Tag: clinical

Shaky Business

Early in the pandemic I avoided seeing my patients for a while, except with virtual visits. After returning to the office I tried to maximize the distance, and minimize the duration of contact to lessen both our risks.

As the pandemic has progressed, both my patients and myself have gradually become more relaxed. I think this is from a combination of vaccinations, having effective treatments, and just habituating to the situation. Initially I had stopped shaking hands, and my patients stopped trying to shake mine. But eventually some did, with either a fist or elbow bump, or sometimes a full hand shake. Some would follow my lead but remark about how they guess we are no longer shaking hands.

A few months ago a plumber came out my house to replace a sprinkler valve system that sprung a leak after an earlier freeze. When he arrived he stuck his hand out to shake. Not wanting to be rude I shook his hand, then was careful to make sure I didn’t touch my face before washing my hands.

Not longer after, someone came out to pump our septic tank. The same thing occurred. No offense to those in the sanitation field, but if you’re a germaphobe, rationally or not, shaking hands with someone who empties tanks with human waste does not sound like a good idea! But again, I didn’t want to be rude, so I did so.

After those encounters, I pondered what I should do with my patients. Having seen plenty of guys in public bathrooms walk out without washing their hands, or with just a cursory rinse, and knowing that most people, myself included, often touch their faces unconsciously, which is how diseases often spread, I’m a little leery of shaking anyone’s hands. Pre-pandemic I overrode those concerns and did so anyway, for the social bonding benefit, but now it’s more socially acceptable to not shake hands.

In the office we wash our hands often, even pre-pandemic. We’re taught to gel in, gel out. That means you use alcohol gel to wash your hands when you walk in to see a patient, then again as you leave the room. Even with that I usually put the gel in one hand, open the door with the other (who knows who touched that door handle last), then rub my hands together as I walk into the room (which also demonstrates to the patient that I washed my hands). If I then shake their hand (and anyone else they came with), then I feel compelled to wash them again lest I touch my face during the visit, or just to avoid potentially contaminating the keyboard (though my nurse does wipe it down often). That can easily add up to washing my hands over 50 times a day. Certainly the alcohol is a lot faster than using soap and water, but is more drying on the skin.

So where does that leave things? Basically I shake hands when my patients offer it, and occasionally other times, as I continue to weigh the pros and cons. I suspect after the current wave of infections declines I’ll relax more and be able to shake off the feeling of impending doom.

Omicron OMG!

Just when it looked like it was going to get safe to get back into the water, now we have a new COVID-19 variant with which we have to contend. Named after the Greek letter Omicron.

We don’t have enough information yet to know how serious of a threat this is, and whether it will significantly change what we do, but at best it’s tiresome news, and at worst it may cause significantly more cases.

For now, continue to wash your hands frequently and wear a mask in crowded places. If you’re fully vaccinated then there are a number of considerations about which situations it’s safe to not wear a mask. It includes the number of cases where you live, the chances of being exposed to those not wearing masks, and you personal risk.

Getting a booster is now a much simpler process. According to the CDC, if you’re 18-years or older and it has been 6 months since you last Pfizer-BioNTech or Moderna vaccine, get a booster. If it has been at least 2 months since a Johnson & Johnson vaccine, get a booster.

You may mix and match boosters. If you had a Johnson & Johnson vaccine, you will probably get a better response from having a Pfizer-BioNTech or Moderna vaccine booster compared with another Johnson & Johnson booster.

Stay tuned!

A is for Aspirin

You probably recently read in the news something about aspirin recently, and maybe you’re wondering if you should stop taking it, or you went ahead and already did. I know lots of my patients have been asking me.

The article by the U.S. Preventive Services Task Force talks about the use of aspirin to prevent heart attacks and strokes. They said for primary prevention (meaning to prevent a first heart attack) they recommended shared (between patient and their doctor/provider) decision making for starting aspirin in 40 to 59-years-olds with a 10% or greater risk of having a major heart event (such as a heart attack) in the next 10 years who do not have increased bleeding risk. They recommended not starting aspirin in those 60 and older who have less than a 20% risk.

There are a number of key points.

  • This is a draft recommendation. There is a public comment period and changes will be made before it’s finally published, probably in 6 or more months.
  • The recommendations only apply to starting aspirin.
  • The recommendations do not apply to people who have previously had a heart attack or stroke.
  • They make no recommendations about stopping aspirin other than considering stopping at 75 years old for primary prevention.

For patients who have had a heart attack, stroke, or peripheral artery disease (blocked artery to one’s arms or legs), the benefits of aspirin generally outweigh the risk of bleeding.

The decision to use any medication is always a balance of the benefits versus the risks (and sometimes the cost). Why the change in recommendations? Well in part we generally get progressively better as we accumulate more scientific information. But probably in this case it’s more due to treatment changes. When the original recommendations came out to use aspirin for primary prevention we did not have very good treatment for the conditions that cause heart disease, particularly cholesterol. With improved treatment, there is less incremental benefit from aspirin, yet the bleeding risk remains. That may shift who we should treat.

For now, I’m not recommending any changes before the final recommendations come out. Aspirin was first recommended for primary prevention over a century ago! If taking aspirin was that risky we’d have known there was a problem long ago. I don’t think there is any reason to make any rushed decisions unless someone is having a problem with aspirin.

So you if you are already on aspirin and doing fine on it, and your next appointment to see your doctor will be within 9 months or so, I suggest considering not even asking your doctor until your next appointment. That gives time for the final report to be published, and time for your doctor to consider the information. That’s better than making a decision based on a headline.

Exploring Cuba – Part 2

In my prior post, I discussed a trip I made to Cuba in December. In this second part I will focus on some medical aspects.

When my patients ask about foreign travel where there may be health concerns, I usually direct them to the CDC site. It’s also where I go to check for my own travel, though I look at the more detailed Clinician view.  To start off it recommends typhoid vaccination.  You have a choice of the oral or injected. The oral is a live virus that is taken every other day for 4 doses, starting 12 days before potential exposure. It gives better immunity, but should not be taken by people with a suppressed immune system, such as those on steroids. The injected form is a non-live vaccine, a single injection taken at least 2 weeks before potential exposure. The injected form is harder to find, and even pharmacies that carry it may need to order it in advance. The injection is more expensive, and neither vaccine is usually covered by one’s health insurance. There are other vaccines recommended, but typhoid was the only one I needed.

Cuba has mosquitoes that may carry Dengue Fever, and more recently Zika. I chose to travel in December because it was outside hurricane season, it was the cooler time of the year, and there are less mosquitoes around that time. Cuba does a better job than many other countries controlling mosquitoes, but I was still cautious. Due to the cost, they don’t use insecticides to fumigate buildings, but rather burn oil, as can be seen in the photo above. We checked in to one place not long after they had done their weekly spray, and had to wait 30 minutes for smoke to stop poring out the window! I sprayed much of our clothes with permethrin spray, and applied DEET to exposed skin, especially in the evening when the mosquitoes are more apt to bite.  I texted PLAN to 855-255-5606 to get periodic updates from the CDC about Zika before the trip.

Food is generally safe to eat, but we avoided street food. The tap water is not safe, however. We mostly depended on bottled water and avoided ice except at a few restaurants and bars that filtered their own water. Bottled water is kind of pricey at times. The best deals are on large (3-4 liter bottles) that you can find sometimes in stores. They often cost the same price or less than a one liter bottle that is more readily found. I also brought along a SteriPEN which sterilizes water with ultraviolet light. I didn’t have enough experience to trust it completely to replace buying bottled water, but used it to sterilize water to rinse our toothbrushes, and would have used it if we didn’t have bottled water. I also recommend bringing Imodium, and an antibiotic from your physician for traveler’s diarrhea. I’d also bring some toilet paper. Many public toilets often didn’t have any, or  you’d get a small amount from an attendant after giving a tip.

Bring sunscreen. It’s not easy to find places that sell it in Cuba, and it’s expensive.

Months before my trip I tried to arrange to visit a hospital. It so happened that the fiancée of a Cuban in the travel industry who helped with some of the arrangements was an anesthesiology resident. He told me that he would love to show me his hospital, but that unfortunately the government required a 30-50 dollar payment, despite the fact that I said I would be bringing some medical supplies. He also said I would not be allowed to tour the medical school due to, “national security!” After I arrived we talked a number of times, and ultimately he could not get government approval for me to see his hospital, even though he said everyone at the hospital wanted me to come. He said the only exceptions they made were for those with an educational visa, coming to teach basically, and even then they needed at least 3 months notice.

Although I could not tour the hospital, I had some long conversations with that doctor and learned a lot about their system. All things considered, the Cuban doctors are apparently pretty good, but they are particularly hampered by old equipment and lack of medications and supplies. The anesthesiology resident showed me photos of anesthesia equipment they currently use that are from the 1980’s. He said they don’t have air scrubbers in the operating rooms, so sometimes everyone gets sleepy!  He told me about a colleague of his who was working with a nurse anesthetist. She let her go home early because she wasn’t feeling well. Later she had to intubate a pregnant patient. Unfortunately it didn’t go well and the patient suffered brain damage. During a subsequent investigation the government argued that had she not let the nurse anesthetist go home early, maybe the patient wouldn’t have died because she would have had additional help. She was sentenced to 12-15 years in prison, and even if she gets out after 5-7 years for good behavior, she won’t be allowed to be a doctor anymore! Because physicians are held responsible for a bad outcome, Jehovah’s Witness patients are told they can’t refuse blood if needed, though they do take measures to minimize the need. Doctors are paid poorly (the resident said after he finished he would make 80 CUC (about $80) a month), often less than taxi drivers. It’s very difficult for specialists to be allowed to leave the country, even on vacation, for fear they won’t come back. If they go on medical missions they are paid better than usual, but they only pay them the bare minimum while they are abroad to encourage them to return home after the mission. I was surprised to learn that they are fairly tolerant in terms of LBGT, in part due to Raúl Castro’s daughter, and they even have doctors who do sex reassignment surgery to change gender.

Many Cubans rely on natural formulations, such as herbs, they call ‘green medicine,’ due to cost or personal preference. The anesthesiologist told me that for a man to get a prescription for Viagra (sildenafil) he has to see his primary care doctor, a urologist, and a psychiatrist. Once they get a prescription, though, they are basically assured of getting it indefinitely. He said many patients research their condition and tell their doctors what prescription they want, and they often comply.

One of the most dangerous things in Cuba are the cars. They are famed for their old cars, many of which look fabulous, but they lack safety features, such as seat belts and airbags. In fact we were in a car accident. We hired a car and driver for 6 days through a contact in the travel industry in Havana. He was probably around 60-years-old, and reportedly one of their best drivers. He was very nice, funny, and knowledgeable, and arrived to pick us up in a pretty new Chinese car, a BYD (Build Your Dream). On the first day as we were driving, while my wife and daughter were sleeping in the back, the car started drifting to the left. I grabbed the steering wheel, noting the driver had fallen asleep. He quickly awakened, pulled the car to the side of the road, and got out to stretch. He came back in and apologized, saying he had gotten up early to pick the car up. The next day he said that actually he hadn’t slept well because he had witnessed a teenager, who was not paying attention listening to music, hit by a car the day before.

In the middle of the car trip I met with the doctor I mentioned above and told him about the incident. I wondered if he might have sleep apnea, though the driver had said he had never had such a problem.  He said that they don’t test for sleep apnea because they don’t have CPAP machines to treat it.

The rest of the road trip went fine until the final day. Once again my wife and daughter were sleeping in the backseat when the driver fell asleep again. This time he swerved too quickly for me to reach the wheel. We hit a guard rail, damaging the front end and side mirror and puncturing two tires. The driver said he did not know why he fell asleep and that he had been well rested. One theory I came up with is the possibility of carbon monoxide poisoning from a leak in the exhaust system. Our driver obtained another car and driver for us, who brought us back to Havana.

No one was serious injured, but my wife was seated behind the driver and her left elbow hurt immediately afterward. Back in Havana we went to a clinic that caters to foreign visitors. X-rays showed no fracture.  She was given a skinny piece of gauze to use for an arm sling (she had been using my belt up until that point). When it came time to leave they said we owed 100 CUC (about $100).

Boarding Pass

 

Cuba requires one to have medical insurance to visit the country, and they add $25 to the price of each airline ticket to cover it. Delta Airlines said to show the boarding pass if needed as proof of insurance. I showed the boarding pass, but they said it wasn’t good because it said AeroMexico on the top. I pointed out that below that is said that it was operated by Delta Airlines. They said they would have to investigate it. They gave no indication how long it would take, and given that it was the evening I didn’t think they would get an answer that night. I eventually gave up, paying the money so we could get her passport back and leave. I wrote Delta Airlines and explained the situation, sending them copies of the boarding pass and the medical bill. We were on something like their 4th commercial flight to Cuba, so I figured they would be eager to work out any glitches. I was wrong. Besides some email exchanges, they called twice at 7 am. When I pointed out the early hour I was told it was 10 am on the East coast. You would think an international airlines understood the concept of time zones! In any case, ultimately I was told we, “..must request a refund of the insurance premium directly with the Cuban insurance provider.” Really? They expect their customers to request a refund from the Cuban government?! All I was asking for was the approximately $100 I paid for the clinic. Not the taxi ride there and back, the medical costs after we got home, to say nothing of pain and suffering. Imagine someone of lesser means ended up needing much more care and being told the insurance they thought covered them didn’t. That might keep people from choosing to visit Cuba, at least on Delta Airlines.

Let’s be Clear on ClariSpray

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Bayer, the maker of Claritin, has a new product, ClariSpray. This is a good product, but with a confusing name. It has nothing to do with Claritin, other than they are both used for allergies (allergic rhinitis).

It’s actually fluticasone nasal spray, the same ingredient as Flonase, a prescription product, but now available over-the-counter.

Their website does takes pains to explain this, but there are some things things they don’t mention. They don’t say how it compares with Flonase or Nasacort. Although there are slight differences, and some people may prefer one over the other, they are basically similar, and just a matter of personal preference. Bayer’s website also doesn’t tell you that you shouldn’t take ClariSpray if you are taking Flonase or Nasocort, or one of the other nasal steroid sprays only available by prescription.

Who Are You Calling Old?

Moth on bricksA local family medicine residency program sends second year residents to rotate through my internal medicine clinic. Reviewing the note that one of them wrote, I saw that he described my 66-year-old patient as, “Elderly, ” though did note that she appeared younger than her age. I let that young whippersnapper know that age is relative, and that I doubted he would consider 66 as elderly once he reached his 50’s!

Prostate Cancer – A Fish Tale

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Have you heard that fish oil supplements cause prostate cancer? The news items come from an article published online July 11, 2013 by Brasky et al. in the Journal of the the National Cancer Institute, “Plasma Phospholipid Fatty Acids and Prostate Cancer Risk in the SELECT Trial.”

This study looked at 834 men diagnosed with prostate cancer, and compared them with 1393 men, matched for age and race, that did not have prostate cancer. They then looked at the amount of omega-3 in their blood and compared the groups.

They found that those with the highest omega-3 levels had the highest risk of prostate cancer, 44% higher over all. This study followed up on one published earlier by the same group that suggested increased risk from fish consumption. The levels of omega-3 in the highest group were fairly modest, equivalent to eating an oily fish, such as salmon, twice a week.

Before jumping to the conclusion that men should not take fish oil or consume much fish, there are a number of things to consider. First of all, association does not imply causation. What does that mean? Just because two things occur together, it does not mean that one caused the other. If you look outside on a rainy day, you will see many people carrying umbrellas. But you would be wrong to conclude that carrying umbrellas caused it to rain.

It could be that it wasn’t the omega-3 in fish, or fish oil supplements, that caused prostate cancer, but rather something else in the products, such as mercury or other toxins in the fish. If you ate fish raised in places low in pollution, or consumed ultra-filtered fish oil, then perhaps it would not be a problem. This study does not answer that question.

Even if eating fish or taking supplements increases the risk of prostate cancer, studies have shown it decreases the risk of cardiovascular (heart) disease, which is far more common.

This study was not the preferred double-blind, placebo controlled study, and the conclusion may just be wrong. After all, other studies have shown that fish consumption decreases prostate cancer. For example, one in the Lancet showed decreased risk of prostate cancer in those who ate moderate or high amounts of fish. Also consider that Japanese men consume much more fish then American men, yet have far less prostate cancer.

So until I see more convincing evidence, I’ll continue to take my fish oil capsules, and enjoy eating salmon.

Aspirin – Coated or Naked – Does it Matter?

Aspirin is often used to prevent heart attacks and strokes. Patients usually take an 81 mg (baby aspirin) or 325 mg (regular strength) pill. It also comes in plain, enteric coated, or buffered. Enteric coated aspirin is often recommended to decrease the risk of ulcers, the idea being that it doesn’t dissolve until it gets past the stomach, though there is limited evidence that it really makes a difference.

Another concern over the past decade is that some patients may be resistant to aspirin, and perhaps needed to be on more expensive medications, such as Plavix (clopidogrel), which recently went generic, though is still pricier than aspirin.

Now a new study from the University of Pennsylvania, published in the magazine Circulation, questioned the idea of aspirin resistance, and said that some patients who did not respond to the coated aspirin did respond to plain aspirin. But that does not mean you should conclude that taking coated aspirin may put you at increased risk for a heart attack.

This study looked at 400 health volunteers and gave them a single 325 mg dose of aspirin, either plain or coated, and measured the chemical cyclooxygenase-1 to see if it worked. If they appeared “resistant” then they gave one week each of coated 81 mg aspirin and clopidogrel. Although 49% of the volunteers did not respond to the single aspirin, they all responded to the daily dosing.

So the bottom line is if you take a coated aspirin every day, you probably don’t need to be concerned about it not working. If you don’t regularly take aspirin, but experience chest pain, after you call 911, take a plain aspirin, and preferably chew it to speed absorption. If you only have coated aspirin, it should work just as well if you chew it. Coated aspirin, made by Bayer and other manufacturers, are a little more expensive than plain aspirin, but are still fairly inexpensive.

Dangers of a Transparent Medical Record

Over the years there has been a push to allow more patient access to their records. Patients in our system that have signed up for MyChart with our electronic medical record Epic, can see most of their test results shortly after they are back, even if not yet reviewed by the physician who ordered them.

To avoid patients misinterpreting or reacting badly to the results, certain tests, such as HIV and pathology, are not automatically released. Although releasing the results automatically acts as a safeguard for abnormal results that may have been missed by the physician, it also opens the possibility of patients inappropriately acting on the results.

I’ve had patients make changes in their medications after seeing their results, and without even discussing it with me until their next visit. One patient who saw that his sleep study showed he had sleep apnea, borrowed a friends extra CPAP machine, adjusted the settings based on his research on the internet, then tried it out for 2 weeks!

As the saying goes, a little knowledge can be dangerous. Patients should use the information in their charts to inform them, and help ask educated questions, but not to replace their physician. There is often a lot more to making a diagnosis and deciding on a treatment than just looking at test results.

Chiropractic Care

I have a confession. Last year I went to a chiropractor for the first time. I had been having some neck and sacroiliac pain. I went to a massage therapist a few times. Although it felt good, especially for the neck, it didn’t seem to last more than a few weeks at most. Anti-inflammatory medications only gave temporary relief. Thus I was interested in trying something else, particularly when I started having some acute left sacroiliac pain that made it difficult to move around at times. I also had intermittent low back pain, left trochanteric bursitis, knee pain and plantar fasciitis. In Timothy Ferriss’s interesting book, The 4-Hour Body, he recommended active release techniques and a Functional Movement Screen (FMS), which I was curious about and thought might help. When I looked into it more, I found that these were pretty much only offered by chiropractors.

Physicians are trained to be scientific, and tend to dismiss what is called alternative, complementary, or allopathic medicine, including homeopathy, naturopathy, chiropractic, and traditional Chinese medicine. I wanted some relief from my symptoms, and I was also curious about what chiropractors do, so I decided to go there, rather that to physical therapy. Patients often ask me what I think about going to a chiropractor, but I had no personal experience. I justified to myself that it would be like a journalistic endeavor, which it sort of is, now that I’m blogging about it.

I purposely chose a clinic about 12 miles from my office. As I pulled into the parking lot I had second thoughts. I felt like I was breaking a taboo. Even though I figured it was unlikely I would be seen by a patient or anyone else I knew, I looked around before getting out of the car. That evening I told my wife not to tell anyone that I had gone to see a chiropractor.

Fifteen minutes after my scheduled appointment time the chiropractor came out to the waiting room, addressed me by my first name, and said she would be out shortly after reviewing my chart. She was young and attractive and had graduated about two years earlier. She came back and said, “I guess I should be calling you Dr. Ginsberg”. We went back to an exam room and she took a thorough history of the various pains I had. She asked about duration, severity, onset, exacerbating factors and prior injuries. She asked if I’d ever been to a chiropractor before and I said no. She said I was her first also (physician patient)! She asked me about my practice. When I complained about the paperwork, she pointed to her desk and said she has the same problem. Like a lot of doctors fresh out of school, she also had a lot of debt.

Next she did a very thorough musculoskeletal and neurological exam, other than checking cranial nerves and cerebellar function. Her range of motion and testing of strength and sensation reminded me of what I used to do as a medical student and intern, but now often shortcut. She discussed active release techniques then did some, including the Graston Technique. She asked if I was willing to have adjustments and I expressed some hesitation, particularly having it done to the neck. She said had no I had no red flags and that she did did this maybe 20 times a day. I initially agreed to let her adjust my back. After twisting me like a pretzel and throwing on her weight, causing a not unpleasant popping sensation in my back, she told me, “You just had your first adjustment.”

She then did more active release technique on my back, using a special table that moved,  making my back flex and extend. Then she did an adjustment on my mid and perhaps upper back.  She asked if I wanted to have my neck done, and reminded me of the decreased range of motion I had on one side. I thought about my patients who refused medications for their cholesterol or diabetes for fear of side effects, despite my recommendations, so I reluctantly agreed to trust her expertise. I was a bit nervous and she had to tell me me to relax. It was not especially uncomfortable when she twisted my head suddenly, but I had visions of a farmer breaking a chicken’s neck and I hoped I would not becoming a quadriplegic. Thankfully that did not come to pass.

We talked a little about the traditional distrust physicians have of chiropractors. She said some people just need a quick adjustment, but admitted that 75% of people come in with problems that are due to underlying muscle weakness or imbalance, and that they won’t fix the problem without addressing the issue. She said unfortunately some chiropractors don’t deal with this and only do adjustments. She knew one who had the same patient penciled in for every Friday at the same time for a year.

She said to return, preferably within 3 to 5 days, though I made it a little later due to my schedule, to have another treatment and a Functional Movements Systems evaluation.

I couldn’t really tell a difference after the first session. She warned me I might be sore at first, but I was not. Although massage may help various body aches and pains, I suspect many people like it for the therapeutic touch. I was surprised that chiropractic was similar, and I suspect that’s part of the reason for its popularity.

I later returned for another appointment. I underwent their own functional performance exam with one of the trainers. They said it was more thorough then the Functional Movement Screen. I later found out that FMS is a widely marketed system, for which chiropractors and others pay a lot to get certified, but that’s a different story.  In any case, the trainer said that I did pretty well, but was particularly weak in my medial glutes, which surprised me.  He recommended at least setting up an appointment to set me up with a home exercise program as I said coming in for regular treatments would be difficult.

Next I had another session with the chiropractor. She again did Active Release Techniques and adjustments. She was unable to adjust my neck as I involuntarily tensed up. I asked her why insurance companies require referrals for physical therapy but not chiropractic. She said it’s because chiropractors can make diagnoses.

I returned one more time to work on various exercises. Although I’ve exercised at the gym for decades, I started incorporating some of the exercises the trainer taught me, and I’ve had very little sacroiliac pain since then.

Scientific data showing the benefit of chiropractic care for back pain is sparse. Recently an article showed benefit in chiropractic care for neck pain, but another showed potential risk.

So what do I tell patients now about chiropractors? For neck and back pain I still preferentially refer patients for physical therapy. If patients ask about getting chiropractic treatment, I  am now less likely to object, assuming they don’t have a medical condition that would make it riskier, but I caution them about getting neck adjustments.  Just like physicians, not all chiropractors are equally skilled. A good chiropractor probably does a better job evaluating back pain than most primary care physicians, but watch out for those who over treat. Most importantly don’t take the lazy approach of just getting, “adjustments,” but do the work to correcting muscle weaknesses that often cause the problem.

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