Medical Myths Debunked Part 2

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.

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

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

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.

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 Stop Smoking

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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:

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

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

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.