy into the mix. Techniques include muscle relaxation, breathing exercises and cognitive therapies that try to replace worry about sleep with more positive thoughts.
There are of course some basics when it comes to sleep hygiene. You should keep the same sleep schedule regardless of whether it is a weekend or not. Try to avoid the temptation of sleeping in once Saturday and Sunday roll around. You should sleep as much as you need to in order to feel rested. If you cannot sleep for fifteen minutes, it is recommended that you engage in another activity for a while (i.e. reading a book or watching T.V.) Do not read, eat, watch T.V. or work in bed. The bedroom should be a place of comfort; cool with minimal distractions like noise or light. Get rid of the computers and T.V. Those who engage in regular exercise generally report better sleep. Lastly, limiting alcohol and/or caffeine at bedtime can also help prevent insomnia.
Finally, medications can be used if all else fails. Over the counter medications like valerian and melatonin have been used for years with varying degrees of success. Most studies do not support their efficacy. Your physician can prescribe a host of agents that may help induce sleep. Popular agents like lunesta and ambien can be beneficial but may be potentially addictive and may be problematic in older adults due to their sedative properties. Rozerem claims to work by helping maintain the natural sleep architecture through sleep-wake cycles and does not appear to have the adverse effects or dependence that is seen with other agents. Your physician can assist you in finding the right medication for you.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

There is No Such Thing As a “Free Lunch”

2009-06-21T11:00:00.001-07:00

I have had several patients ask me about the recent change in the pharmaceutical industry’s indiscriminate practice of giving gifts to physicians. It has long been known that drug reps were a great source for an assortment of pens, staplers, coffee mugs, and even years ago, elaborate fishing and golf trips. I daresay I haven’t purchased a pen in over seven years and have provided many a nurse with the latest gadget. Recently, the Pharmaceutical Research and Manufacturers of America (Pharma) has noted that branded gifts “are not based on informing physicians about medical and scientific issues” and subsequently banned all gifting to doctors. No more pens. No more note pads. The pharmaceutical companies have always hoped that use of their pens may ultimately influence physician prescribing habits, thus increasing their bottom line. This practice has come under great scrutiny as research suggests that they may be right!

Further, even the practice of drug sampling has been examined. Drug reps typically leave a slew of their expensive “branded” products for doctors to dispense. It is quite handy to be able to provide the samples to patients as a “free trial”. The reality is that these free trials result in greater long-term prescription costs given that cheaper generic medications may be equally effective. According to studies, out of pocket costs for prescription drugs increased 47% for patients who received free medications to try when compared to those who were not offered samples.

As alluded to above, when physicians have access to samples, they tend to prescribe more expensive medications. Medication sampling accounts for $16 billion a year, or roughly half of the industry’s marketing budget. The annual cost of prescription drugs is $227.5 billion per year, or 10% of all health care spending in the United States. This is a disturbing trend, certainly. I personally make every attempt to limit an individual’s expenditure and will only use branded drugs if I feel it is absolutely necessary. I’m a consumer, too, and would hate to feel ripped off if there was a cheaper, equally efficacious alternative.

The pharmaceutical industry also offers a litany of articles supporting the use of their products, many with skewed data and funded by the very company marketing the drug. Is it any wonder their studies so convincingly advocate use of their medication? Most physicians cannot be bothered to systematically examine each article and therefore, they tend to take the data at face value. This may, in turn, result in the skyrocketing use of $200 a month meds As Mark Twain said, “There are lies, damned lies, and statistics”.

Now, where’s my free lunch!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.

2009-05-21T10:04:00.000-07:00

Dear Dr. Spence,
What’s all the flack about flaxseed oil? I have intolerance to zocor and lipitor. Can flaxseed oil improve my cholesterol?
Signed,
The Lorax
Dear Lorax,
Flaxseed oil is a natural plant food that contains large amounts of omega-3 fatty acids that have proven beneficial in lowering triglycerides and other heart parameters. Compared to canola and corn oil that have 10% and 1% omega-3s respectively, flaxseed oil has 57% omega-3s.There have been numerous studies evaluating the cholesterol lowering effects of flaxseed. Though not as powerful an LDL (bad cholesterol) buster, it may drop triglycerides by 36%. The potential positive effects of flaxseed do not stop at triglycerides, however.
It has been estimated that nearly 30-40% of all cancers could be prevented through dietary and lifestyle interventions. Flaxseed oils, which contain certain phytoestrogens known as lignans, have value in blocking hormone dependent cancers such as breast and prostate cancer. With prostate cancer, flaxseed may increase levels of enterolactones, an active product that may confer some benefit. In one large study from Sweden, men with the highest enterolactone levels were 82% less likely to develop prostate cancer.
Given that flaxseed is rich in phytoestrogens, it would make sense that it may provide relief to the millions of women who suffer the discomforts of menopause, i.e. hot flushes. The Mayo Clinic demonstrated that flaxseed oil significantly decreased the occurrence of hot flushes in those women who chose not to take estrogen therapy. Estrogen’s potential link to breast cancer has left many wondering what the best therapy for menopause may be. Phytoestrogens exert both estrogenic and anti-estrogenic effects that may improve the annoying symptoms without increasing worrisome side effects. With more and more women opting for more natural protection against menopausal symptoms, flaxseed may provide a welcome alternative.
Flaxseed is also a rich source of dietary fiber. Soluble fiber forms a matrix with water that adds bulk to stool and promotes more regular bowel movements and freedom from constipation. Insoluble fiber in flaxseed may help slow the release of sugar into the bloodstream after a meal, preventing spikes in blood sugars, certainly a benefit in any diabetic or overweight patient. One ounce of flaxseed contains 32% of the fiber recommended by the United States Department of Agriculture (USDA).
Patients should use ground flaxseed and sprinkle it on cereal, yogurt, salads or vegetables. In fact, a simple internet search can provide hundreds of healthy recipes that may incorporate flaxseed into the daily diet.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose

2009-05-01T11:19:00.000-07:00

Dear Dr. Spence,
What is Bell’s palsy?
Signed,
Lotta Drooping
Dear Lotta,
Bell’s palsy is an acute paralysis of the facial nerve that typically results in the fairly sudden onset of facial drooping on one side, as well as possible taste loss and inability to close the eye on that same side. It is unclear as to what is the cause of this entity, though many suggest it is viral in origin. It is cause for great distress as its symptoms closely mimic that of an acute stroke. Bell’s palsy affects roughly 20 to 30 people per 100,000 each year. Most of the time, full recovery of the paralysis occurs, but up to 30% can have residual symptoms, including facial weakness or pain.
The great debate has been how to treat these patients, as the literature has yielded conflicting results. A new study from the New England Journal of Medicine does shed light on the controversy. In the past, practitioners have used steroids, anti-viral medications like acyclovir, or both. The study consisted of 551 patients who were placed in one of four different treatment groups – acyclovir and placebo, steroid and placebo, steroid and acyclovir or placebo alone. After three and nine months analysis, those individuals in the steroid arm had a greater likelihood of making a full recovery. There was no benefit to adding the anti-viral agent acyclovir to the mix. In essence, if caught early enough (within the first 72 hours), steroids like prednisone are a valuable addition to treatment of Bell’s palsy.
Dear Dr. Spence,
I have tried nearly every diet on earth. What do you think is the best for me?
Signed,
Gotta Stuffless
Dear Gotta,
From the standpoint of weight loss, nearly all diets have been shown to be approximately equivalent after about one year. I have extolled the virtues of the Mediterranean diet for some time. Heavily based on fruits, vegetables, lean meats, red wine, olive oils, fish and nuts, the Mediterranean diet has been proven to reduce mortality in varying patient populations and may also result in a small degree of weight loss. The Lyon Heart Study looked at 300 patients adhering to the diet and showed a 73% risk reduction for heart attack and a 70% risk reduction in overall death (relative risks). Another Italian study showed similar, though not nearly as impressive, results as the Lyon study. The difficulty with adhering to this diet is the inherent cost. Certainly, fresh fruits and vegetables are more expensive than some canned and packaged products. Sometimes, cost can trump the long-term benefits of a healthier living.

Celiac disease

2009-04-19T15:33:00.001-07:00

Dear Dr. Spence,
I have problems with frequent diarrhea and abdominal pain. A friend suggested I may have celiac disease. I’ve never heard of it. Could I have it?
Signed,
BM

Dear BM,

Celiac disease is an inability to digest gluten, the primary component found within wheat and wheat like products. Resultant symptoms include anything from diarrhea, bloating and abdominal pain to joint pain, extreme fatigue and infertility. Interestingly, patients may even present with functional constipation as their main symptom. Most, however, have symptoms that mimic those of irritable bowel syndrome. The prevalence of celiac disease is estimated to be at 1% of the general population, though most people have never heard of it.

Diagnosis is centered initially on blood testing, specifically antibody testing. Patients with iron deficiency anemia may have a 3-9% likelihood of celiac disease which is comparable to the 3-8% of diabetics afflicted. Diagnosis is often confirmed via intestinal biopsy. It is important to make a diagnosis early as mortality is increased if delayed greater than ten years. These patients are at risk for malignancy, specifically lymphoma.

Management of celiac disease involves elimination of gluten from the diet entirely – this includes discontinuation of wheat, rye or barley products. Most of the time, assistance from a registered dietician is crucial at maintaining adherence to the dietary restrictions. Continued problems with diarrhea etc. are usually the result of inadvertent gluten consumption. My experience is that many patients do have substantial problems in maintaining a gluten-free diet, but a positive attitude is a critical factor in success.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Osteoporosis II – Prevention and Treatment

2009-03-25T13:59:00.000-07:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Previously, I commented on the diagnosis and potential courses of both osteoporosis and osteopenia. This installment focuses more on actual prevention and treatment options for those patients so affected.
Calcium has long been recommended for prevention of osteoporosis. Doses of at least 1200 mg per day have been suggested, but effectiveness at reducing fractures is unclear. Calcium carbonate is inexpensive but should be taken with meals to enhance absorption. Calcium citrate, though more expensive, can be taken without food. Commonly, dosing may be limited by constipation or stomach issues. Absorption can be impaired when used in conjunction with thyroid medications, blood pressures medications (specifically ACE inhibitors like lisinopril) or iron, and dosing should be separated by several hours at a minimum.
Vitamin D is critical, as I have mentioned in previous articles. Doses of 800-1000 IU per day are needed. The number needed to treat to prevent one hip fracture is 45 over 2-5 years of treatment. Given its benefit at potentially decreasing risk of stroke and certain cancers, there is no reason that patients should not supplement. This is one of the few supplements that I take personally!
For the most part, therapy revolves around a group of medications known as the bisphosphonates. Included in the class are fosamax, boniva and actonel. These medications inhibit bone turnover and therefore increase bone mineral density and strength. Trials demonstrate a reduction in spine and hip fractures with both actonel and fosamax. The number needed to treat over three years to prevent one fracture is 91 for fosamax and 79 for actonel. Despite weekly and monthly dosing schedules that are now available, noncompliance remains an issue with many patients stopping the medication entirely. Problems surround use of bisphosphonates in that they can cause significant problems with heartburn and esophageal symptoms. They must be taken with a full glass of water and patients must remain upright for at least 30-60 minutes after dosing. A newer option is once yearly intravenous infusion with reclast. Many patients like the convenience of once a year administration and the decreased likelihood of side effects. Cost can be problematic, but we have found that any patient with medicare and a supplemental insurance (i.e. AARP) will have near complete 100% coverage.
Concern has arisen over the potential for destruction of bone at the jaw. The complication is rare and has generally only been noted after intravenous use in patients diagnosed with cancer.
Other medications exist as far as treatment goes, but they are less commonly used and not worth discussing given constraints of space and for fear of completely losing any or all readership I may have secondary to boredom. What about hormones like estrogen? The Women’s Health Initiative trial did report that estrogen did reduce the risk of vertebral and hip fractures with a number needed to treat of 385 over five years. The benefits, however, do not outweigh the risks of estrogen therapy which include increased likelihood of breast cancer, stroke and heart disease. Generally, I do not recommend hormone therapy for treatment of osteoporosis unless the patient has compelling reasons to do so, like horrible hot flashes.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Osteoporosis

2009-03-11T14:43:00.000-07:00

Dr. Spence:
Please tell me all about Osteoporosis.
Thanks,
Imma Bender

Osteoporosis I – Definitions and Evaluation
Osteoporosis remains a significant health risk in this country. Estimates suggest that nearly eight million women and two million men in the United States have osteoporosis and another 34 million may have osteopenia, considered a precursor to osteoporosis. It is characterized by low bone mass and structural deterioration of bone strength resulting in an inherent increased risk of fracture. Shockingly, about 1 in 2 white females will suffer an osteoporotic fracture in her lifetime. Should you fracture your hip, mortality increases 10-20% at one year. Twenty five percent of patients with hip fractures will require long-term nursing home care.
It is suggested that all women greater than 65 years of age and all men greater than 70 should be screened for osteoporosis. Other patients that should be screened are those adults who have had a previous fracture or have certain clinical factors that place them at increased risk. These factors include low body weight, history of falls, excessive alcohol use or use of certain medications (i.e. steroids like prednisone, or anti-seizure medications like dilantin).
Screening is traditionally done by bone mineral density testing (DEXA scan) which measures bone strength at the hip and lower spine. Heel testing, as done in some offices, is reasonable, but follow-up on abnormal screens is recommended. A so-called "T-score" is generated that arbitrarily compares your bone strength with that of a 30 year old female. Any T score less than -2.5 meets the definition of osteoporosis whereas scores of -1.0 to -2.5 represents osteopenia.
There are various secondary causes of osteoporosis that should be note. Though most elderly patients have pure osteoporosis as a result of age and loss of estrogen production, there are secondary issues that may require different treatments. For example, reversal of a patient’s vitamin D deficiency may improve bone mineral density and may be all that is required for formal therapy. Other common conditions that may cause osteoporosis include hyperthyroidism, diabetes, emphysema, kidney failure and rheumatoid arthritis. Again, many prescribed drugs may ultimately result in loss of bone mass.
Treatment should generally be initiated for any patient with a calculated bone mineral density of less than -2.5 or any patient who has suffered a hip or vertebral fracture. Guidelines further suggest treatment for those with osteopenia. My experience has shown, however, that insurance companies are less to apt to cover the costs of therapy in cases of osteopenia. Given that treatment may very well prevent progression to overt osteoporosis, it seems ludicrous that insurance companies would block access to potentially valuable medication, but this is typical of our spiraling healthcare system. This is a topic for a whole separate discussion!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose 2/26/09

2009-02-25T15:04:00.000-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Dear Dr. Spence,
Please tell me about the flu. I am a health care worker and am concerned about contracting the disease.
Signed,
Hacker

Dear Hacker,
The flu, or influenza, is a virus that is responsible for a substantial number of infections every year in the United States. In fact, is it estimated that 5 to 20% of the U.S. population is affected by the flu on a yearly basis and more than 200,000 people are hospitalized each year for complications related to the flu. More than 36,000 people die annually. It is highly contagious and, therefore, steps at prevention are globally recommended (i.e. flu vaccines).
The flu causes a host of symptoms. I should know as I had it last week! Most prominently, flu is characterized by high fever, often not relieved substantially by ibuprofen or acetaminophen (Tylenol). Other symptoms include sore throat, headache, severe muscle aches, runny or stuffy nose, and fatigue which is often quite dramatic. In my office, the typical scenario is a patient who presents with rapid onset of high fever, malaise, and the feeling that they were "hit by a truck". Complications may include bacterial pneumonia, dehydration or worsening of other disease such as asthma or congestive heart failure.
As it is spread from direct contact with an infected individual or through respiratory droplets, universal precautions such as hand washing are mandatory! A person may pass on the disease to others one day prior to having symptoms and up to five days afterward. Treatment may inhibit viral replication and prevent spread to others and is therefore generally recommended.
More importantly, prevention via vaccination is a must. We typically recommend the vaccines to nearly all patients, though there are certain subsets of the population who are certainly at greater risk. All children age 6 months to 19 should get the vaccine, as should patients over the age of 50 or anyone with specific medical conditions. All healthcare workers, pregnant women and nursing home patients should get the vaccine as well (note to self!). The vaccine consists of an inactivated or killed virus that is given by injection. The Center for Disease Control attempts to predict the particular flu strains for the upcoming year and the vaccine reflects these predictions. Unfortunately, it is never foolproof. Many patients refuse to get a flu shot claiming they "got the flu" after administration. I try to assure them that one does not get the actual flu given that it is a killed virus. It is possible to feel bad and get a "flu-like" illness, but there is a big difference.
For those who are completely needle-phobic, a nasal influenza vaccine does exist. It is a weakened live virus, again incapable of causing flu. It is recommended for healthy non-pregnant patients between the ages of 2-49.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose- 2/5/09

2009-02-06T08:22:00.000-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

As suggested previously, allergy season is nearly upon us. My last article touched on methods of allergen avoidance what to look for, or avoid, in over the counter remedies. Along that same vein, I will now focus on physician driven treatments, i.e. drug and injection therapy, and finish with some comments about allergies in general, hopefully dispelling some popular misconceptions about management.

If OTC medications fail, what next?
Despite your best intentions, mere avoidance coupled with OTC medication may fall flat. At this point, your primary physician may be necessary to assist in controlling your symptoms. Most of the time, allergies should be controlled within one to two weeks from initiation of therapy. There are several options available. First, standard prescription strength antihistamines remain the most commonly used agent. Antihistamines like allegra or xyzal block the release of histamine, a chemical responsible for the itching, sneezing, etc. Second, nasal steroid sprays such as nasonex or flonase can be used to decrease inflammation and symptoms of nasal stuffiness or runny nose. Finally, leukotriene inhibitors like singulair block the chemical effects of leukotrienes which are released in response to an allergen contact.

Do I need allergy shots?
The same applies – if medications do not control symptoms over time, then you may need to consider stepping up to allergy injections. Generally, these are administered once or twice per week and therapy may last for several years. Patients will require antihistamines in addition to the shots, at least in the beginning.

Will steam cleaning carpet reduce allergies?
Only one study has formally evaluated this issue. No benefit was seen. To remove dust mites and pet allergens, it is suggested that all carpeting be removed. The coolness of the concrete floor beneath combined with indoor humidity increase the allergen load substantially. Certainly, removing carpets is an extreme measure, not to mention a potentially expensive one.

What about washing your pets? Using a HEPA filter?
As it turns out, neither has any proven efficacy. It takes 12-16 weeks to reduce cat allergens down to the level of a house without a cat! Outside of getting rid of the animal, keep it out of bedrooms and remove upholstered furniture and carpets from the house. HEPA filters have been studied extensively and were found to be ineffective. Despite removing cats from the bedroom, applying an impermeable mattress cover and running the cleaners 90% of the time, one study showed no difference in allergy symptoms over six months.

What’s new in allergy treatment?
A new type of treatment known as sublingual immunotherapy may replace allergy shots completely. Treatments are given 1-2 times per week, but drops are given under the tongue. No needles necessary! The drops are slow release formulations which allow patients to build up resistance over time with less potential for side effects, such as anaphylaxis (severe allergy reaction).
Sublingual immunotherapy is currently under investigation in trials and may take some time to reach the mainstream, but the wait may well be worth it.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose 1/8/09

2009-01-07T12:15:00.001-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Dear Dr. Spence,
I recently read in the paper that a new study suggests that all patients may benefit from cholesterol lowering medications regardless of any individual risk. Should I be taking zocor or lipitor or is this all media hype?
Signed,
Statin-less

Dear Statin-less,
The study you are referring to is the JUPITER trial, recently published in the New England Journal of Medicine. The study involved nearly 18,000 patients and showed that giving a cholesterol lowering statin drug to seemingly healthy people with normal cholesterol levels could cut the risk of heart attack, stroke and death by nearly 50%. These findings provide the best evidence to date that a statin can reduce cholesterol and inflammation within arteries. The patients in the study had normal cholesterol but they all had elevated levels of C-reactive protein, a potential marker of artery inflammation and heart disease.
Half of the patients in the trial were given crestor; the other half received a placebo. Those in the crestor group experienced 54% fewer heart attacks, 48% fewer strokes and 20% fewer deaths – findings so impressive that the study was stopped after only two years so that those taking a placebo could be offered the study drug.
A separate analysis speculates that giving statins to everyone in the United States whose heart risk matches those in the study could prevent about 250,000 heart attacks, strokes, bypass surgeries and deaths in the next five years.
The patients in the JUPITER trial all had LDL cholesterol levels less than 130 mg/dl. Crestor significantly reduced the incidence of major cardiovascular events despite the fact that they were well below the threshold for treatment. Most would not be considered candidates for statins at all. LDL levels were less than 55 mg/dl in 50% of the study participants on crestor with 25% below 44 mg/dl. This raises the question of exactly how low LDL should be in order to prevent deleterious outcomes. Levels that low approximate those of a newborn. One could argue that anything above that level may incrementally increase risk.
Other questions remain. In an accompanying editorial in the New England Journal of Medicine, risk of cardiac events was only reduced from 1.8% in the placebo group to 0.9% in the crestor group; thus 120 patients were treated for 1.9 years to prevent one event. Is that worth it? The theoretic cost to prevent that one event may be on the order of hundreds of thousands of dollars. Would a generic medication like zocor be an equivalent substitute? As of yet, the answer is not known. Caution must be taken when interpreting the data, but it certainly deserves thought. I suspect, in one sense, these agents provide more benefit than just cholesterol lowering. Time will determine whether they should be as readily available as over the counter supplements (which some have suggested).

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose- 12/25/08

2008-12-24T08:42:00.000-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
I have written previously on the subject of vitamin D supplementation in the general population. I think the importance of vitamin D deserves another look – perhaps with more enlightening statistics (as everyone knows, I am a tremendous fan of statistics).
Between 40-90% of elderly individuals have defined vitamin D deficiency (levels less than 30 ng/ml). Even in Florida where the average is 64%. Replacement with standard doses (400 IU) is ineffective at raising levels appreciably, and it does nothing to enhance bone mass, prevent falls, or fractures. Most people believe the sun or milk consumption provides us with all of our inherent vitamin D needs. Unfortunately, it would mean getting a mild sunburn to the arms and legs at least four days a week to get the minimum amount that may be required. Further, it would take twenty glasses of milk or orange juice per day to achieve the same effect.
Two studies from 2007 have elucidated the benefits of vitamin D. The first, from the American Journal of Nutrition, evaluated 1180 post-menopausal women after four years of vitamin D supplementation (1000 IU/day). The risk of contracting any cancer was 60% lower in the vitamin D group as compared to those on nothing. Risk reductions with individual cancers included breast (50%), colon (50%), prostate (49%) and ovary (36%).
The second study published in the reputable New England Journal of Medicine suggested that anywhere from 40-100% of all elderly patients in the United States and Europe have insufficient or deficient vitamin D levels. The authors calculated the rates of various diseases affected by vitamin D status and have churned out the following numbers:
● 200% increase in Type I diabetes mellitus in vitamin D deficient children
● 37% reduction in Type 2 diabetes in those taking 800 IU of vitamin D plus calcium
● 72% reduction in falls
● 30-50% more cancer in vitamin D deficient people
● 42% reduction in risk of multiple sclerosis if taking greater than 400 IU/day
They go further to suggest that inadequate vitamin D levels increase the likelihood of hypertension, depression, osteoarthritis, schizophrenia, autoimmune disease and pulmonary disease.
Recently, the recommended amount of daily supplementation has increased from 400 IU to 800 IU per day. This may not even be enough! A dose of 1000 IU/day will increase blood levels 11.6 ng/ml – experts suggest patients shoot for levels greater than 60 ng/ml, which far exceeds what is now considered standard.
Dr. William Faloon notes that our shortsightedness in globally recommending higher vitamin D doses and higher blood levels has taken twelve times as many American lives as were killed in World War II. I suggest all middle age adults start now and supplement with at least 800-1000 IU per day. Vitamin D is extremely safe up to doses of 10,000 IU per day and it is dirt-cheap. I see no great excuse at not jumping on the vitamin D bandwagon – your body will thank you.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose- 12/18/08

2008-12-18T13:34:00.001-08:00

Dear Dr. Spence,
I recently had a mini-stroke. The doctor in the ER told me I am at huge risk for a full stroke in the next several months. Now I’m panicked – what can I do?
Signed, Hardly Strolling

Dear Hardly,
Mini-strokes, or transient ischemic attacks (TIAs) occur anywhere from 200 to 500 thousand times per year in the United States. The risk of TIA increases dramatically with age, with the majority occurring in patients over the age of 70. The definition of a TIA is a neurologic event that resolves within a 24-hour period. In other words, signs and symptoms of stroke (whether it is numbness, weakness, speech disturbance etc), disappears over the course of only a day. Risk of full stroke appears to be higher at two days (3.1% risk), one week (5.2%) and three months (10-15% increased risk). Patients with TIAs need rapid assessment and may require evaluation of the carotid arteries for blockage, or ultrasounds of the heart to rule out clot formation.
More recent studies suggest a so-called "ABCD" system for predicting future stroke risk. This allows patients to be stratified according to their inherent medical risks and determines whether or not they need elaborate investigation. The ABCDs studied are age (greater than age 60 = 1 point), blood pressure (> 140/90 = 1 point), diabetes (present = 1 point), clinical features (weakness = 2 points, speech impairment = 1 point), and duration of symptoms (>60 minutes = 2 points, 10-59 minutes = 1 point). Any score greater than three warrants further evaluation. A score of three imparts only a 1% risk at 90 days out from the previous TIA, whereas a score of seven increases the 90-day risk to 6%.
It’s hard to say whether or not you need formal evaluation, as more clinical information is required. I will say that obvious risk prevention measures are in order. I recommend lowering LDL (bad cholesterol) to less than 70. Use of a statin like zocor may be indicated regardless of lipid levels given their potential ability to stabilize plaques and prevent strokes and heart attacks. Blood pressure should probably be lowered to less than 130/80. If you are a smoker, you need to quit, as this remains a huge risk for recurrence. Finally, the addition of an anti-clotting agent like aspirin has definitive data behind and I add 81 mg of aspirin to nearly all patients who have suffered a TIA.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Wisdom Teeth "To Go or Stay?"- Dec. 11, 2008

2008-12-11T07:40:00.001-08:00

By Dr. Spence
Most adults had to deal with the eruption or lack of eruption of their wisdom teeth. Frequently, dentist will recommend the surgical removal of wisdom teeth. Many people have questions concerning whether to extract their wisdom teeth or leave them in their mouths. Here are some factors that are considered when making this decision about wisdom teeth extractions.
The predominant problem with wisdom teeth is their location in the jaw. The amount of space available for eruption and the tooth’s position are major factors. Often small-framed people do not have enough room for their wisdom teeth to fully erupt. This lack of space also allows for the forming wisdom tooth bud to assume a position or angle, which does not allow for the tooth to ever completely erupt. As a person grows and matures into their middle to late teen years, the development of the wisdom teeth is approaching completion. As the teeth mature and grow, they are naturally attempting to erupt into the mouth as they were designed to do. If space, position, angle, or location will not allow for full eruption, a huge problem is created.
Often, the wisdom teeth only partially erupt allowing for bacterial invasion into the gum and bone surrounding the partially erupted tooth. This sets the stage for major inflammation and possibly a large infection to develop in the area. If allowed to go untreated, the inflammation-infection process usually comes and goes until eventually the infection spreads into the facial areas causing enormous pain and swelling. The cause of the problem is the position of the wisdom teeth, and the only permanent solution is the surgical removal of the tooth. Many people ask if taking antibiotics alone could solve the problem. While antibiotics will help the body fight the infection, it will not solve the problem itself. Besides the gum and bone infection that can occur, often the wisdom teeth sit directly against other teeth causing excess pressure that can lead to decay or erosion of the adjacent second molar. If that damage goes undetected for a long enough time, the adjacent tooth may become infected necessitating a root canal or a surgical extraction of an additional tooth.
Of utmost importance, in regards to wisdom teeth is the timing of the decision to extract. If there is a strong indication that there is a lack of space, poor position or angulation, then the younger you are, the better your chances for the best outcome. The older a person is, the more difficult the surgery, with an increased chance for a difficult recovery. Consult with your dental professional for yourself or your family member for the best guidance concerning the extraction of wisdom teeth.

Dec. 4, 2008

2008-12-10T11:17:00.000-08:00

Dear Dr. Spence,
Is there any value in treating high blood pressure in an 84 year old? My father is on three medications. He is generally healthy, but the cost is progressively becoming an issue.
Signed,
Heir Apparent

Dear Heir,
Great question. I think there is great value in maintaining blood pressure in an elderly patient and this has been supported in the literature. The HYVET study (Hypertension in the Very elderly Trial) evaluated 3845 patients with an average blood age of 83.6 who had a systolic blood pressure greater than 160 mm Hg. These patients were placed on either one or two drugs depending on response. At two years, anti-hypertensive drug therapy reduced fatal stroke by 39%, death from cardiovascular disease by 23%, death from heart failure by 64% and death from all causes by 21%. Not only that, these patients were generally free of underlying heart disease. One may have expected even more impressive numbers had they used a more representative sampling of the geriatric population as nearly 70% of patients over 80 years of age have heart disease or diabetes.
Blood pressure control is crucial regardless of age. It is recommended to treat at least 140/90 or less for the majority of patients. Cost is certainly an issue, however. Generic combinations can generally be effective in achieving optimal control.

Dear Dr. Spence,
What’s all the fuss about liver damage with the use of medications like lipitor or zocor? I saw the TV ads and now I’m paranoid that I’m destroying my liver completely!
Signed,
Hadda Sclerosis

Dear Hadda
Undoubtedly, the perceived risk associated with the use of statins medications (those for cholesterol lowering) are grossly overstated. The FDA recommends checking liver functions, a marker of liver damage, at the start of therapy, at 6-12 weeks and periodically thereafter. An analysis of 35 studies involving 74,102 patients reported the risk of liver function test elevations to be 4/1000. Other studies suggest that severe elevations may only occur in 0.1% of patients treated. The FDA reports only 0.69 cases of true liver failure or hepatitis for each one million prescriptions written.
There does seem to be widespread concern about the damaging effects of these drugs. I have witnessed it countless of times in my own office. It is crucial to recognize the positive effects that the statin class may provide. Only 27 patients would need to be treated with a statin to prevent one cardiovascular death whereas the number needed to harm one patient is approximately 3400. Usually, even with an increase in liver function tests, discontinuation of the offending agent quickly reverses these numbers back to normal.
Given the overwhelming greater likelihood of dying from a massive coronary versus suffering statin induced liver damage, I say use the statin. Further, though it is suggested that periodic testing be done to evaluate for liver damage (every six months is standard), there is really no evidence proving it is either helpful or necessary. I still check as recommended mostly because I’m not fond of lawyers (no offense).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Medical Myths Debunked Part 2

2008-11-28T03:00:00.000-08:00

I continue from last weeks investigation into the various medical myths and misunderstandings that often surround various medical conditions.

Arthritis:
Arthritis remains one of the most common causes of disability in the United States with an estimated 46 million Americans affected. With the aging of our population, those numbers are only expected to skyrocket. Much of our understanding of arthritis and its manifestations have been clouded in misunderstanding of the disease process. First is that arthritis only affects the elderly. In actuality, 2/3 of sufferers are younger are younger than 65 years of age, though these cases may not be strictly osteoarthritis (the most common type). There are multiple types of arthritis – from the standard non-inflammatory osteoarthritis to the more disabling types such as rheumatoid arthritis (among others).

Despite the suggestions that there is generally no treatment for arthritis, this is indeed a myth. Though standard osteoarthritis is a progressive disease of aging and joint overuse, there are certainly a variety of modalities that may be used to counter the effects. Examples include everything from physical therapy to pool exercise programs and bracing to medications. Weight loss may be a critical factor as studies show that even the shedding of ten pounds may decrease the risk of knee arthritis by 50%.

Another myth is that exercise or continued use will worsen arthritis pain. In actuality, exercise is crucially important in maintaining muscle strength and joint stability. Regardless of severity, I always encourage my patients to get up and move.

There is some evidence to suggest that elderly patients with arthritis can predict changes in the weather. A study from the United Kingdom indicates that there may be an association with changes in barometric pressure and the subjective sensation of increasing arthritic pain. I have yet to meet a patient with arthritis who did not generally ache more in colder, gloomier weather.
Of note, there is no evidence that cracking your knuckles increases the likelihood of developing future arthritis. Sorry mom.

Exercise and weight loss:
No one disputes that exercise is an important tool in assisting with weight loss. The question is: How much and how often? Previously, it has been suggested that patients get 30 minutes of moderate intensity exercise at least three to four days per week. A recent two year study at the University of Pittsburgh has challenged their recommendations and given more concrete advice on how to maintain weight. Investigators studied the effects of exercise on weight loss in 191 overweight women. They were all prescribed a 1500 calorie diet (not much!) and were assigned to one of four levels of exercise. As a group, they lost an average of 17 pounds in six months, and then gradually regained half of that amount in the following 18 months. Exercise amounts followed the same pattern, increasing in the first six months, then falling off over time. Those subjects who maintained their weight over the two year study engaged in at least 1800 calories per week of physical activity which translates to 275 minutes of exercise per week. Thus, if you expect to lose weight and maintain it, a low calorie diet coupled with the burning of an additional 1800 calories per week is necessary. That corresponds to more than thirty minutes of moderate intensity exercise daily! Those who think their jobs provide them adequate exercise are gravely mistaken – it may provide some baseline calorie shedding but it is not enough to reverse the process of obesity.

Medical Myths Debunked

2008-11-13T08:47:00.001-08:00

By: Dr. John Spence

Medical Myths Debunked
The next several installments focus on issues that are commonly misunderstood by the general population. Sometimes popular misconceptions surrounding a particular ailment are a byproduct of old wife’s tales or media error. Regardless, issues such as sleep hygiene, arthritis and hypercholesterolemia are extremely common and deserve some discussion. I have started the ball rolling this week by tackling the topic of sleep – I don’t think I’ve met too many people who claim to sleep well on a regular basis or couldn’t stand to get a few more hours of shuteye here and there.
Sleep:
It has been estimated that 74 million Americans experience some form of sleep disorder. Adequate sleep is a priority – skimping on sleep typically does not solve workload issues and ultimately may impair productivity. We have all heard stories about how famous intellectuals like Benjamin Franklin or Thomas Jefferson only required four hours of sleep per night. The truth is that most people require seven to nine hours per night to function at an optimal level. Task performance suffers exponentially as sleep intervals incrementally decrease.
One myth that surrounds sleep hygiene is that teenagers need the same amounts as their adult counterparts. Another variation on this is that teenagers are inherently lazy and sleep all the time. The reality is that teens may physiologically require 9 ½ to 10 hours of sleep each night. Teens tend to become sleep deprived by going to bed late and getting up early for school. They try to make up for sleep deprivation during the week by catching up on the weekends and sleeping until 1 pm. This rarely works and may lead to chronic sleeping problems, not to mention potentially impaired thinking and school performance.
Many individuals think that snoring is more nuisance than a true problem. We know that, in fact, it may be a sign of sleep apnea which has been associated with heart disease, stroke and hypertension. Sleep apnea has been discussed in previous articles, but may be manifested by snoring, daytime sleepiness and general fatigue, morning headaches and changes in personality (i.e. irritability). A recent 14 year study investigating moderate to severe sleep apnea showed a mortality rate of 33% compared with 7.7% mortality in the group without sleep apnea. Put another way, sleep apnea has the same effect on mortality as getting 18 years older. I recognize that no one really wants a sleep study nor cares to sleep with a cumbersome, potentially uncomfortable CPAP mask and machine, but I’m quite sure no one wants to die earlier than necessary! Get checked out if you think you’re at risk!
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Poison Ivy & Lice

2008-11-10T10:45:00.000-08:00

Dear Dr. Spence,

Yes, I’ve got it. Poison ivy. Can you tell me how I can treat this and get some relief! Does it ever go away?

Signed, Imma Itchin

Dear Imma,

I used to think I was immune somehow to the effects of urushiol, the chemical substance responsible for the horrendous itchy eruption we call poison ivy. Fact is, I guess I’d never actually made contact with the vine. Not only was it a miserable experience, but a learning one as well. The biggest single myth, that it can be spread through scratching other areas of the skin, is completely false. At initial exposure, if it contacted your hand and then you touched your face, then it may appear on your face. Once the chemical is washed off, however, the potential for spread is gone. Typically, the rash will be at its worst on days five through seven with resolution occurring in approximately three weeks. To assist with the intense itching, avoid hot showers or baths and sun exposure. Application of wet, cold towels to the area may also offer relief. Over the counter agents such as calamine, techno or saran can be used with varying degrees of success. In a pinch, depending on the surface area involved, I use a tapering dose of oral prednisone. Not only is it dirt cheap, but it is also more effective than the pre-packaged dose packs that often result in a flare once the pack is completed.

Dear Dr. Spence,

My child has lice. What’s going on – how can I treat them effectively without recurrence? Signed, "Bugs" Onnus

Dear Bugs,

Anyone can get lice, but it is most commonly affects children ages 3-11. An adult louse is about the size of a sesame seed and is tan or gray in color. It can live on the scalp for a month. They feed on blood – it is the saliva of these little beasts that is felt to cause the itching. A female louse may lay six to tens eggs (or nits) per day. These may be mistaken for dandruff, but they are close to the scalp and affixed to the hair shaft. Most kids contract lice through direct head to head contact at school, on the playground, at camp or at a slumber party. They can also be passed on via clothes, combs or brushes. There are dozens of potential treatments for lice, some over-the-counter, and some by prescription. Clothes and linens should be washed thoroughly in hot water then dried at high heat for at least 20 minutes. All non-washable items (stuffed animals) should be placed in sealed plastic bags for two weeks. Floors and furniture should be vacuumed and all combs and brushes should be soaked in rubbing alcohol for one hour.

Questions on Stop Smoking

2008-11-07T14:08:00.000-08:00

Dear Dr. Spence,
How can I stop smoking?
I have heard there are some new medications that may help me.
Signed,
Nick O’Tine

Dear Nick,
Cigarette smoking is one of the single biggest modifiable risks known in health care. We all know its effects on the lungs, but it is directly linked to six of the eight most common causes of death. It can affect nearly every organ system, therefore, attempts at smoking cessation, though difficult, are absolutely worthwhile. Based on data from the Surgeon General’s report from the United States Department of Health, at day one after the last cigarette there is no further damage to the skin from smoking. At day two, carbon monoxide levels in the blood return to normal. At two to twelve weeks, lung function may increase and circulation may improve. At one year, risk of coronary artery disease is one-half of that of a smoker’s and at ten years, the risk of lung cancer is half as well. Finally, at fifteen years, the risk of stroke and coronary artery disease are equivalent to that of a nonsmoker. A host of agents have been utilized to assist patients in their quest to stop smoking; most have shown minimal to moderate benefit. These include tried and true products like patches, gum, lozenges and inhalers that mimic the hand-to-mouth "psychologic" aspects of smoking. Others have tried zyban (also marketed as wellbutrin for depression) albeit with mixed results. The newest agent in the war against smoking is varenicline (chantix), a nicotine receptor blocker that appears to block the ability of nicotine to exert its effect, namely the stimulation of the central nervous system. Further, the stimulation of dopamine centers in the brain appears to be the driving force in the reward and reinforcement of smoking. Chantix appears to blunt this "reward" system. Studies indicate a fairly high quit rate in those taking chantix. My own experience is quite positive. I venture to guess that 60-75% of my patients have had success, even the most hardened, yellow fingered professional smokers! Side effects include nausea (30% in studies), sleep disturbances, constipation, flatulence and vomiting, though I have not seen a tremendous amount of these issues pop up. There may be a worsening of pre-existing psychiatric illness, so care should be taken in those patients with a history of any mental disorder. Cost can be prohibitive – imagine that! The up-front cost may exceed $100 but the long-term savings may be magnified 10-fold, both monetarily and from an overall health standpoint. In my clinic, it appears that 50% or more may quit with the first prescription (starter pack) while the rest may require a second month (continuation pack). The company recommends at least a twelve week period of therapy with a possible extension out to 24 weeks.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Herbal Medications Part Three

2008-11-07T14:07:00.000-08:00

Previous articles have focused on the use of herbal supplementation for a variety of systemic ailments. There is mounting evidence that many readily available and widely used herbs may ease the nagging discomfort of arthritis. Over-the-counter remedies such as glucosamine, chondroitin sulfate and SAMe have been studied extensively for osteoarthritis (OA) and do seem to impart substantial benefit. Lesser known, however, in the battle against OA is the use of the following five common kitchen spices. They all appear to exert their effect through antioxidant and anti-inflammatory properties.
(1) Saffron – Saffron is a potent antioxidant herb that is handpicked from crocus blossoms. It is expensive (tapping in at $45 per ounce), but can be used either as a brewed tea or as a topical agent that can be rubbed directly into the joints.
(2) Ginger – As noted in previous installments, ginger has long been used as a traditional Asian remedy for arthritis pain. It tends to improve blood flow to the joints, certainly important during the rainy season when patients complain the most of arthritic flares. Many use ginger in oral supplements at doses of 500 milligrams three times per day whereas others prefer ginger tea (one teaspoon of ginger in hot water, steep for 20 minutes, strain, enjoy!).
(3) Cayenne – We all know cayenne is capable of burning your lips off, but it can also block a substance known to transmit pain signals in the body. It is generally used topically much like saffron and acts as an "herbal heating pad".
(4) Tumeric – Tumeric has been shown to decrease inflammation, reduce swelling and even prevent cartilage destruction. It is typically found in curry, a well-known staple of East Indian diets. Consumption of curry dishes several times per week or supplementation with tumeric capsules (100 mg two to three times per day) is recommended in order to exert the fore mentioned effect.
(5) Rosemary – Generally found in Mediterranean diets, rosemary contains phytochemicals and antioxidants that decrease joint inflammation and subsequent pain. Add six drops of rosemary to a ½ teaspoon of almond oil and rub into painful joints. Obviously, OA can be a progressive and debilitating condition without cure. These herbs may not be effective for everyone, but given their potential benefit and ease on the wallet, it may certainly be worth the taste!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

The Daily Dose 2/28/08

2008-11-07T14:06:00.001-08:00

I am always amazed at how medicine changes. Treatments that were previously considered to standard of care have come under great scrutiny and some are now recognized as potential harmful. Some issues that immediately come to mind are the controversies surrounding estrogen replacement therapy, and the use of vitamin E as an antioxidant. Even in the short time I have practiced medicine I have been witness to several of these "awakenings". My mentor in residency training (who was in his late 40’s) speculated that 50% of what he had learned was either obsolete or outdated. A recent study by Dr. Bolland and his associates in New Zealand further challenge medical knowledge. In a five-year study of 1471 osteoporosis patients, Bolland has found that calcium supplementation may in fact be harmful and contribute to an increased number of cardiovascular events. In the study, women were randomized to receive calcium at 1000 mg per day or placebo. All women were postmenopausal and over the age of 55. Ten percent were older than 80. Every six months, they evaluated the two groups for death, chest pain and stroke. A total of 21 of the 732 women in the calcium group had heart attacks compared with only 10 of the 739 in the placebo group. This was determined to be statistically significant. The authors suggest therefore that supplementation with calcium may be harmful. Many experts caution that it is too early to recommend that females discontinue this practice, but it certainly does open a lot of eyes. It has been postulated that the amount of calcium in the older female declines in bone but somehow manifests itself within the lining of blood vessels thereby speeding up the process of arteriosclerosis. Additional intake of calcium may hasten the process and increase risk of cardiovascular events.
A study from 1999 revealed a one-third decrease in cardiovascular deaths in those women who had the highest amount of calcium intake. Obviously, this is in complete opposition to the Bolland study. What does all this really mean? My general reaction is that one study is rarely enough to generalize treatment for a whole group. Conflicting results from previous studies only cloud the matter and serve to confuse patient and physician alike. Women may certainly ask me what to do in this case. I think it is premature to suggest they stop their calcium or vitamin D. In fact, until further data proves a definitive link between calcium intake and cardiovascular mortality, I will continue to suggest 1200-1500 mg of calcium and 800 IU of vitamin D per day for most women. In five years, we may laugh at ourselves and ask, "What was I thinking?" This seems to be the trend in medicine, a trend towards humility in the face of an ever-growing body of knowledge and sophistication.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Cholesterol Lowering & Levels

2008-11-07T14:04:00.000-08:00

Dear Dr. Spence,
I am concerned with recent news regarding the use of the cholesterol lowering medication, vytorin. Am I being placed at unnecessary risk by being on it?
Signed,
HDL

Dear HDL,
The concerns behind the "mass hysteria" about this drug are all based on the results of the ENHANCE trial. This study investigated plaque formation in the carotid artery and found that there was no significant difference between the uses of zocor versus vytorin (vytorin is the equivalent of zocor and zetia in combination). Given the fact that zocor is generic and has proven benefit, it has been argued that adding the zetia component is useless. Unfortunately, this study was not designed to assess whether or not either medication was superior in preventing heart attacks or strokes. As of yet, it is unclear if the zetia component makes a difference in preventing serious outcomes. Should a patient be taken off vytorin? This is a complex question. We do know that lower LDL cholesterol (bad cholesterol) remains the primary focus of lipid lowering strategies. Vytorin seems to be the best at doing this, so one would argue that it is the best medication to be on, period. Again, studies comparing vytorin and zocor are underway, therefore we cannot say vytorin is inherently better at preventing strokes and heart attacks. I always look for the cheapest alternative without compromising health and zocor is certainly a great first line choice in lipid lowering. If a patient is at goal on vytorin, it may be wise to keep them on the medication rather than rock the boat. Final answers to this question will be available in 2010 (roughly) once the head-to-head trial has been completed.

Dear Dr. Spence,
What should my cholesterol level be? I am 45 years old without any medical problems.
Signed, Curious George

Dear George,
From the standpoint of LDL cholesterol (bad cholesterol), we know that for every 30 point increase there is an increased risk of heart disease by 30%. This underscores the importance of lipid lowering in combating death from heart attack. Generally, a physician will evaluate overall risk and determine a cholesterol goal. In your case, it is recommended that the LDL be less than 160. On the other hand, throw in risks like smoking and hypertension, and then the goal may change to 130 or less. Patients with known diabetes are encouraged to keep their LDL levels below 100 and patients with known coronary artery disease are urged to push to below 70. The other parameters (i.e. triglycerides and HDL or good cholesterol) are also important but take a back seat compared to LDL. HDL should be as high as possible, preferably greater than 40-45 depending on sex. Triglycerides should be generally less than 150.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Polycystic Ovary Syndrome

2008-11-07T14:03:00.000-08:00

Dear Dr. Spence,
Could you please give me some information regarding polycystic ovary syndrome? I have been doing some research into my infertility and am concerned I may have it.
Signed,
Concerned

Dear Concerned,
Polycystic ovary syndrome, or PCOS, is a common endocrine disorder affecting approximately 6% of reproductive age women. I can empathize with your position – PCOS is the leading cause of infertility. Its cause is unknown, but seems related to the overproduction of hormones like testosterone. Afflicted women have a constellation of signs and symptoms including the infertility, but also menstrual abnormalities, obesity, acne, excessive hair growth and an increased tendency towards diabetes mellitus. Women tend towards enlarged ovaries with multiple cyst formation, thus the name. It should be noted that women with PCOS are three times more likely to develop uterine cancer. Lab evaluation can be helpful; often the diagnosis is clinical. Supporting labs include elevated luteinizing hormone (LH) with possible increases in testosterone, and elevated blood sugars, so-called insulin resistance. Treatment is directed at improving and/or controlling symptoms of the disease. To assist with fertilization efforts, as in your case, drugs like clomiphene are used. Clomiphene can improve ovulation rates to 70% though actual pregnancy rates may fall to 30-40%. Women with PCOS who desire fertility are generally referred to and managed by reproductive endocrinologists. Women with menstrual irregularities not concerned with conception often use low dose oral contraceptive pills or medroxyprogesterone (proevra) every day for 10 to 14 days each month. This decreases the likelihood of abnormal uterine cell growth which is a contributing factor in the development of endometrial (uterine cancer). Women with excessive hair growth may use oral contraceptive pills as well and will usually note improvement after six months of treatment. Other medications that may be used for this condition include spironolactone and flutamide – they work by inhibiting androgen production which has been implicated in the aforementioned symptoms of PCOS. Finally, insulin resistance and elevations in blood sugar may eventually result in overt diabetes mellitus. To combat this, many physicians may use metformin (glucophage) initially as a stabilizing medication, though it is unclear if it should be used in those with normal glucose levels Certainly, the most important factor with polycystic ovary syndrome is in making a diagnosis in the first place. Like many diseases, it is under recognized in a clinical setting unless certain telltale symptoms arise. Many times these develop late in the course of the disease itself, delaying diagnosis for years.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Herbal Medications Part Two

2008-11-07T14:02:00.000-08:00

This represents a continuation of a previous article discussing some of the risks and benefits of herbal medication. As noted, herbal use has topped annual sales in of $1.5 billion. Many physicians have been reluctant to endorse them given their lack of FDA regulation and potential for possible adverse effects.
Kava: Kava is derived from a shrub found in the South Pacific and has been used in those cultures for over 3000 years. As a ceremonial beverage, it purportedly has relaxing and sleep enhancing effects. The downside, however, is the trend toward excessive sedation and its ability to potentiate other "sedative" type drugs i.e. alcohol, antidepressants and barbiturates, etc. Randomized studies have shown success with the short-term use of kava for the treatment of anxiety disorder, but caution must be taken when considering the use of this herbal preparation. Side effects include possible gastrointestinal distress, dermatitis and possible yellowing of the skin (which is fortunately reversible).
St. Johns Wort: Many are familiar with St. Johns wort, an herbal supplement indigenous to the United States that has been shown to improve the signs and symptoms of depression. Of all the herbal medications, St. Johns wort has received the most popularity and, therefore, the most clinical evaluation. Twenty three studies (over1750 patients) demonstrate efficacy in treating mild to moderate depression, thus it remains a reasonable initial choice for many patients. It should not be used in combination with over-the-counter decongestants, red wine, cheese, or smoked meats. I know that sounds odd and completely random, but it has to do with specific chemical interactions between the medicine and certain foodstuffs. At doses of 300 milligrams three times per day, side effects are minimal and include dry mouth, sedation and GI upset.
Saw Palmetto: Saw palmetto is used to treat the urinary symptoms of an enlarged prostate by decreasing the amount of prostatic fluid within the gland and acting as an anti-androgen to shrink the gland itself. Trials with 2939 men have shown that it is as effective as proscar, an established medication used for BPH (benign prostatic hyperplasia) that is available by prescription. Doses of 160 milligrams twice a day are recommended – side effects include headache and once again, gastrointestinal upset. It is critical for physicians to assess for herbal medications use given its increasing popularity. Estimates suggest that greater than sixty million Americans use herbal supplements. Many docs may not ask about supplements on a regular basis (myself included!) therefore I always suggest that patients alert their providers about such use.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Herbal Medications Part One

2008-11-07T14:01:00.000-08:00

Herbal medication has skyrocketed in popularity over the last decade with annual sales in excess of $1.5 billion. Many physicians are reluctant to endorse these products given their general lack of stringent FDA control, possible adverse effects or interactions with other medications and lack of safety data. The following represents an overview of several of the more popular agents on the market; much of the information provided is based on randomized placebo controlled trials, which essentially means they have been tested against sugar pills.
Echinacea: Many studies have investigated the use of Echinacea in the treatment of the common cold, but none have ever proven its efficacy. The mechanism by which it works is unknown. It should not be used beyond eight weeks due to continued stimulation of the immune system. Those with HIV, tuberculosis, multiple sclerosis or other immune disease like lupus also should not use it
Gingko: Gingko leaf extract, taken from the oldest living species in the world (gingko tree) has been used to treat dementia, headache, hearing loss, the symptoms of peripheral artery disease or PAD, and potentially improve memory. Doses of 120-240 milligrams per day have been demonstrated in clinical trials to improve cognition in Alzheimer’s dementia. One small study (202 patients) showed improvement in cognitive scores that were comparable with the Alzheimer’s drug, aricept. Studies also have confirmed improved walking distance in those with severe peripheral arterial disease. Gingko is generally considered to be safe with only occasional complaints of headache, dizziness or abdominal distress. It should be pointed out that gingko can contribute to bleeding abnormalities in those already taking blood thinners (i.e. aspirin or coumadin).
Ginseng: Ginseng has been used for medicinal purposes for over 2000 years on the Asian mainland. It is felt that it has a positive effect on stamina and resistance to stress, improving both memory and physical endurance. It has shown some effect on glucose metabolism in diabetics with average drops in blood sugar of 15-20 points. Average dosing of Asian ginseng is 200-600 milligrams per day for one to three months with a two-week ginseng free interval between cycles. Side effects include diarrhea, euphoria, insomnia and vaginal bleeding among others. The next segment in this short series will delve into several other over-the-counter supplements that have become extremely popular throughout the United States and future articles will focus on several of the lesser known (but not uncommon) agents that are available.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Osteoporosis

2008-11-07T14:00:00.000-08:00

Dear Dr. Spence,
I have been informed of a new medication for osteoporosis that is given only once per year. Is it effective and can I get it?
Signed,
Curious George

Dear George,
Zoledronic acid, or reclast, is a novel infusible agent used to treat osteoporosis. It is given as an intravenous infusion once yearly and generally takes approximately fifteen minutes to administer. Ten million people in the United States have osteoporosis and there are 300,000 hip fractures each year. When one considers that women with hip fractures are three times more likely to die within the next six months, we realize just how important prevention is. Previous therapies revolved around the oral osteoporosis drugs called bisphosphonates (actonel, fosamax, boniva). One study in greater than 35,000 women over age 45 showed a 45% risk reduction in fracture over two years. The number needed to treat to prevent one fracture was 125. Unfortunately, compliance with these medications was a major obstacle. Only 20% of the women enrolled in the aforementioned trial completed the study at one year. These drugs can cause significant gastrointestinal side effects including nausea, stomach upset and severe reflux. They need to be taken with an 8-ounce glass of water prior to eating or drinking and the patient must remain upright for at least 30-60 minutes. Reclast, on the other hand, appears to be a viable alternative with fewer complications. Studies have shown a reduction in vertebral fractures by 70% and hip fractures by 41%. Even more amazingly, there was a 3.7% absolute risk in death. Only twenty-seven patients need to be treated for two years to prevent one death, or nineteen to prevent one clinical fracture. One caveat – at $1200 per dose it can be an expensive option. Fortunately, it looks like medicare will reimburse for reclast infusions, thus making it an even cheaper option for treatment of osteoporosis. At this juncture, few physicians provide the infusion. Our office has been sending patients to other clinics that do carry the medication. Dear Dr. Spence, How do I know if I have irritable bowel syndrome? Signed, Crampy Dear Crampy, Irritable bowel syndrome (IBS) is an extremely common condition. It is generally a clinical diagnosis based on patients presenting complaints and is the gastrointestinal specialists most common diagnosis after referral. There are no clinical tests that help make a concrete diagnosis, but they are often used to rule out other pathologies. Patients are usually classified as being constipation predominant, diarrhea predominant or mixed. If you want to get technical, there are specific ROME criteria to assist in establishing a diagnosis of IBS. Patients may present with bloating, constipation, gassiness, or abdominal pain and cramping often relieved by bowel movements. Treatment remains challenging - zelnorm was a great agent until its removal from the market. Now we try antidepressants, antispasmodics and a host of medications geared towards treating constipation (i.e. amitiza.)

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Vitamin D

2008-11-07T13:59:00.000-08:00

Dear Dr. Spence,
How important is vitamin D? Don’t I get enough from my diet?
Signed,
Dee Dee

Dear Dee Dee,
Vitamin D is critically important in maintaining healthy bones, this much is clear. It is estimated that one billion people worldwide have a vitamin D deficiency. Amazingly, a study at a Boston hospital found a whopping 32% of healthy students, residents and physicians were vitamin D deficient despite intake of multi-vitamins and a glass of milk per day! Most vitamin D is obtained from sun exposure (3000 IU per exposure of 10 to 15 minutes) versus dietary sources (one cup of milk = 100 IU). Recent data suggests that most women should ingest 800 IU per day, whereas previous recommendations were set at 400. Many patients diagnosed with osteoporosis actually have vitamin D deficiencies. Bisphosphonates like fosamax will not treat osteoporosis in these cases and may actually lead to severe low calcium levels. It becomes increasingly important that any patient diagnosed with osteoporosis be screened for vitamin D deficiency. Most patients can supplement with 800 to 1000 IU per day to help maintain normal levels, but those with malabsorption may require 25,000 to 50,000 IU per week. So what? We know that supplementation of vitamin D may help prevent osteoporosis, but more recent studies show it may decrease the risk of falls in elderly populations and may decrease cancer rates. A study of 1180 women older than 55 years of age revealed that supplementation with 1000 IU of vitamin D plus calcium decreased the risk of cancer by roughly 35%. The number needed to treat to prevent one case of cancer is only 21 with an absolute risk reduction of 5%. Not bad for something as simple as vitamin D, which generally has minimal, side effects, even at massive doses. Update on peripheral vascular disease (PAD): A German trial of 6880 patients greater than 65 years of age revealed a five year mortality rate of 19% in those with PAD. None of those patients had symptoms! The rate rose to 23% in those with symptoms; a very small, insignificant difference. The bottom line: PAD carries a poor prognosis regardless of whether a patient has signs or symptoms of leg pain or not. Mortality as a whole is increased by 60-80% in patients with PAD. Recommendations by the German authors are that all patients older than 70, or those aged 50-69 with cardiac risk factors, should be screened. Not a bad idea given the relative low cost, good insurance coverage, and ease of testing.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Physical Exam & Preventive Services

2008-11-07T13:57:00.000-08:00

Dear Dr. Spence,
I am 79 years old and have not had a physical exam in quite a while. What sort of preventive services can you recommend?
Signed,
Gertrude

Dear Gert,
Guidelines for preventive care have been determined by the United States Preventive Services Task Force (USPSTF) who has set up specific screening protocols for physicians to follow. They, of course, are merely recommendations and individual discussions should be held between patient and physician. Unfortunately, most of these guidelines do not take into consideration those patients older than 75, therefore some of the recommendations are extrapolated out based on available data. BREAST CANCER: The USPSTF recommends that women begin Pap screening within three years after the start of intercourse and no later than age 21. Further, once a woman reaches the age of 65 (unless she is at high risk), screening may cease. As mentioned in a previous article, Pap screening can be extended out to once every three years if the patient has had three consecutive negative annual exams. COLON CANCER: Screening should begin at age 50 and generally should be performed every 10 years thereafter if full colonoscopy is the screening method used. Some trials suggest that a life expectancy of at least five years is required before screening benefits are appreciated. In other words, screening of the oldest old may not be advisable. One study detected invasive cancer in 5% of 157 patients screened (all patients involved in the study were older than 85). Those confirmed to have cancer were symptomatic and had either blood in the stool, abnormal physical exam findings, or anemia. Thus, in the much older patient, perhaps we should only screen those with certain red flag symptoms. This is not the case in younger patients in whom most cases of cancer are detected in those without any symptoms at all. CARDIOVASCULAR DISEASE: CVD is the leading cause of mortality in the United States and causes 50% of all deaths in those 85 years of age or older. All patients should be screened for hypertension and hypercholesterolemia given the prevalence and associated risk. Recent studies suggest that treatment of high cholesterol in the elderly can still provide dramatic reduction in risk of cardiovascular death, assuming the patient has good general health otherwise. OSTEOPOROSIS: About one half of all postmenopausal women over the age of 50 will suffer an osteoporotic fracture in their lifetime. Women age 75-79 have a 14 fold greater risk for osteoporosis than those ages 50-54. The USPSTF recommends screening of all women greater than 65 years of age or older than 60 if that patient is at high risk. Interestingly, no specifics surrounding screening in men have been delineated, though there still appears to be an inherent risk as a man ages.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Shingles

2008-11-07T13:56:00.000-08:00

Dear Dr. Spence,
Would you please provide some information regarding the new vaccine for shingles?
Signed,
Imma Rash

Dear Imma,
I appreciate the question – this is a good opportunity to discuss several new vaccines that hit the market recently. First is the zostavax vaccine to prevent herpes zoster, or shingles. Herpes zoster is essentially a reactivated chicken pox virus. Nearly 99% of the population will test positive for antibodies to the chicken pox regardless of whether they had it or not. The virus remains dormant in the body for years then reappears along the course of a peripheral nerve. Shingles is an extremely painful condition associated with burning superficial skin pain and a horrible blistering rash. Many patients may develop a post-herpetic neuralgia, a chronic, often debilitating pain syndrome that remains long after the rash disappears. Zostavax is used in adults over the age of 60 to help prevent shingles. It contains a weakened chicken pox virus that can decrease your risk of developing shingles by an estimated 51%. Further, should a patient still develop shingles, the vaccine will help decrease the likelihood of developing post-herpetic neuralgia by 66% as well. One frequently asked question is whether the vaccine can be given to patients younger than 60 years of age or in those who have previously had shingles. Studies have not been performed to formally address these questions, but it is suspected that the vaccine may be effective in any age group (of course, insurance companies may not reimburse them). Secondly, the risk of getting shingles a second time is only 5%. Though not inherently harmful, the question that remains is whether $250 is worth dropping the risk of recurrence from 5% to 4%. The only side effects from vaccination are localized skin reactions (redness, pain, swelling, bruising) or headache. The second vaccine recently approved is gardasil, a vaccine geared towards girls and young women ages 9 through 26 to help prevent cervical cancer, precancerous lesions and genital warts. Again, though not studied, it appears to be both safe and effective for women older than 26. It may soon be approved for men as well to help prevent the spread of HPV (human papilloma virus), the virus believed responsible for causing cervical cancer. It is not known if the vaccine confers life-long protection or not. Preliminary data suggests that a booster may not be necessary. Time will tell.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on What is New in Diabetes Care

2008-11-07T13:54:00.000-08:00

Dear Dr. Spence,
What’s new in the world of diabetes care?
Signed,
I.N.Sulin

Dear I.N.Sulin,
Diabetes and diabetes care is in the midst of a "mini-revolution". Within the past year or so, several novel agents have found their way to the market. Unfortunately, at the same time, one drug has already been eliminated from the market while another is potentially on its way out. Pfizer introduced an inhaled insulin earlier this year in hopes of allaying the "fear of needles". Sales were abysmal; I suspect this was in part secondary to physicians reluctance to prescribe a bulky, difficult to use agent with potential adverse lung effects. Either way, they scrapped the drug entirely thus limiting insulin to injection only administration Another popular drug, avandia, has come under close scrutiny by the FDA after preliminary data suggested an increased risk of cardiovascular events. Though not removed from the market, enough controversy surrounds it to limit its use in most cases. Its sister agent, actos, remains a viable option without the inherent cardiovascular risk, though it can cause both weight gain and edema (swelling). Newer medications include both Januvia and Byetta. Januvia can be used in combination with most drugs and seems to do a fair job at lowering blood sugars. It acts directly by inhibiting the destruction of a crucial enzyme that plays a role in glucose metabolism. It decreases production of endogenous (within the body) glucose production among other effects. Byetta, though injectable, may be the most interesting and powerful new weapon in our diabetes armamentarium. Given subcutaneously twice a day, byetta works by decreasing appetite and increasing post-meal satiety (feeling of fullness), and by decreasing the body’s ability to produce excess glucose (much like januvia). These mechanisms translate to lower overall blood sugars, but also the propensity for weight loss, oftentimes quite dramatic. The package insert suggests an average weight loss of 11.2 pounds. I have personally seen patients lose upwards of 60+ pounds; some may be due to lifestyle interventions but I suspect most is directly attributable to the effects of the medication. Current research revolves around the utilization of Byetta depots which may allow patients to administer the injection on a once a week or once monthly basis. They may even provide more profound weight loss than that currently seen with standard byetta regimens. Panhandle Family Care has joined forces with Emerald Coast Research Group to bring diabetes research to our area. We are currently involved in three separate diabetes studies funded by large pharmaceutical companies. These companies enroll eligible volunteers in clinical trials and in return offer free medications, labwork, office visits, testing supplies and education. On occasion, they offer a financial stipend to those enrolled. One such study offers patients free study drug and 300 dollars for their participation in a one month trial. Any patient suffering from diabetic neuropathy (painful burning, numbness or shooting pain the feet) may be eligible. If interested, please contact Kelly Schroeder, the research liaison, at 850-598-3274.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Part Two of Medication Use in the Elderly

2008-11-07T13:53:00.000-08:00

The following represents the second in a two-part series on medication use in the elderly. In my previous installment, I discussed my process for evaluating elderly patients and their individual pharmaceutical regimens. My ABCDs of geriatric polypharmacy and compliance includes ASK and BEERs (as in Beers criteria for potentially dangerous medications). To further this discussion, we look at C and D.
C: Complications and Cost – Is my blood pressure therapy contributing to worsening constipation in Mrs. Jones? Would it be worthwhile to use another agent? Will medication X potentially act adversely with medication Y? Physicians need to be aware of a host of intervening factors that ultimately drive effective management of a disease process. Often these are not decisions based on medical knowledge but rather on knowledge of insurance formularies, patient feelings and expectations regarding their care, and cost issues. Does my 96 year old patient with heart disease really need clodiprogrel (plavix) as compared to simple aspirin at pennies a day? This may effectively decrease cost by over hundred dollars a month or more. Further, can I substitute a four dollar generic medication over a sixty dollar brand name when they have the same proven efficacy? Again, careful consideration of these factors will decrease polypharmacy and improve compliance, both of which will improve outcomes.
D: Discuss and Discontinue – Patients appreciate concern over medications and costs. In turn, this drastically improves trust within the doctor-patient relationship. Trust equals compliance. We are all guilty of so-called clinical inertia – a failure to act. There are many suggested reasons for clinical inertia – time constraints, cost, and drug coverage or simply, the patient looks good and has no complaints on their current regimen. To combat this, there must be an open discussion with patients to assess medical needs, risk of adverse effects and expectations of therapy etc. in order to determine the best course. Then, after all is said and done, axe some medicines. Though by no means exhaustive, this list of geriatric ABCDs can be utilized on a daily basis with minimal effort. As the elderly population sky-rockets and the number of available pharmacological agents rises, such efforts become critical in maintaining the health and welfare of this most important patient group.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Part One of Medication Use in the Elderly

2008-11-07T13:52:00.000-08:00

The following represents the first in a two-part series on medication use in the elderly. As medical director of a local nursing home, I feel it is my responsibility to address important topics with regards to geriatric medicine.
As our elderly population grows dramatically and our reliance upon prescription medication spirals upwards, polypharmacy takes center stage. Though not necessarily affecting you directly, we all have parents or grandparents who it certainly may affect. Studies show that most patients older than 65 years of age are on five or more medications. Can we, as providers, modify patient medication lists while at the same time decrease adverse risks and drug to drug interactions while improving compliance? The answer is a resounding yes! I have developed my own process for the evaluation of patients and their medications, my so-called ABCD’s of polypharmacy and compliance. Every single one of my office visits or trips to the nursing home applies these principles, thereby assisting in the ultimate elimination of unnecessary medicine.
A: ASK – the most obvious step in decreasing unnecessary medication use can be achieved by simply asking patients what medications they are taking, both by prescription and though over-the-counter/herbals supplementation. This needs to be done at every visit! A provider needs to ask themselves why a particular medication is being used. Is medication X being used to treat side effects from medication Y? Is medication Y still needed at all or was it originally used for a short-term condition? A perfect example might be a patient who took prilosec for a gastric ulcer. They took phenergan for associated nausea and antivert for dizziness and now take three medications six month later for an ailment requiring only four weeks of treatment. We must always ask ourselves if medications can be weaned or discontinued entirely.
B: BEERS - The Beers criteria is a well-defined list of potentially inappropriate medications for patients over the age of 65. The list has been consistently updated since its inception in 1991 to keep up with the ever-changing pharmaceutical armamentarium. Meds are listed as either high or low risk depending on their inherent danger to the elderly patient. The list includes common medications like darvocet, iron (325 mg/day), doxazosin (cardura) and cimetidine (tagamet), which are all considered lower risk. Higher risk medications include cyclobenzaprine (flexeril), oxybutynin (ditropan), amitriptyline (Elavil), alprazolam (xanax), antihistamines like benadryl, demerol and nonsteroidal anti-inflammatories like ibuprofen/Motrin. The list is lengthy and often surprising. I always make attempts to discontinue or change medications that are on the Beers list, a practice common in the nursing home setting and one which is gradually becoming standard of care.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Hemochromatosis & Sleep Apnea

2008-11-07T13:51:00.000-08:00

Dear Dr. Spence,
My uncle has been diagnosed with hemochromatosis and says I may have it as well. What can you tell me about the disease?
Signed,
Aches and Pains

Dear Aches,
Hemochromatosis is the most common genetic disorder in the United States affecting one in 250-300 whites in the population. It is grossly under diagnosed and under recognized as many patients never present with any substantial symptoms. It is estimated that every physician encounters a patient with hemochromatosis every two weeks whether they are aware of it or not. Hemochromatosis is a disorder of iron metabolism and is associated with an increased intestinal absorption of iron and deposition of excess iron in the liver, pancreas and other organs. Most patients are diagnosed after the age of 40 and most are symptom free. Common manifestations of the disease are fatigue, impotence and joint pain, with possible progression to overt diabetes mellitus and liver cirrhosis. There may be a darkening of the skin; "bronze diabetes" has been used as a descriptor. Diagnosis requires evaluation of iron status through simple bloodwork and genetic testing is available as well. Phlebotomy is the preferred treatment and entails removing approximately 500 ml of blood each week until the hemoglobin (red blood cell level) is lower than normal. Most individuals require 4-8 phlebotomies per year in order to maintain their levels.

Dear Dr. Spence,
Why is sleep apnea such a big deal?
Signed,
Masked and unhappy

Dear Masked,
OSA (or obstructive sleep apnea) should be suspected in anyone who is overweight, snores loudly or has chronic daytime somnolence and fatigue. I probably miss the diagnosis regularly since 99.9% of patients I end up sending for sleep studies actually have it. Perhaps I wait too long or perhaps it is not something we think enough about as a cause of patients symptoms. Either way, there is no doubt that sleep apnea contributes to long-term mortality. For starters, most patients feel miserable and often have suffered for years with chronic fatigue. Less obvious are those health problems that are directly attributable to sleep apnea such as uncontrolled hypertension and heart failure. CPAP (continuous positive airway pressure) is the most effective treatment for clinically significant OSA and consists of using a breathing apparatus at night that provides pressure to airways to keep them open. Unfortunately, tolerability remains a barrier to compliance. Complications include general discomfort, claustrophobia, nasal and eye irritation, nasal dryness and congestion. Strategies to improve adherence are critical and include adding humidification, treating nasal disease, allowing patients greater options with regards to masks and mask comfort, and providing regular follow-up.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on PAD & Burning Mouth

2008-11-07T13:50:00.000-08:00

Dear Dr. Spence,
I have recently seen the media advertise about the importance of being screened for PAD. What is this and what should I do?
Signed,
Ami Clogged

Dear Clogged,
PAD, or peripheral artery disease, essentially refers to decreased blood flow to the lower extremities secondary to arteriosclerosis. It is estimated that nearly 20% of those over 70 years of age are afflicted with PAD. Often, PAD coexists with coronary artery disease or cerebrovascular disease. Over five years, 4-8 % will require procedures to improve blood flow and 2-4% will require amputation. Patients who have symptoms (not all do!) will present with pain in the buttocks, thighs or calves that is elicited by exertion and relieved by a period of rest. Progression of the disease may lead to non-healing ulcers of the lower extremities and ultimate gangrene and amputation. The good news is that evaluation is both inexpensive and convenient. Essentially, a ten minute, in-office, non-invasive ABI (ankle-brachial index) will allow for easy assessment of vascular impairment. ABIs are calculated ratios between blood pressures taken in the arms and the legs. Any ratio less than 0.95 is considered abnormal and may require further investigation Management of the disease consists of both conservative and medical therapy. The most obvious risk modification can be achieved through smoking cessation. Patients need to stop smoking! Walking can also dramatically improve symptoms and complication as can stringent control of blood pressure and cholesterol levels. Secondary management consists of anti-platelet agents such as aspirin or plavix that are used to prevent clotting. Studies demonstrate that patients achieve an 18% risk reduction in stroke and heart attack if one of these agents is utilized. The newest drug for treatment of PAD is cilostazol (pletal). Fifty percent of patients suggested that their exercise tolerance/walking distance had improved on pletal; 84% on placebo felt their symptoms had worsened. Given the fact that September was officially PAD Awareness Month, there is no better time to address this issue and advocate more aggressive screening. And yes, we do screen in our office.

Dear Dr. Spence,
My mouth seems to burn and ache constantly. My doctor insists that there are no problems or diseases present. Am I going crazy?
Signed,
Hot Lips

Dear Hot Lips,
Your burning mouth issues are probably secondary to burning tongue/mouth syndrome. I know it sounds made-up and ridiculous, but it is a well known phenomenon in the medical literature that has no known cause. We think it is a variant of a neuropathic pain syndrome, or nerve pain syndrome. Irritation of a nerve often results in pain that is described as burning, shooting or stabbing; sometimes it is simply numbness. Treatment is geared towards decreasing nerve irritability. Options include amitriptyline (elavil), clonazepam (klonopin), capsaicin (hot pepper) and anti-seizure medications (neurontin). I have had some success with lyrica, but I must admit treatment remains frustrating for both patient and physician alike.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Mammogram Screenings & Adkins Diet

2008-11-07T13:46:00.000-08:00

Dear Dr. Spence,
What benefits should I expect from yearly mammogram screenings?
Signed,
CC

Dear CC,
Mammography remains a clinical conundrum. Should we or should we not screen for breast cancer? Given that breast cancer is the second leading cause of cancer death in the United States and that an estimated 40,000 will die from the disease this year, most might immediately advocate widespread screening. A woman’s chance of dying from breast cancer is 1 in 500 from the age of 40 to 49 with the risk nearly doubling for each additional decade of life. The real answer is substantially more complex. Studies demonstrate a 0.1% reduction in breast cancer death with mammography – not particularly impressive. In essence, if 2000 women receive yearly mammograms for 10 years, only one would have her life prolonged. That’s 19,999 mammograms that make no difference in patient outcomes. Furthermore, 10 healthy women would be unnecessarily treated and nearly 200 would suffer emotional distress and undergo additional testing due to false positive mammograms. These are certainly sobering statistics. Approximately 1792 women age 40-49 would need to be screened for 14 years to prevent one death (225,088 total mammograms). Obviously, the decision to screen for breast cancer is an individual one that needs to be discussed thoroughly with your physician.

Dear Dr. Spence,
What do you think of the Adkins diet?
Signed,
Dr. Adkins

Dear Doc,
I hate to be a naysayer, but I truly believe that most fad diets are ineffective in the long term and destined to fail. Studies consistently suggest that weight returns to baseline after two years regardless of what diet is chosen. What’s more, Adkins is tough to adhere to; just ask anyone who has tried it! Despite being a high fat, low carbohydrate diet, it does not appear to effect cholesterol readings, so at least it does not appear to be inherently unhealthy. Weight loss is obviously not easy. As a whole, a patient needs to have a caloric deficit of 3500 calories in order to lose one pound. With strict adherence to low calorie diets, a vigorous exercise regimen and a heap of patience, weight loss is possible though generally slow. I recommend the Mediterranean diet. Though not really a weight loss regimen, the cardiac benefits appear to be substantial.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Blood Pressures & Heartburn

2008-11-07T13:43:00.001-08:00

Dear Dr. Spence,
My blood pressures have consistently been 160/100. Should I panic?
Signed,
Headache

Dear Headache,
Great question, hypertension is the bread and butter of office practices, but an issue that is grossly undertreated. Seventy five percent of patients over age 50 can be classified as hypertensive, of which only 50% are actually being treated for their disease. Interestingly, only 50% of treated patients are at goal pressure levels! In my opinion, blood pressure is the single most important modifiable risk factor in medicine. Maintaining good blood pressure helps prevent stroke, heart attack, heart failure, kidney failure and a host of other ailments. For every 20 points above a systolic blood pressure of 115 (the top number), mortality increases two-fold. Based on your readings, you are at a four-fold risk. Guidelines recommend blood pressures less than 140/90 as a rule – I tend to be more aggressive and push for 120-130/60-80. Given the incredible number of blood pressures medications on the market, many of which are dirt-cheap, there is no reason that adequate blood pressure control cannot be achieved. Would I panic? No. Would I suggest I get my gluteus maximus in gear and see my doctor? You bet!!

Dear Dr. Spence,
Can I take medication for my heartburn forever?
Signed,
Jolly Joe

Dear Jolly Joe,
Many patients suffer significantly from heartburn or gastroesophageal reflux disease (GERD). Short-term therapy can be used in cases of documented gastritis or peptic ulcer disease. In the case of continued reflux, many patients remain on medications for years. Only recently, several interesting associations been made with their-term use. First, in some patients (mostly debilitated elderly patients), there may be an increased risk of pneumonia with the use of medications like nexium, prevacid, etc. Secondly, there has been an association between these medications and the development of vitamin B12 deficiency. B12 deficits may result in fatigue, anemia, mental status changes and other unpleasantries. The jury is still out on long-term safety. Like most medications, one must weigh the benefits of taking the drug versus the potential risks of not.

Dear Dr. Spence,
Should I get a Pap smear? I had a hysterectomy 10 years ago.
Signed,
Fireball

Dear Fireball,
According to ACOG guidelines (American College of Gynecologists), women who have had hysterectomies no longer need Pap screening. The exception is the case of hysterectomy due to cervical or uterine cancer wherein screening is generally recommended every three years after three consecutive negative yearly Paps. The same holds true for the general population. Of note, screening is not recommended after age 65 secondary to the low likelihood of cervical cancer in these women. Most men are off the hook.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Stomach Infection

2008-11-07T13:41:00.000-08:00

Dear Dr. Spence,
I am currently being treated for some kind of stomach infection. Sounds crazy to me. How could I have contracted such a thing?
Signed,
Bellyaching

Dear Bellyaching,
I presume you have been diagnosed with the bacteria heliobacter pylori, or H. pylori. Incredibly, it is estimated that one half of the world’s population is infected with an estimated prevalence of thirty percent in North America. We know that H pylori has been implicated in gastric and duodenal ulceration as well as in the development of gastric cancer. Treatment appears to decrease the risk of rebleeding from peptic ulcer disease while at the same time decreasing risk of cancer. It is unknown at this time how H.pylori is transmitted though it seems more prevalent in conditions of poor socioeconomic conditions or family overcrowding. There may be an ethnic or genetic predisposition as well. Diagnosis is generally confirmed one of three ways. Serum antibody testing is a rapid and readily available technology but positive results do not necessarily confirm active infection and may represent previous exposure. Better screening methods include breath testing, stool analysis, or endoscopy with biopsy. Treatment consists of multi-drug regimens that extend from one day therapy to two weeks. Assuming the patient can tolerate eighteen pills in one day (most can in my experience), I prefer one day therapy given its 95% likelihood of H.pylori eradication and relative low expense.

Dear Dr. Spence,
My legs ache at night or any time I rest and I always feel like I have to move them. I was told that this could be restless legs syndrome. Is this a possibility?
Signed,
Jumpy Legs

Dear Jumpy Legs,
Restless legs syndrome, or RLS, is a very common neurological problem that may affect up to 2-15% of the population. Most patients generally describe a relentless achiness, pulling, burning, creeping, crawling or bug like sensation under the skin. Many describe simply a restless feeling. It can be extremely debilitating and often interferes with one’s quality of life due to pain, fatigue and sleep disturbances. Though most cases are of unknown origin, your doctor may request lab work in order to rule out other conditions such as iron deficiency, kidney problems or even pregnancy (less likely in males!). Treatment can be challenging. I prefer, in most cases, to use medications like clonazepam. They tend to be highly effective, are relatively safe and most importantly, are quite cheap. For treatment failures, I often try anti-Parkinson drugs like mirapex or requip which have shown efficacy in clinical studies. Patients generally have dramatic improvement in their symptoms and general well-being. More information is available through the Restless Legs foundation at rls.org or by contacting them at 877-INFO-RLS.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Weekly Dose, P.O BOX 6107, Marianna, FL 32446.

Question on Atopic Dermatitis

2008-11-07T13:40:00.000-08:00

Dear Dr. Spence,
I would appreciate any information you could give with regards to atopic dermatitis and any possible support groups that may be available.
Signed,
Ima Scratchin

Dear Ima Scratchin,
Atopic dermatitis, or eczema, is a chronic, itchy skin condition affecting roughly 15-20% of children and 1 to 2% of adults. Onset is usually before two years of age, though it can manifest itself at any age. It is worse between the ages of two and four, but generally improves over time and is often characterized by inflamed, red, blistered or weepy patches during a flare. In between, skin may be normal or have chronic eczema with dry, thickened itchy areas. Atopic dermatitis seems to occur more frequently in people who have an "atopic tendency" – in other words, the condition is linked to diseases like asthma and allergic rhinitis. These conditions tend to be familial with a parent or sibling being affected as well. There is consensus that there is no known single cause of atopic dermatitis. There may be an immunologic link, though theories suggest possible contributors such as skin cell defects, gene mutations or even bacterial contamination. Of course, treatment primarily focuses on avoidance of any potential trigger, environmental or otherwise. Dry skin is an exacerbating factor, therefore use of regular emollients (lotions, cream, petroleum jelly) is recommended. Winter weather, frequent bathing, soaps and chlorinated pools all may increase skin dryness and effect outcomes. Environmental allergies (i.e. grass, dust, cat dander), stress and food allergies may also play a role in the disease (one-third of patients will have a food allergy). There is no cure for atopic dermatitis, but aggressive management may alleviate and control symptoms. As mentioned, emollients to prevent dry skin are the mainstay of therapy. Topical steroids are next in the arsenal. They are extremely effective but their use is limited in areas with thin skin (face, groin) due to the potential for skin atrophy. Newer agents like protopic and elidel, so-called calcineurin inhibitors, may treat mild to moderate disease and are generally used to prevent flares while steroids are better for the flare itself. There are innumerable websites with information on this subject. I particularly like www.dermnetnz.org/dermatitis/atopic - the Kiwis do a nice job! The National Eczema Association has a quarterly newsletter available called the Advocate (www.nationaleczema.org). A free book for children entitled "Under My Skin" can be obtained through the National Eczema Association for Science and Education (NEASE) at 415-499-3474. This organization also has information regarding support groups within the state and even has an application so you may start your own. Good luck!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Hypertension

2008-11-07T13:39:00.000-08:00

Hypertension– The Scourge of our Existence? Aggressive reaction to elevated blood pressure is very important. Most people recognize the importance of lowering blood pressure in preventing disease and cardiovascular outcomes. I have been passionate with regards to the aggressive diagnosis and treatment of hypertensive patients. Perhaps this is due to the fact that hypertension affects 92 million Americans, 60% of those over the age of 50. Perhaps it is because we know that after 50, the lifetime likelihood of developing hypertension approaches 90%. For every 20/10 increase in blood pressure reading, risk of cardiovascular death increases by 50%, as does one’s risk of stroke. In other words, a one-point drop in blood pressure translates to a 4% decreased risk of major cardiovascular event. Unfortunately, physicians are traditionally poor at initiating and/or titrating medical therapy, a well-recognized phenomenon known as "clinical inertia". Clinical inertia can be a major obstacle in effective management of hypertension. It is a complex issue that is multi-factorial in origin. First and foremost, cost issues can often limit the addition of medications to a patient’s regimen. Now with the upstart of specific four-dollar generic pharmacy plans, cost may not be as prohibitive. Physicians may be concerned about polypharmacy (use of multiple meds) and possible interactions between agents. Finally, there may be a "good enough" mentality whereby a physician may ignore a 145/95 blood pressure and view it as acceptable. Reasons for this may include a tendency to blame "white coat hypertension" or the belief that a patient’s home readings are much lower. Many patients fail to monitor their own ambulatory blood pressure readings, and thus cloud the issue even further. Patients may have their own reservations about taking medication. Factors include cost, polypharmacy and complex dosing regimens (twice or three times a day meds). Furthermore, they may be perceived as non-compliant when they are unable to tolerate the medication due to side effects. Lastly, patients may be in denial about there disease and refuse to take pills in favor of lifestyle modifications (most of which never work or are never undertaken). Because of the dramatic impact on cardiovascular health, I encourage patients to work closely with their physicians in formulating an aggressive plan in treating their hypertension. It does no good to add a medication then follow-up in six months. Studies demonstrate that lower is better regardless of the medications used. There is no reason we can’t do better.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Pneumonia Vaccine

2008-11-07T13:38:00.000-08:00

Dear Dr. Spence,
What are the advantages of getting a pneumonia vaccine? I have known people who get the shot but still end up getting pneumonia.
Signed,
Imma Wheezin

Dear Imma,
The Advisory Committee on Immunization Practices recommends pneumococcal vaccination for all adults over the age of 65. Despite this, it is speculated that only 50% of eligible patients actually receive the vaccine. Obvious blame can be placed on physicians who may fail to question patients about their immunization status given time constraints. Patients may also be hesitant to get the vaccine secondary to their lack of information regarding benefits and efficacy, or simply they fear the injection/needle itself. The pneumovax protects against streptococcus pneumoniae, which remains the most common causative organism in bacterial pneumonia. There are probably 175,000 annual hospitalizations that can be linked to strep pneumonia and pneumococcal disease accounts for more than 6000 deaths per year. More than 50% of these cases are in patients whom vaccination was recommended based on age alone. The vaccine is considered extremely efficacious. A three-year study of over 47,000 people over the age of 65 revealed that the pneumonia vaccine reduced the risk of serious pneumococcal disease by 44% and decreased the risk of mortality by 16%. It does not prevent the incidence of community-acquired pneumonia, but it does decrease the likelihood of more severe life-threatening infections that are associated with the bug. Rates of death or admission to the ICU were decreased from 21% to 10% when patients were vaccinated previously. Again, the pneumovax is recommended for any patient over the age of 65. For those less than 65, the vaccine may be indicated based on individual health risks and co-morbidities. For example, it is generally suggested that patients at increased risk of illness or death from pneumococcal pneumonia be immunized as well. This may include anyone suffering from chronic obstructive pulmonary disease (COPD), coronary artery disease, diabetes mellitus or others. Though it is felt that the pneumovax is a one-time injection, the CDC recommends boosters at ten-year intervals. Vaccines are an important public health measure for disease prevention. Global success depends on patients and clinicians working together to adhere to published vaccination guidelines. Assuredly, this will help decrease morbidity from pneumococcal disease, which in turn will translate to saved lives.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Melanoma

2008-11-07T13:37:00.002-08:00

Dear Dr. Spence,
Being light skinned, I am concerned about the possibility of developing melanoma. Is there any way I can protect myself? What are the warning signs of melanoma? Please tell me about the disease?
Signed,
Holy Moley

Dear Holy Moley,
Melanoma is the least common of the skin cancers, but unfortunately, it is the most deadly. The American Cancer Society estimates an annual incidence of 62,000 new cases of melanoma of which 8000 people will ultimately die. It is most commonly a direct result of sun exposure – UV radiation may cause damage to the DNA of melanocyte cells in the skin. Sustained damage may eventually result in cancer formation. We use the standard acronym of ABCD to describe the identifying factors in melanoma diagnosis.
A: asymmetry – If the lesion is cut in half, does it match the other half?
B: border – Is the edge of the lesion irregular, ragged or blurry?
C: color – Is the color of the lesion uniform or variable, or dramatically dark?
D: diameter- Is the lesion greater than 6 mm wide? These are all potential warning signs. For example, a mole that has a ragged border, is itchy, and multi-colored (black/blue) has a greater likelihood of malignancy.
Perhaps even more important is "E" – an "evolving" lesion. This may represent a change in color or size, or may be a mole that has suddenly bled or itched. All would warrant a trip to the doctor.
Prevention is key. The most obvious risk, sun exposure, is easily controlled. Intermittent exposures with associated burns appear to be more dangerous than chronic exposure. Darker skin (as with chronic sun worshippers) may be protective against the development of melanoma. It is also speculated that chronic exposure may increase the amounts of vitamin D in the body. Vitamin D has been shown to potentially limit a patient’s risk of developing certain cancers. The easiest way to prevent melanoma is to avoid the sun entirely, especially between the hours of ten and two. Application of sunscreen with SPFs of 15 or more, or the use of sun protective UV blocking clothing are other methods that decrease risk. Avoiding sunburn is critical! As noted above, since vitamin D may decrease the development of certain cancers, including melanoma, dietary supplementation may confer some benefit at prevention. Vitamin D rich foods such as salmon and cod liver oil can be added to the diet, or one may also supplement with 800-1000 IU of vitamin D per day. Simply put, if you are concerned about melanoma, avoid direct sun exposure and tanning beds. If your idea of tanning is sitting on a tar roof with the assistance of accelerants like baby oil, Crisco or PAM, you are setting yourself up for skin cancer, or at the very least, alligator skin.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Coronary Artery Disease

2008-11-07T13:37:00.001-08:00

Dear Dr. Spence,
I’ve recently heard that drinking tea may help decrease the likelihood of coronary artery disease. Is there any validity to this?
Signed,
Nestle

Dear Nestle,
There has been a growing body of evidence suggesting the vascular benefits of teas, the second most commonly consumed beverage on the planet. A recent French study examined the relationship between tea consumption and plaque formation in the carotid arteries. The study of 6597 patients under the age of 65 showed that those with increasing intake of tea exhibited a lower prevalence of plaque build-up in the carotids. Prevalence rates were 44% in those who drank no teas and dropped to 33.7% in those who drank three cups or more per day. This difference was only seen in women, however. At the end of the day, women tea drinkers may show a decreased risk of vascular disease compared to their male counterparts. How much of a difference this will make in decreasing the actual risk of heart attack or stroke is unknown, but for the sake of a few cups, it may be worthwhile. Of note, the French did not look at the benefits of sweet tea, so results cannot be extrapolated to this Southern staple. Dear Dr. Spence, What do you believe is the best diet for general health and weight maintenance? Signed, Fat and Sassy Dear F & S: I have been a firm believer in the Mediterranean diet for years. Popularized by the Miami cardiologist, Dr. Michael Ozner, the Mediterranean diet has been proven to decrease your risk of cardiovascular disease and lower one’s overall risk of cancer. The diet is characterized by fresh fruits, vegetables, lean meats (chicken and fish), whole grains, legumes and olive oil. Extra virgin olive oil lowers LDL (bad cholesterol) and is a staple of the Mediterranean diet, much like fish which is rich in omega-3 fatty acids. Given that there is one death every 36 seconds in the United States attributable to cardiovascular disease, prevention via diet may be one of the biggest, and smartest, things we can do. Research suggests that a middle-aged Greek man is 90% less likely to have heart disease compared to an American. Multiple studies have demonstrated the substantial benefits of the Mediterranean diet, from weight loss and improvement in cholesterol to reduced risk of stroke, Alzheimer’s dementia and osteoporosis. The diet may prevent the incidence of colon cancer by 25%, breast cancer by 15% and prostate cancer by 10%. All in all, there may be a 20% reduction in all-cause mortality. Strict adherence to any diet is understandably difficult, but patients who can are much likelier to be healthier and slimmer.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Hepatitis C

2008-11-07T13:36:00.001-08:00

Dear Spence,
Should I be screened for hepatitis C? I know that it can result in liver cirrhosis and I want to make sure I’m not infected.
Signed,
Ura Medic

Dear Ura,
Hepatitis C is a virus that is generally transmitted through blood or blood products or via sexual contact. It ranks second in the United States behind alcohol as a cause of liver disease and is the leading indication for liver transplantation. Fifteen to twenty percent of those infected will clear the virus without consequence whereas the remaining 80% will suffer from chronic hepatitis C. Twenty to fifty percent of those may ultimately develop liver cirrhosis within 10-20 years. Liver cancer or liver failure occurs in one-half of those who developed cirrhosis. Unlike hepatitis A and B, there is no vaccine to prevent the disease. Most people with the virus were contaminated as a result of blood transfusions given prior to 1992 when blood products were not adequately screened for the virus. Most people remain asymptomatic for years and are diagnosed "accidentally" after having been found to have abnormal liver function testing. Treatment is directed at trying to prevent viral replication. The most common used agent is interferon alpha, an injectable drug that is given three times a week. Unfortunately, only 1/5 who take it may show a clinical response. Side effects include depression, flu-like symptoms and suppression of white blood cell counts. Data suggests that interferon may be more effective if taken for at least one year. On top of the interferon therapy, lifestyle changes are extremely important. Patients should avoid alcohol consumption and medications that may contribute to or accelerate liver damage (i.e. Tylenol). They must be cautioned about the potential exposure to others. Wounds should be covered, sharing of toothbrushes and razors should be discouraged, and care should be taken with regards to sexual contact. So, should you be screened? The following risks should prompt immediate evaluation for hepatitis C as formal symptoms maybe lacking. 1) exposure to blood 2) received an organ transplant prior to 1992 3) had dialysis for kidney failure 4) received a blood transfusion or clotting factors prior to 1992 5) had tattoos, piercings or acupuncture using unsterile equipment 6) used illicit intravenous or intranasal drugs.

Question on Chemotherapy

2008-11-07T13:34:00.000-08:00

Dear Dr. Spence,
I am a cancer patient who now suffers from hair loss as a consequence of chemotherapy. Outside of wigs, are there any other options for hair loss that may appear more natural?
Signed,
I. Wantta Brush

Dear I. Wantta,
Alopecia (hair loss) due to chemotherapy is one of the most distressing side effects of cancer treatment. Unfortunately, therapy aimed at cancerous cells is generally non-selective to the malignant cells and it may affect others in the body as well. Generally, it may affect the more rapidly dividing cells (such as hair) and alopecia may appear within days of actual therapy. Though it does grow back, it may take upwards of three to six months to regain a full head of hair. Hair loss may also occur after radiation therapy, but usually it is isolated to specific areas undergoing treatment. Hair loss in these cases is usually temporary, but the speed and type of re-growth is dependent upon the length and quantity of radiotherapy received. It may take six to twelve months for re-growth and may be patchy or dissimilar to one’s current hair. Of course, alopecia can be horribly distressing to patients. In addition to the already existing burden of disease, this change in appearance may further affect self-esteem and confidence. A new technology involves a procedure known as cranial prosthetics. It offers a more realistic approach to alopecia and provides patients more freedom with their hairstyle and maintenance of such. Multiple measurements are made of each person’s head which helps assure a perfect fit. Specific information regarding a patient’s lifestyle is obtained in order to guarantee optimal results. This may include a patients swimming habits or desire to wear or remove the prosthesis at night. Cranial prosthetics are made from real hair which may allow it to be curled, colored, permed and styled over and over again. The advantage over a wig is fairly obvious in this case. As a whole, these appear more natural than their wig counterparts and have more versatility. Insurance companies have generally been receptive to cranial prosthetics, allaying fears of further expense. I encourage any patient or family member who is experiencing alopecia as a result of chemotherapy or radiotherapy to fully investigate the options that are available. For further information on local cranial prosthetic providers, contact Advanced Hair Care Solutions at 850-482-6030.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.

Some interesting tidbits on cancer

2008-11-07T13:32:00.000-08:00

Some interesting tidbits on cancer – perhaps some of my readers have been privy to this information via e-mail, but it was of great interest to me so I thought I would share it. John Hopkins School of Medicine, long-recognized as one of the leading medical centers in the world has released information regarding recent trends in cancer "thinking". It is generally accepted that everyone has cancer cells in the body, but unfortunately our tests are not sensitive enough to find and diagnose them until the cell counts have reached into the millions. Cancer cells may occur six to ten times in a patient’s life. A strong immune system may help destroy cancerous cells and prevent multiplication of them as well. A diagnosis of cancer may represent an underlying nutritional deficiency that could be related to, or worsened by, genetic, environmental, or lifestyle factors. An effective method at battling cancer may be to change the diet or take nutritional supplements that enhance the immune system. Chemotherapy may destroy cancerous cells but it is non-specific and may destroy healthy tissue as well, namely cells of the bone marrow or gastrointestinal tract. Chemotherapy and radiation will reduce tumor size, but prolonged use may not result in any more tumor destruction. Chemotherapy may compromise the immune system and expose patients to various types of infections and complications. Therapy can result in mutation of cancer cells that allow them to become more resistant to treatment. Perhaps a better way to fight cancer is to starve the cancer cells by not feeding it those foods that it may need to multiply. A prime example is that of dioxins. Dioxin chemicals are known carcinogens and are directly responsible for breast cancer (among others). Freezing plastic water bottles may release dioxins as may heating food in the microwave using plastic wraps or plastic containers. It is safer to use tempered glass or Corning ware. The combination of heat, fatty food and plastic causes release of the dioxin from the plastics which then may ultimately infiltrate the cells of the body. Some may view this as paranoia, but given the alarming increase in cancer rates, one can’t be too sure. Next week, I will further discuss the topic including lifestyle changes that John Hopkins has proposed as a first line defense against cancer. I am a firm believer that our lifestyle and environmental exposures (some avoidable, some not), are what drives the development of cancer. Genetics play a role, but it may in fact be driven by other factors as well.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.

Avoiding Cancer Risks:

2008-11-07T13:31:00.000-08:00

John Hopkins has recently given updates with regards to cancer prevention. It is quite reasonable to suggest that many cancers are highly preventable based on our destructive eating habits and resultant exposure to dietary carcinogens. The following represents some recommendations that, if implemented, may enhance one’s health and diminish the risk of developing invasive cancer. 1) Cancer cells enjoy an acidic environment. Red meat is a huge contributor to this therefore a diet based on fish or chicken is preferable to one based on pork or beef. Meat may also contain growth hormones, antibiotics or parasites which may be harmful and potentially carcinogenic. 2) Cancer feeds on sugar. Sugar substitutes like Equal or NutraSweet contain aspartame that may be even worse. Suggested more natural sweeteners include molasses or Manuba honey. It is also known that table salt has a chemical additive to make it white. An alternative in this case is Bragg’s aminos or sea salt. 3) As mentioned earlier, cancer thrives on an acidic environment. A diet consisting of 80% fresh vegetables, fruits, nuts and whole grains allow more alkalinity. Twenty percent of the diet can be from cooked foods. Fresh vegetable juices provides enzymes that enhance the growth of healthy cells and can be obtained by drinking fresh vegetable juice and eating 2-3 servings of raw vegetable per day. These enzymes are destroyed at temperatures greater than 104 (i.e. cooked). 4) Caffeinated beverages like tea, soda and coffee should be avoided. Green tea is an acceptable alternative given its cancer fighting properties. Dark chocolate may provide inherent cardiac benefits. Water is excellent and low calorie (of course!) but should be purified or filtered to avoid exposure to possible heavy metals or carcinogens. 5) Meat is difficult to digest and requires large amounts of enzymes. Cancer cells have a tough protein covering that can be destroyed by these same enzymes. It is thought that eating less meat may free up enzymes so they may help degrade unwanted cancerous cells. 6) Some supplements may help boost the immune system and in turn will help enable the body’s own "killer cell" to destroy cancerous ones. We have previously discussed the use of vitamin D as a supplement – it has much research behind it suggesting a decrease in several cancers including breast, and a decrease in all-cause mortality. I think that much of what has been discussed is generally valid. Common sense dictates that eating "closer to the garden" ensures longevity. As a Western civilization, we eat poorly. This has led the United States to be a leader in obesity with nearly 1/3 of our population being classified as such. Our eating habits are unnatural – much of it is processed and refined. Though tasty, a burger and fries certainly may not pave the road to longevity. A balance is required as it is nearly impossible to adhere to all the theoretical dietary restrictions. However, keeping these factors in mind may give us a few more years to enjoy what life has to offer.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.

Questions On Foot Spurs & Headaches

2008-11-07T13:30:00.000-08:00

Dear Dr. Spence,
I have been having significant foot pain at the heel. Do I need surgery to treat "spurs" or is there something else I can do?
Signed,
Heelp

Dear Heelp,
It sounds as if you may be suffering from plantar fasciitis, a chronic irritation of the fibrous tissue that connects at the base of the heel. Patients like yourself tend to complain of heel pain often described as a tearing type sensation that is worse upon waking in the morning and taking that first step. Interestingly, it really doesn’t seem to matter what the ultimate treatment is, the natural course of plantar fasciitis predicts complete resolution within about nine to twelve months. Generally, spurs do not contribute to the ailment. Treatment can be difficult. In my office, I advocate use of heel cup inserts as first line treatment. Other options include anti-inflammatory agents, stretching exercises, night splints and possible injections. In advanced cases, I will attempt off-loading and immobilization with walking boots/casts. Surgical intervention is rarely indicated but is certainly an option in those who fail to respond to traditional therapies.

Dear Dr. Spence,
I suffer from severe daily headaches. I have been told it may be my sinuses but medications have not helped? I take Motrin every day to no avail. Help!
Signed, Mi Grain

Dear Mi,
I suspect you may very well be the victim of migraines, which have now progressed to chronic daily headaches. Research suggests that patients presenting with this complaint in a primary care setting rarely suffer from sinus-associated headaches. More than likely, true migraines are the culprit. Your daily use of ibuprofen has undoubtedly complicated the clinical picture by precipitating a rebound phenomenon, a worsening of symptoms secondary to medication overuse. The more medication you use to treat your headache, the more likely you are to experience a snowball effect of increasingly frequent and intense headaches. Migraine management can be broken down into two components – acute migraine therapy and chronic preventative therapy. Acute therapy consists of migraine specific medications such as triptans (imitrex, maxalt etc.), which tend to resolve headaches in up to 60-70% of cases. Failure to respond to one agent in no way predicts potential response to another within the class. Of course, reduction in the use of over-the-counter medications will help prevent the development of chronic daily headache and rebound. All available medications have some potential to cause rebound. A subset of migraineurs may need preventative therapy due to the sheer frequency of their headaches. There are many drugs that have proven beneficial in these cases. Among these, beta-blockers (metoprolol, propranolol), antidepressants (amitriptyline), and anti-seizure medications (depakote, topamax) are used most commonly and are relatively inexpensive. They certainly decrease the frequency of migraine when used at appropriate doses. Though not necessarily indicated, I have used topamax short-term (one month or less) to abort the cycle of chronic daily headache. It seems to allow for a more rapid discontinuation of over-the-counter agents while triptans treat the acute attacks.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Gastric Bypass

2008-11-07T13:28:00.002-08:00

Dear Dr. Spence,
I have seen your articles on the complications of gastric bypass. I am contemplating undergoing gastric banding which I understand is less risky. Can you comment?
Signed,
Big Mac

Dear Mac,
Health risks associated with obesity are well documented and include diabetes mellitus, hypertension, osteoarthritis, gastroesophageal reflux and sleep apnea. The cardiac risks are enormous. For the first time in nearly a century our life expectancy has actually declined. The presumption is that this is a consequence of our trend towards expanding waistlines. Recent studies suggest that up to 1/3 of our population is obese. The above conditions severely impact quality of life and potentiate the risk of life-threatening disease. Unfortunately, despite dietary restrictions, exercise, behavior modification and weight loss medications, many individuals are still unable to lose weight or have problems with maintenance. At two years, all diets (i.e. Adkins, South Beach, bread and water) result in a trend back towards one’s pre-diet weight. Surgery remains the only proven long-term option available for obese patients (body mass index greater than 40). Laparoscopic banding offers a minimally invasive and safe surgical option as opposed to formal gastric bypass surgery. This adjustable gastric banding system consists of an inflatable band that encircles the upper portion of the stomach, effectively restricting intake. An implanted access port allows the physician to tighten or loosen the band by injecting or withdrawing saline. Therefore, the band can be adjusted based on factors such as inadequate weight loss (too loose) or symptoms of nausea and vomiting (too tight). Unlike standard gastric bypass, there is no cutting of the stomach or disruption of one’s internal anatomy. This dramatically reduces morbidity and mortality. Four separate studies have provided illuminating data as to the efficacy of the procedure. Over 90% of patients have experienced resolution or improvement of their diabetes, sleep apnea or even asthma. Forty-four to seventy-five percent of patients could actually discontinue treatment for their concomitant issues. Weight loss at three years appears to be comparable to gastric bypass. There are over 1200 lap-band surgeons in the United States alone. Information can be obtained at www.lapbandcentral.com or at 1-800-LAPBAND (527-2263). The site allows users to find qualified surgeons close to home for referral and gives insight as to how to navigate through the world of insurance coverage. Typically, patients need six months of consecutive monthly visits with their primary physician in order to be considered for the surgery. They will need to make appointments with a dietician and with psychiatry to ensure they are psychologically ready for the surgical intervention and its effects on eating habits once all is said and done.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at scripna@hotmail.com or by mailing your question to Daily Dose, P.O BOX 6107, Marianna, FL 32446.

Questions on Varicose Veins

2008-11-07T13:28:00.001-08:00

Dear Dr. Spence,
Can you explain what treatments are available for varicose veins? How can they be prevented? Signed,
Imma Changin

Dear Imma,
Everyone hates varicose veins, those unsightly, uncomfortable blue bulging ropes underneath the skin. Affecting nearly 40 million Americans, varicose veins are a consequence of valves that become less elastic and fail, allowing for poor blood return to the heart. In essence, that decreased flow results in pooling of fluid in the legs resulting in swelling, achiness and heaviness. Furthermore, the veins may enlarge and swell to over four times their normal width and cause a cosmetic nightmare. There are several typical causes of varicose veins, some of which are relatively obvious. Age is the single biggest factor as normal wear and tear and a lifetime of being on your feet can take a toll on the veins and the valves. Secondly, if mom had them, there is a good chance you will be equally blessed, as nearly 50% of cases are genetic. Seventy percent of women in their 60’s have varicosity as opposed to only 40% of men, thus gender differences appear to play a role. Pregnancy and obesity may contribute simply due to compression of veins in the lower pelvis that restrict blood flow. Treatment revolves around maintaining normal weight, getting regular exercise and ensuring you do not sit or stand for long periods of time without moving. Leg elevation and the use of support hose may also help. When all else fails, a trip to the doctor may be in order. First line therapy may include use of prescription compression stockings that squeeze the veins and improve flow back to the heart. Sclerotherapy is a procedure whereby the physician injects smaller veins with a chemical (usually 3% normal saline) that causes them to collapse and disappear. Vein excision via a series of skin punctures is a second option for smaller vessels. Larger varicosities may require catheter ablation – a thin flexible tube is inserted into the vein and heat constricts the vessels and closes them off. This is effective in 40% of cases – sclerotherapy and excision can be used to treat any remaining vessels. Finally, vein stripping can be performed under general anesthesia and can help tie off and remove larger veins. Spider veins are similar in that they can be unsightly, but they are generally of minimal consequence. They involve only the smallest blood vessels and appear as those reddish or blue lines at the surface of the skin. They have no potential to become varicose veins, but many are still turned off by their appearance. They can be cosmetically closed through sclerotherapy or laser. Sclerotherapy of spider veins is relatively straightforward and is widely offered, even in our own office.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Osteoporosis & Constipation

2008-11-07T13:27:00.001-08:00

Dear Dr. Spence,
You hear about osteoporosis in women all the time in the news. What about osteoporosis in men? Is this something to be concerned about?
Signed,
Week Femur

Dear Week,
Valid point. Though much of the literature and lay press focuses on osteoporosis in women, there is no doubt that men are affected as well. In fact, men with osteoporosis are twice as likely to die within one year of fracturing a hip, therefore, prevention is key. Unfortunately, men are generally unaware of potential risk and physicians tend not to screen as often as they might screen their female counterparts. The American College of Physicians has released a set of guidelines to help identify those patients who may be at greater risk of developing osteoporosis and should be screened with bone mineral densitometry. - age older than 70 - physical inactivity - low body weight (body mass index less than 25) - prior light trauma fracture (breaking bones doing something non-strenuous) - use of certain medications i.e. steroids, anticonvulsants, diuretics. Males with osteoporosis should be evaluated for secondary causes of decreased bone mineral density. Vitamin D screening is critical given its high prevalence.

Dear Dr. Spence,
What can I do about my constipation? I don’t feel like anything helps and it has lasted for years.
Signed,
Ima Fuller

Dear Fuller,
Chronic constipation typically lasts for several months or more and is defined by frequency and consistency of bowel movements. Normal for one individual may not be normal for another. If you begin to have less frequent bowel movements or if stools become harder or more difficult to pass, you are probably constipated. Your doctor will ask about medical history and associated symptoms accompanying the constipation. Constipation coupled with abdominal pain, bloating or fullness may be irritable bowel syndrome. It is also critical to investigate medications as a potential cause. Many common agents for hypertension, depression or heart disease are notorious for causing constipation and may need to be replaced. A patient’s diet may be low in fiber or fluids. Simple adjustments in intake may help, as may an increase in exercise. Physicians may suggest a variety of tests to ensure your issues are not related to anything more ominous. If you are over the age of 50, colonoscopy is almost always indicated to rule out colon cancer. Women who have given birth vaginally may have problems with the pelvic floor muscles that are involved in having a bowel movement. Some women in these situations may benefit from biofeedback that retrains the pelvic floor musculature. Finally, I generally treat with over the counter medications initially. Milk of magnesia once or twice daily is well-tolerated and safe even at higher doses. One or two ounces a day are usually sufficient. Patients may also use senna or polyethylene glycol (miralax) as over the counter alternatives. I discourage the use of frequent stimulant laxatives as some studies suggest the bowel may develop "dependence" on these agents to function properly. There are several prescription medications that can be used as well. A newer agent, lubiprostone (amitiza) allows more fluid to enter the colon and theoretically allows stool to pass more easily.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Question on Diabeties & Bell's Palsy

2008-11-07T13:25:00.000-08:00

If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.

Dear Dr. Spence,
I am a diabetic. My feet feel like they are on fire and my friends tell me that I have nerve damage. What can I do outside of cutting them off?
Signed,
En Fuego

Dear En Fuego,
Diabetic neuropathy is generally an inevitable consequence of long-standing diabetes mellitus. It appears related to the length of time with the disease as opposed to absolute blood sugar control, though certainly brittle diabetics may be more quickly susceptible. It is secondary to the detrimental effects of elevated blood sugars on peripheral nerves and tends to affect the hands and the feet in a "stocking-glove" distribution. Patients describe anything from burning pain to shooting, aching, numbness or needle-like pain. Patients may be treated with a variety of agents. Traditionally, anti-depressant medications like amitriptylline (elavil) have been utilized to treat the problem, but side effects like sedation have often limited their use. Other agents, i.e. valproic acid (depakote) or gabapentin (neurontin) have proven efficacious as well. Recently, I have successfully used pregabalin (lyrica), though cost may be an issue. Our clinic has been participating in a pharmaceutical study using a novel agent known as ALD5854 that appears to block delta opioid receptors and thus block pain. This class of drugs, known collectively as DORAs, may be effective in treating neuropathic pain while minimalizing side effects and the potential for dependence. I encourage any patient with painful diabetic neuropathy to contact us (482-5802). The study is only one month in duration but does pay approximately $350 to eligible participants. Not only does this study potentially open the door to a new class of agents that may alleviate pain, but it helps supplement your income.

Dear Dr. Spence,
What is Bell’s palsy? How do I treat it?
Signed,
Droopy

Dear Droopy,
Bell’s palsy is a paralysis of the facial nerve that is presumed secondary to viral syndromes. Most cases are short-lived but can be quite distressing. I have actually discussed this topic previously, but I thought it may be interesting to share some more recent data on treatment options. Data from the New England Journal of Medicine suggests that there is no benefit in treating patients with anti-viral medications like acyclovir (a popular choice among physicians). It is clear that a ten day course of an oral steroid (either prednisone or prednisolone) is most effective. The researchers recommend prednisolone 25 milligrams twice per day for ten days – treatment must be initiated within 72 hours in order to increase the likelihood of neurologic recovery.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Testosterone Levels & Aspirin a Day

2008-11-07T13:22:00.000-08:00

Dear Dr. Spence,
I have been told that my testosterone levels are low. Would you suggest therapy?
Signed, Les Lustin

Dear Les,
Testosterone deficiency is another under-diagnosed condition we see quite regularly in our clinic. It is estimated that 20% of males age 60-69 have clinical deficiency with nearly 50% of those older than 80 affected. Low levels of testosterone can produce a number of symptoms. Most commonly, patients present with fatigue, depression, decreased sexual desire and/or erectile dysfunction. In younger patients, checking prolactin or LH levels is advisable to rule out other causes of testosterone deficiency such as pituitary gland dysfunction. Testosterone is generally either replaced via intramuscular injection or by topically applied gels or patches. Injections, though cheaper, do not provide the same smooth release that gels may offer and tend to result in transient supraphysiologic levels that quickly drop in a matter of weeks. Gels and patches provide improved delivery but are quite pricey. Men with prostate cancer should not receive testosterone supplementation. Treated patients should have blood work on a regular basis to monitor hemoglobin levels and prostate specific antigen (PSA). Not all patients experience resolution of symptoms, therefore a careful case-by-case analysis of response should be undertaken to determine efficacy and need for continuation of the medication on a long-term basis.

Dear Dr. Spence,
Should I take an aspirin a day?
Many thanks, Lotta Thinblood

Dear Lotta,
The general consensus, after rigorous analysis of the data, is no. Unless a patient has substantial risk factors for heart attack or stroke, aspirin therapy is considered potentially harmful (i.e. the risks outweigh the benefits). Risk factors include diabetes mellitus, hypertension, coronary artery disease, cerebrovascular disease and hypercholesterolemia among others. Patients with these underlying conditions should receive aspirin as a preventive medication. Doses of 81 mg are probably sufficient. An otherwise healthy adult taking aspirin may be more at risk for gastric ulceration with the potential for resultant peptic ulcer disease and possible gastrointestinal bleeding. Again, in this case, the small benefit from taking aspirin is overshadowed by the possible adverse effects. An apple a day may be better. As a side note, I provide some interesting information regarding diet and health. Researchers have suggested that daily intake of a proposed "Polymeal" may decrease heart disease by 76% and increase actual longevity by up to 6.6 years. There are no pills, no hefty costs and minimal side effects. The "Polymeal" consists of the daily ingestion of four ounces of red wine, a small piece of dark chocolate, a handful of almonds, one clove of garlic, and multiple servings of fruits and vegetables. Combine the above with four servings of fish per week and you have a recipe for good heart health (albeit with some less than desirable halitosis).

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

How to Treat Cold Symptoms in Children

2008-11-07T13:16:00.000-08:00

How to Treat Cold Symptoms in Children
With recent recommendations by the FDA to ban the use of cough and cold medications in children under the age of two, questions arise as to what remedies may be effective to treat these and other ailments in kids. Certainly, studies reveal a general lack of efficacy with most over-the-counter medicines and many may be more likely to result in adverse side effects than actual benefit. Here are some cheap alternatives to expensive scripts. Sore throat: Soothe soreness by using cold foods and drinks to ease irritated throats. Ice cream, Popsicles, slush drinks etc. are great and are rarely refused by children. My long-term favorite has been a mixture of 50% Benadryl liquid in combination with 50% Maalox liquid. Swish and spit this mix and expect immediate improvement. Colds: Homemade nose drops can be an effective option to assist with clearing up a stuffy nose. Mix ¼ teaspoon of salt with ½ ounce of water, and then use an eyedropper to insert two to three drops in each nostril. Or if you have access to ocean water, a quick dip may help more than any over-the-counter preparation or home concoction. Vomiting/Diarrhea: A general rule of thumb is not to suppress neither vomiting nor diarrhea. The most important factor is maintaining hydration. Small amounts of clear fluids are a good start and hydration status can be readily determined by urination patterns. Consistent urination or wet diapers are a positive indicator that the child is doing okay. Bland foods like toast, rice, bananas or applesauce can be given if tolerated. For diarrhea, sugary or starchy foods may be given as they are easily digested. Consider Jell-O, dry cereal, 7-Up and Sprite – basically those remedies that mom always suggested. Fever: Fever tends to be the determining force as to whether a child feels good or not. I have seen kids with a temperature of 104 who appeared nearly comatose – after Tylenol dosing they seemed to bounce right back to normal, acting as if nothing had ever happened. Both Tylenol and ibuprofen are acceptable alternatives for fever relief. A temperature of 100.5 or greater in a child less than four months of age deserves more immediate attention and warrants a doctor visit. For the most past, in older children, fevers do not send me into a panic mode, as most are secondary to viral illnesses. A playful, active child with a temperature of 103 is much less of a concern than a lethargic child with a temperature of 99. Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on MRSA

2008-10-26T15:11:00.000-07:00

Dear Dr. Spence, I am concerned about the supposed "super bug" they call MRSA. Am I at risk? Signed, Concerned to the point of complete panic

Dear Concerned,

MRSA, or methicillin resistant Staphylococcus aureus, refers to a particular strain of bacteria that has developed a resistance to standard penicillin products. This may be a result of physician overprescribing of antibiotics and the gradual trend towards bacteria developing resistant genes. It has been in the press quite a bit lately secondary to its prevalence among athletic teams. Several members of an area football team, in fact, have been plagued with skin abscesses directly attributable to MRSA. Most commonly, MRSA affects the skin and causes large, often painful abscesses that often need formal drainage in order to heal. More virulent strains may affect immune compromised patients resulting in possible severe pneumonia or infections of the bloodstream. Generally, MRSA is spread via direct contact with a lesion, but many patients are nasal carriers who risk spreading it to others in close quarters. Nationally, most strains appear to be sensitive to antibiotic treatment with either sulfa drugs or clindamycin. I usually suggest treatment of the nostrils to eradicate a potential carrier state. Oftentimes, I treat family members as well. Recurrences are not uncommon and usually demand further intervention. Dear Dr. Spence, My friends have suggested B12 injections to "cure" my fatigue. What do you think? Signed, Sick and tired Dear Sick and Tired, Older physicians still utilize B12 injections as a way to boost energy. The reality is that no study has ever shown a confirmed benefit from B12 unless the patient has a true deficiency. I regularly check patients for B12 problems regardless of age. I have been shocked at how prevalent the condition is, especially in those with complaints of fatigue. Studies suggest 15 % of the population has a low B12 level. We are grossly undertreating this condition in my opinion. Of those I screen, close to 80% have a deficiency. B12 deficiency can result in fatigue, anemia, neurologic change resembling dementia, and general nerve damage. It is suspected that the deficiency stems from problems of malabsorption in the gut, a condition that becomes more demonstrable as one ages. For this reason, most physicians have relied on 1000 microgram injections each month in order to bypass the gut altogether. A reasonable alternative is to supplement with daily 1000 microgram pills (available over the counter). It appears that equivalent levels can be achieved with either the oral or injectable form; many may opt for pills to avoid a painful injection. I suggest close follow-up with B12 monitoring to ensure an adequate dosing regimen. Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Strokes

2008-10-26T14:43:00.000-07:00

Dear Dr. Spence,
I had a stroke last year and I am terrified at the thought of having another, more severe one? What can I do to prevent this from happening?

Signed,
Terrified Joe

Dear Joe,
There are approximately 700,000 strokes per year in the United States of which nearly 1/3 are recurrent. Fourteen percent of those with a new stroke will go on to have another and 270,000 people die annually from stroke and its complications.

The most important initial step is a basic evaluation for possible risks and causes. Most patients will undergo heart ultrasounds (echocardiograms), EKGs (electrocardiograms) to rule out abnormal heart rhythms and carotid ultrasounds to evaluate for blockages. Assuming these have all been done and are normal, the next step is modifying those risks that you may have. Though I cannot comment on your individual risks, I generally assess five potential problem areas.

(1) Hypertension – Studies have consistently shown a decreased risk of stroke with improvement in blood pressure. A goal of 140/90 or less is recommended but I strive for 120-130/60-80 if possible. The best medication appears to be an ACE inhibitor like lisinopril combined with simple diuretics like HCTZ or chlorthalidone

(2) Diabetes – Control of blood sugars has never truly been proven to reduce the risk of stroke but diabetics do need close monitoring and aggressive treatment. Not to overemphasize the blood pressure issue, diabetics are encouraged to maintain pressures less than 130/80.

(3) Cholesterol – High cholesterol remains a very modifiable risk factor. Bad cholesterol (LDL) should be decreased to below 100 in most, or less than 80 if the patient has cardiovascular disease. I tend to use statins (lipitor, zocor, etc.) even when patients have reasonably normal LDL readings as the data suggests additional benefits from these medications beyond LDL lowering. Recent studies with lipitor have shown that 52 patients would need to be treated for five years to prevent one stroke or 29 to prevent one heart attack.

(4) Lifestyle – Smokers need to quit, alcohol use needs to decrease and exercise needs to be implemented to assist with weight loss and general health. Enough said!

(5) Blood thinners – I recommend aspirin at a dose of 81 mg per day for most patients. Other drugs are on the market but most do not provide any additional protection when compared to their potential adverse effects and cost. Aggrenox may be a better overall agent but can be cost prohibitive.

Of course, strokes are not entirely preventable regardless of our interventions, but we certainly can intervene to decrease the overall likelihood.

Questions on Prostate Cancer & Carpal Tunnel Syndrome

2008-10-26T14:35:00.000-07:00

Dear Dr. Spence,

I have been having problems with urination and I am concerned about prostate cancer. How do I know if I have it?

Signed, Concerned in Marianna

Dear Concerned,

First, prostatic symptoms correlate poorly with disease state. At least fifty percent of men over the age of fifty will have some symptoms of prostatic enlargement, also referred to as BPH (benign prostatic hyperplasia), but few will actually have cancer. Symptoms of BPH include frequent urination (especially at night), dribbling, hesitancy and urgency, and a generally weakened stream. Of course, medications are available to treat this condition.

Prostate cancer screening consists of checking the blood prostate specific antigen (PSA) and performing a digital rectal exam. Neither is particularly sensitive nor specific at detecting cancer. PSA velocity, the rate at which the PSA rises over time, may also be an important clinical indicator in deciding when a biopsy should be considered. At present, there is insufficient evidence to determine whether screening for prostate cancer reduces mortality or impacts quality of life. Only forty percent of patients with an elevated PSA will have cancer but most will have undergone expensive and painful prostatic biopsies. Prostate cancers are also notoriously slow growing. Autopsy data suggests that perhaps greater than 50% of patients older than 85 years of age have prostate cancer. Rarely is this the cause of death, however, What do we do with this information? Prostate cancer still claims an estimated 27,050 lives annually and 1 in 34 men will die from the disease. I generally recommend starting screening around age 50 unless family history warrants earlier testing. Though not a perfect science, it is the best screening tool currently available.

Dear Dr. Spence,

My doctor has sent me to an orthopedic surgeon for carpal tunnel syndrome. Are there any other options besides going under the knife?

Signed, Wrist pain in Sneads

Dear Wrist pain,

Two randomized trials have demonstrated that oral steroids like prednisone can be effective in treating the symptoms of carpal tunnel syndrome (CTS). Perhaps even more efficacious are localized injections at the carpal tunnel itself. I have personally had great success with the latter and have helped many patients prolong or even prevent surgery. The medical literature is divided on the efficacy of night splints, but given the relative lack of overall risk, they remain a reasonable and inexpensive first option if not tried previously.

Questions on Why? Part 3

2008-10-26T14:31:00.000-07:00

Last but not least, this is the third in a series of articles globally entitled: Medicine Demystified. I have attempted to break down some of the inherent barriers that frequently disable good doctor-patient relationships. I will finish with a word about the so-called "god complex" and then address several difficult issues encountered in an office setting..

God complex: I have a real problem with physicians who purvey an attitude of invincibility. We are all human. I just happen to be good at what I do and went to school a long time to get there. We can all be good at whatever we’re trained to do. Ask me to fix your car – it won’t happen. The so-called "god-complex" disables good doctor-patient interactions, destroys autonomy and has no place in medicine. Confidence does not equal arrogance and arrogance does not guarantee better care. Find a doctor without the ego.

Difficult Issues: Physicians dislike narcotics (at least most do!) Too many habitual drug users manipulate their MD for pain medications through doctor shopping, faking injury or milking their own misfortunes. Patients who abuse or divert medications for secondary gain have burned us all. The sad truth is that it is extremely difficult to weed these folks out.

I generally try to give my patient the benefit of the doubt when it comes to pain management. Unfortunately, not all physicians are the same – they refuse to manage pain syndromes at all and treat these individuals with suspicion and contempt. They fear lawsuits, DEA disapproval and have a general concern about being manipulated. Until there is a universal computerized tracking system for prescriptions, this narcotic dilemma will persist.

Another pet peeve of mine is the failure to treat pain. I have multiple geriatric patients who suffer miserably from severe intractable pain as a consequence of a chronic medical condition such as osteoarthritis or restless legs syndrome. They have seen other doctors who have refused to prescribe pain medications stating, "I don’t want you to get addicted" or "you’re getting older; you should expect some pain at your age"

This logic is ridiculous and near-sighted. Any good doc knows that dependence does not equal addiction. Why should my 92-year-old patient suffer from severe pain when a simple twice a day pain med could alleviate their symptoms? Don’t let your doctor use the above arguments to discourage your quest for pain relief! They are obligated to improve your quality of life!

I am not perfect, but I value my patients’ time, feelings and autonomy. I am not your boss; I work for you and with you. If you are uncomfortable with what you are getting out of your doctor’s visits, look around. Word of mouth speaks volumes. You deserve the best.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on Why? Part 2

2008-10-26T14:25:00.000-07:00

This is the second part of a series entitled: Medicine Demystified. I am attempting to break down the barriers that may exist between patient and physician. Previously, I discussed the nuances of appointment scheduling. Here I will tackle wait times, rooms and reps.

Waiting times: The scourge of our existence, long waits is my biggest stressor. I pride myself on being punctual with a goal of only one hour spent in the office, from check-in to checkout. Understand the unpredictability of scheduling. A visit for a cold may take eight minutes whereas an 85-year-old patient with diabetes, Alzheimer’s dementia and frequent falls may take greater than the aforementioned fifteen minutes. It only takes one walk-in or emergent care visit per day to slow my schedule down considerably. Do not allow your physician to rush you out the door! Again, you deserve 10-15 minutes of his/her undivided attention. If I am behind, my patients still know I will hear their complaints in full without exception. For those who absolutely cannot wait to be seen, I recommend seeking early morning appointments or those just after lunch. Wait times are obviously minimized with this strategy. A 10:30 appointment time is a set-up for potential delays.

In the Room: I don’t mind covering multiple issues, but be sensible. Unraveling the Dead Sea Scrolls of complaints is a recipe for disaster. Remember that fifteen-minute timeframe. Though you are important and have waited patiently, there are many more behind you. Often due to the inherent medical costs and the inconvenience of office visits, patients will present with dozens of problems. Rome wasn’t built in a day. I will try to accomplish as much as possible in that 15 minute to make your visit complete. If you expect ten complaints to be addressed in their entirety, you will undoubtedly leave dissatisfied. In this case, a more reasonable lowering of expectations will improve perceived quality of care. If you are a patient with a long history office visits with multiple complaints, your physician may label you as a nuisance or hypochondriac. This will only further serve to erode your doctor-patient relationship and may adversely affect your health in the long run.

Drug Reps: Many of my patients hate pharmaceutical reps. They view them as mere salesmen who waste my time, slow me down and do nothing more than provide free lunches, golf trips and a plethora of fancy pens that are later sold on e-bay. I disagree. I provide drug rep samples to patients on a regular basis to assist with cost and allow them to "test drive" a new medication before paying a large co-payment to obtain it. The reps do serve a purpose. They occasionally provide valuable information regarding novel agents that can be used to improve a patient’s life.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on WHY? Part 1

2008-10-26T14:19:00.000-07:00

The medical field often to the layman seems cloaked in a shroud of mystery. Why does my doctor do what he does? Why can’t I get an appointment? Why do I have to wait three hours to be seen? Why won’t my doctor listen to me?

As a small town doc, I have attempted here to unravel some of these mysteries and perhaps improve your doctor-patient relationship and overall impression of the medical field. This is the first of a three part series.

Overview: I would like to presume that all patients are ultimately satisfied with their medical care. The reality, however, is that many remain frustrated with long waits, poor communication with their physician and growing expense. Data suggests the average doctor sees 20-25 patients per day, but my experience is otherwise. Many physicians feel overworked, underpaid and under appreciated – there is a growing trend away from primary care. When asked whether they would again choose medicine as a career given the opportunity, many physicians suggest that they would not. Is there any way we can coordinate our efforts as patients and doctor so that we can both live harmoniously and without disdain.

Appointment Scheduling: My pet peeve is poor scheduling. I demand my patients be seen in a timely fashion whenever necessary and with minimal wait. With increasing demand, it is nearly impossible to provide either. Sadly, many patients must wait weeks or months to see their physician. There is no proven method to solve this dilemma. I prefer at least fifteen minutes per visit. There are numerous factors however that prevent this from becoming a reality. There is always demand. Certainly, patients with severe chest pain need more immediate assistance and this can bog down the system. My costs, as your own, rarely decrease. With inflation, medical costs continue to rise at an astronomical rate. I am forced to spend tens of thousands of dollars every month on office mortgage, staff medical insurance, employee wages, liability and disability insurance, malpractice, supplies etc. Medicaid reimbursement is poor at best and Medicare continues to threaten cuts in reimbursement each year. How do physicians’ offset these changes? Obviously, to maintain if not increase revenue, more patients must be seen.

For those of us in large groups with fixed salaries, bonuses may be based on the total number of patients seen or on total revenue, not on quality of care. We are forced to see more than is reasonable or comfortable in order to "get ahead". The reality is that most physicians seek careers in medicine to help and serve patients. But like anyone else, they want financial security and all the benefits that derive from it, general practitioners on average train for eleven years past high school. There is great animosity when physicians earn less than some pharmaceutical reps or car salesmen. Does higher education not equal higher pay? We are not money hungry as many may suggest; but we are driven to achieve financial and academic success.

I suggest that patients find a doctor who spends 10-15 minutes with them on average. We owe it to our patients – there is no excuse!!

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by filling out the form on the webiste or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.

Questions on CT Scans

2008-10-18T17:41:00.000-07:00

I recently commented on the potential dangers associated with CT scanning and the feedback has been impressive. Given the apparent interest, I decided to use this space to elaborate on the risks of medical imaging.

In the United States, it is estimated that 62 million CT scans are performed yearly as compared to 3 million in 1980. Recent data from the New England Journal of Medicine suggests that CT scans may cause breaks in our DNA that results in genetic mutations and possible cancer. Over 20 million adults are unnecessarily exposed to potentially harmful radiation each year. Some even submit themselves to full body CT scans in hopes of "catching disease" early as a preventative (though unproven) measure. Physicians often order unnecessary scans in a so-called "shotgun approach" manner that allows for less likelihood of a missed diagnosis or potential resultant lawsuit.

CT scans are not benign. A single CT scan of the abdomen exposes patients to the radiation equivalent of 500 chest x-rays. X-rays have been linked to cancers of the lung, breast and thyroid as well as leukemias. An article in the New York Times indicated that Americans lifetime per-capita dose of ionizing radiation increased 600% between 1980 and 2006 with the bulk of the increase attributed to diagnostic imaging procedures.

Here are some truly scary statistics. The risk of developing a fatal cancer after one chest x-ray is 1 per one million. The risk increases to 1 in 2000 after just one CT scan of the abdomen. These exposures are nearly equivalent to those unintentionally received by survivors of the atomic bomb explosions in Japan during World War II. Furthermore, 1 in 143 women receiving a scan at age 20 will develop cancer (usually breast). The risk for a 40 year old drops to 1 in 284.

The FDA has never approved CT scanning for general screens of the body nor of any part of the body when there are no symptoms of disease. If this is the case, then why are so many done? Mostly, the answer is because we can. Lost is the art of history taking and physical exam skills – we rely on CT scans to make decisions, though they have never been shown to prolong life nor alter behavior (i.e. smoking). One example is cardiac catheterization. Stent placement has come under scrutiny because it does not improve clinical outcomes more than does optimization of medical therapy and modification of lifestyle. Yet, a cardiac cath exposes us to the equivalent of 120 chest x-rays. Caths may be better suited for unstable patients with persistent chest pain despite maximum medical management. There is a fear of missing the "big one". Unfortunately, in a litigious society such as ours, lawsuits (frivolous or otherwise) are commonplace and are a source of financial worry, psychological trauma and contempt for patients, insurance companies and the legal system.

It’s easy to order a test. Awareness of the potential dangers involved with the test is critical. The Hippocratic Oath says, "First, do no harm". Maybe we should listen.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by filling out the contact form provided on this page.