If you have a medical problem, or something is bothering you or a member of your family, The Jackson County Times now has a local physician, Dr. John Spence, of the Panhandle Family Care Associates available to respond to your questions via e-mail.
I have written previously on the subject of vitamin D supplementation in the general population. I think the importance of vitamin D deserves another look – perhaps with more enlightening statistics (as everyone knows, I am a tremendous fan of statistics).
Between 40-90% of elderly individuals have defined vitamin D deficiency (levels less than 30 ng/ml). Even in Florida where the average is 64%. Replacement with standard doses (400 IU) is ineffective at raising levels appreciably, and it does nothing to enhance bone mass, prevent falls, or fractures. Most people believe the sun or milk consumption provides us with all of our inherent vitamin D needs. Unfortunately, it would mean getting a mild sunburn to the arms and legs at least four days a week to get the minimum amount that may be required. Further, it would take twenty glasses of milk or orange juice per day to achieve the same effect.
Two studies from 2007 have elucidated the benefits of vitamin D. The first, from the American Journal of Nutrition, evaluated 1180 post-menopausal women after four years of vitamin D supplementation (1000 IU/day). The risk of contracting any cancer was 60% lower in the vitamin D group as compared to those on nothing. Risk reductions with individual cancers included breast (50%), colon (50%), prostate (49%) and ovary (36%).
The second study published in the reputable New England Journal of Medicine suggested that anywhere from 40-100% of all elderly patients in the United States and Europe have insufficient or deficient vitamin D levels. The authors calculated the rates of various diseases affected by vitamin D status and have churned out the following numbers:
● 200% increase in Type I diabetes mellitus in vitamin D deficient children
● 37% reduction in Type 2 diabetes in those taking 800 IU of vitamin D plus calcium
● 72% reduction in falls
● 30-50% more cancer in vitamin D deficient people
● 42% reduction in risk of multiple sclerosis if taking greater than 400 IU/day
They go further to suggest that inadequate vitamin D levels increase the likelihood of hypertension, depression, osteoarthritis, schizophrenia, autoimmune disease and pulmonary disease.
Recently, the recommended amount of daily supplementation has increased from 400 IU to 800 IU per day. This may not even be enough! A dose of 1000 IU/day will increase blood levels 11.6 ng/ml – experts suggest patients shoot for levels greater than 60 ng/ml, which far exceeds what is now considered standard.
Dr. William Faloon notes that our shortsightedness in globally recommending higher vitamin D doses and higher blood levels has taken twelve times as many American lives as were killed in World War II. I suggest all middle age adults start now and supplement with at least 800-1000 IU per day. Vitamin D is extremely safe up to doses of 10,000 IU per day and it is dirt-cheap. I see no great excuse at not jumping on the vitamin D bandwagon – your body will thank you.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
The Daily Dose- 12/18/08
Dear Dr. Spence,
I recently had a mini-stroke. The doctor in the ER told me I am at huge risk for a full stroke in the next several months. Now I’m panicked – what can I do?
Signed, Hardly Strolling
Dear Hardly,
Mini-strokes, or transient ischemic attacks (TIAs) occur anywhere from 200 to 500 thousand times per year in the United States. The risk of TIA increases dramatically with age, with the majority occurring in patients over the age of 70. The definition of a TIA is a neurologic event that resolves within a 24-hour period. In other words, signs and symptoms of stroke (whether it is numbness, weakness, speech disturbance etc), disappears over the course of only a day. Risk of full stroke appears to be higher at two days (3.1% risk), one week (5.2%) and three months (10-15% increased risk). Patients with TIAs need rapid assessment and may require evaluation of the carotid arteries for blockage, or ultrasounds of the heart to rule out clot formation.
More recent studies suggest a so-called "ABCD" system for predicting future stroke risk. This allows patients to be stratified according to their inherent medical risks and determines whether or not they need elaborate investigation. The ABCDs studied are age (greater than age 60 = 1 point), blood pressure (> 140/90 = 1 point), diabetes (present = 1 point), clinical features (weakness = 2 points, speech impairment = 1 point), and duration of symptoms (>60 minutes = 2 points, 10-59 minutes = 1 point). Any score greater than three warrants further evaluation. A score of three imparts only a 1% risk at 90 days out from the previous TIA, whereas a score of seven increases the 90-day risk to 6%.
It’s hard to say whether or not you need formal evaluation, as more clinical information is required. I will say that obvious risk prevention measures are in order. I recommend lowering LDL (bad cholesterol) to less than 70. Use of a statin like zocor may be indicated regardless of lipid levels given their potential ability to stabilize plaques and prevent strokes and heart attacks. Blood pressure should probably be lowered to less than 130/80. If you are a smoker, you need to quit, as this remains a huge risk for recurrence. Finally, the addition of an anti-clotting agent like aspirin has definitive data behind and I add 81 mg of aspirin to nearly all patients who have suffered a TIA.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
I recently had a mini-stroke. The doctor in the ER told me I am at huge risk for a full stroke in the next several months. Now I’m panicked – what can I do?
Signed, Hardly Strolling
Dear Hardly,
Mini-strokes, or transient ischemic attacks (TIAs) occur anywhere from 200 to 500 thousand times per year in the United States. The risk of TIA increases dramatically with age, with the majority occurring in patients over the age of 70. The definition of a TIA is a neurologic event that resolves within a 24-hour period. In other words, signs and symptoms of stroke (whether it is numbness, weakness, speech disturbance etc), disappears over the course of only a day. Risk of full stroke appears to be higher at two days (3.1% risk), one week (5.2%) and three months (10-15% increased risk). Patients with TIAs need rapid assessment and may require evaluation of the carotid arteries for blockage, or ultrasounds of the heart to rule out clot formation.
More recent studies suggest a so-called "ABCD" system for predicting future stroke risk. This allows patients to be stratified according to their inherent medical risks and determines whether or not they need elaborate investigation. The ABCDs studied are age (greater than age 60 = 1 point), blood pressure (> 140/90 = 1 point), diabetes (present = 1 point), clinical features (weakness = 2 points, speech impairment = 1 point), and duration of symptoms (>60 minutes = 2 points, 10-59 minutes = 1 point). Any score greater than three warrants further evaluation. A score of three imparts only a 1% risk at 90 days out from the previous TIA, whereas a score of seven increases the 90-day risk to 6%.
It’s hard to say whether or not you need formal evaluation, as more clinical information is required. I will say that obvious risk prevention measures are in order. I recommend lowering LDL (bad cholesterol) to less than 70. Use of a statin like zocor may be indicated regardless of lipid levels given their potential ability to stabilize plaques and prevent strokes and heart attacks. Blood pressure should probably be lowered to less than 130/80. If you are a smoker, you need to quit, as this remains a huge risk for recurrence. Finally, the addition of an anti-clotting agent like aspirin has definitive data behind and I add 81 mg of aspirin to nearly all patients who have suffered a TIA.
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Wisdom Teeth "To Go or Stay?"- Dec. 11, 2008
By Dr. Spence
Most adults had to deal with the eruption or lack of eruption of their wisdom teeth. Frequently, dentist will recommend the surgical removal of wisdom teeth. Many people have questions concerning whether to extract their wisdom teeth or leave them in their mouths. Here are some factors that are considered when making this decision about wisdom teeth extractions.
The predominant problem with wisdom teeth is their location in the jaw. The amount of space available for eruption and the tooth’s position are major factors. Often small-framed people do not have enough room for their wisdom teeth to fully erupt. This lack of space also allows for the forming wisdom tooth bud to assume a position or angle, which does not allow for the tooth to ever completely erupt. As a person grows and matures into their middle to late teen years, the development of the wisdom teeth is approaching completion. As the teeth mature and grow, they are naturally attempting to erupt into the mouth as they were designed to do. If space, position, angle, or location will not allow for full eruption, a huge problem is created.
Often, the wisdom teeth only partially erupt allowing for bacterial invasion into the gum and bone surrounding the partially erupted tooth. This sets the stage for major inflammation and possibly a large infection to develop in the area. If allowed to go untreated, the inflammation-infection process usually comes and goes until eventually the infection spreads into the facial areas causing enormous pain and swelling. The cause of the problem is the position of the wisdom teeth, and the only permanent solution is the surgical removal of the tooth. Many people ask if taking antibiotics alone could solve the problem. While antibiotics will help the body fight the infection, it will not solve the problem itself. Besides the gum and bone infection that can occur, often the wisdom teeth sit directly against other teeth causing excess pressure that can lead to decay or erosion of the adjacent second molar. If that damage goes undetected for a long enough time, the adjacent tooth may become infected necessitating a root canal or a surgical extraction of an additional tooth.
Of utmost importance, in regards to wisdom teeth is the timing of the decision to extract. If there is a strong indication that there is a lack of space, poor position or angulation, then the younger you are, the better your chances for the best outcome. The older a person is, the more difficult the surgery, with an increased chance for a difficult recovery. Consult with your dental professional for yourself or your family member for the best guidance concerning the extraction of wisdom teeth.
Most adults had to deal with the eruption or lack of eruption of their wisdom teeth. Frequently, dentist will recommend the surgical removal of wisdom teeth. Many people have questions concerning whether to extract their wisdom teeth or leave them in their mouths. Here are some factors that are considered when making this decision about wisdom teeth extractions.
The predominant problem with wisdom teeth is their location in the jaw. The amount of space available for eruption and the tooth’s position are major factors. Often small-framed people do not have enough room for their wisdom teeth to fully erupt. This lack of space also allows for the forming wisdom tooth bud to assume a position or angle, which does not allow for the tooth to ever completely erupt. As a person grows and matures into their middle to late teen years, the development of the wisdom teeth is approaching completion. As the teeth mature and grow, they are naturally attempting to erupt into the mouth as they were designed to do. If space, position, angle, or location will not allow for full eruption, a huge problem is created.
Often, the wisdom teeth only partially erupt allowing for bacterial invasion into the gum and bone surrounding the partially erupted tooth. This sets the stage for major inflammation and possibly a large infection to develop in the area. If allowed to go untreated, the inflammation-infection process usually comes and goes until eventually the infection spreads into the facial areas causing enormous pain and swelling. The cause of the problem is the position of the wisdom teeth, and the only permanent solution is the surgical removal of the tooth. Many people ask if taking antibiotics alone could solve the problem. While antibiotics will help the body fight the infection, it will not solve the problem itself. Besides the gum and bone infection that can occur, often the wisdom teeth sit directly against other teeth causing excess pressure that can lead to decay or erosion of the adjacent second molar. If that damage goes undetected for a long enough time, the adjacent tooth may become infected necessitating a root canal or a surgical extraction of an additional tooth.
Of utmost importance, in regards to wisdom teeth is the timing of the decision to extract. If there is a strong indication that there is a lack of space, poor position or angulation, then the younger you are, the better your chances for the best outcome. The older a person is, the more difficult the surgery, with an increased chance for a difficult recovery. Consult with your dental professional for yourself or your family member for the best guidance concerning the extraction of wisdom teeth.
Dec. 4, 2008
Dear Dr. Spence,
Is there any value in treating high blood pressure in an 84 year old? My father is on three medications. He is generally healthy, but the cost is progressively becoming an issue.
Signed,
Heir Apparent
Dear Heir,
Great question. I think there is great value in maintaining blood pressure in an elderly patient and this has been supported in the literature. The HYVET study (Hypertension in the Very elderly Trial) evaluated 3845 patients with an average blood age of 83.6 who had a systolic blood pressure greater than 160 mm Hg. These patients were placed on either one or two drugs depending on response. At two years, anti-hypertensive drug therapy reduced fatal stroke by 39%, death from cardiovascular disease by 23%, death from heart failure by 64% and death from all causes by 21%. Not only that, these patients were generally free of underlying heart disease. One may have expected even more impressive numbers had they used a more representative sampling of the geriatric population as nearly 70% of patients over 80 years of age have heart disease or diabetes.
Blood pressure control is crucial regardless of age. It is recommended to treat at least 140/90 or less for the majority of patients. Cost is certainly an issue, however. Generic combinations can generally be effective in achieving optimal control.
Dear Dr. Spence,
What’s all the fuss about liver damage with the use of medications like lipitor or zocor? I saw the TV ads and now I’m paranoid that I’m destroying my liver completely!
Signed,
Hadda Sclerosis
Dear Hadda
Undoubtedly, the perceived risk associated with the use of statins medications (those for cholesterol lowering) are grossly overstated. The FDA recommends checking liver functions, a marker of liver damage, at the start of therapy, at 6-12 weeks and periodically thereafter. An analysis of 35 studies involving 74,102 patients reported the risk of liver function test elevations to be 4/1000. Other studies suggest that severe elevations may only occur in 0.1% of patients treated. The FDA reports only 0.69 cases of true liver failure or hepatitis for each one million prescriptions written.
There does seem to be widespread concern about the damaging effects of these drugs. I have witnessed it countless of times in my own office. It is crucial to recognize the positive effects that the statin class may provide. Only 27 patients would need to be treated with a statin to prevent one cardiovascular death whereas the number needed to harm one patient is approximately 3400. Usually, even with an increase in liver function tests, discontinuation of the offending agent quickly reverses these numbers back to normal.
Given the overwhelming greater likelihood of dying from a massive coronary versus suffering statin induced liver damage, I say use the statin. Further, though it is suggested that periodic testing be done to evaluate for liver damage (every six months is standard), there is really no evidence proving it is either helpful or necessary. I still check as recommended mostly because I’m not fond of lawyers (no offense).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
Is there any value in treating high blood pressure in an 84 year old? My father is on three medications. He is generally healthy, but the cost is progressively becoming an issue.
Signed,
Heir Apparent
Dear Heir,
Great question. I think there is great value in maintaining blood pressure in an elderly patient and this has been supported in the literature. The HYVET study (Hypertension in the Very elderly Trial) evaluated 3845 patients with an average blood age of 83.6 who had a systolic blood pressure greater than 160 mm Hg. These patients were placed on either one or two drugs depending on response. At two years, anti-hypertensive drug therapy reduced fatal stroke by 39%, death from cardiovascular disease by 23%, death from heart failure by 64% and death from all causes by 21%. Not only that, these patients were generally free of underlying heart disease. One may have expected even more impressive numbers had they used a more representative sampling of the geriatric population as nearly 70% of patients over 80 years of age have heart disease or diabetes.
Blood pressure control is crucial regardless of age. It is recommended to treat at least 140/90 or less for the majority of patients. Cost is certainly an issue, however. Generic combinations can generally be effective in achieving optimal control.
Dear Dr. Spence,
What’s all the fuss about liver damage with the use of medications like lipitor or zocor? I saw the TV ads and now I’m paranoid that I’m destroying my liver completely!
Signed,
Hadda Sclerosis
Dear Hadda
Undoubtedly, the perceived risk associated with the use of statins medications (those for cholesterol lowering) are grossly overstated. The FDA recommends checking liver functions, a marker of liver damage, at the start of therapy, at 6-12 weeks and periodically thereafter. An analysis of 35 studies involving 74,102 patients reported the risk of liver function test elevations to be 4/1000. Other studies suggest that severe elevations may only occur in 0.1% of patients treated. The FDA reports only 0.69 cases of true liver failure or hepatitis for each one million prescriptions written.
There does seem to be widespread concern about the damaging effects of these drugs. I have witnessed it countless of times in my own office. It is crucial to recognize the positive effects that the statin class may provide. Only 27 patients would need to be treated with a statin to prevent one cardiovascular death whereas the number needed to harm one patient is approximately 3400. Usually, even with an increase in liver function tests, discontinuation of the offending agent quickly reverses these numbers back to normal.
Given the overwhelming greater likelihood of dying from a massive coronary versus suffering statin induced liver damage, I say use the statin. Further, though it is suggested that periodic testing be done to evaluate for liver damage (every six months is standard), there is really no evidence proving it is either helpful or necessary. I still check as recommended mostly because I’m not fond of lawyers (no offense).
Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.
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