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“Computer Hospital Intensive Care Operator”

Friday, February 24th, 2012

The doctor was controlled by a joystick, moved on three wheels, had a built-in stethoscope, and a flat screen as a face. Chico (a far more manageable name than “Computer Hospital Intensive Care Operator”) allowed doctors and other medical workers at Miami’s Jackson Memorial Hospital to virtually examine patients, speak to them, and access their digital files – even from miles away. As our population ages, and the healthcare professional shortage becomes even more serious, video-conferencing robots like Chico may represent one face of medicine’s future.

Years ago, when I first joined the staff at Downey Regional Medical Center, I was often greeted by a robot traveling through the halls and in and out of elevators, delivering food trays. That robot is no longer in use at our local hospital, but more sophisticated robotics are finding inroads into healthcare. You may be surprised at some of the applications being used.

Certainly, robots have proven their abilities in hospitals to perform relatively straightforward tasks such as washing floors, cleaning equipment, and carrying hot meals to patients’ bedsides. Robots are used in hospital pharmacies to count, bottle, and deliver medicines to the wards. Robots are used to lift and rotate bed-ridden patients, saving the backs of nurses.

When we think about ideal medical care, most of us imagine a concerned, compassionate and intelligent human practitioner. However, it is clear that some of our jobs can be done better by our non-human counterparts, and that machines can free up humans so that we can do other jobs better.

One significant area where robots have exploded onto the healthcare scene is in training. A group of medical students who were trained to perform a pelvic exam on a robotic simulation stood out from their non-simulator trained peers when working with real women. The training made them comfortable with the exam and they were able to focus more on the patients. Haptic (sense of touch) devices are also becoming commonplace in surgical training programs, including simple laparoscopic workstations that allow students to palpate (touch), incise, or suture virtual tissues and organs.

In order to serve remote areas and environments such as aboard military ships or rural areas, Virtual Presence Robots (VPR) have been developed and tested. A physician or floor nurse directs the robot to examine a patient while speaking with and viewing that patient on a monitor. Robots have the ability to visit the bedside and to record the pulse, blood pressure, and breathing of patients who require frequent and ongoing surveillance.

Telesurgery can also serve these remote areas. A skilled surgeon might assist a local surgeon (tele-assistance), teach the surgeon (tele-mentoring), or conduct critical portions of surgical procedures (tele-surgery). Surgeons utilize tele-strators placed over the operative site to describe a proposed action, much as a sports announcer might use such a device to explain a play or highlight a player during a broadcast!

Surgical robots can perform procedures, including general, urologic, gynecologic, lung, and heart. The da Vinci surgical system, for example, can improve a surgeon’s performance because it is more stable that the human hand, yet as flexible as the human wrist. The actual surgeon, however, will not yet be found out on the golf course – he or she directs while viewing on a monitor.

Robots are used in some orthopedic surgeries to mill perfectly round holes in the shafts of fractured bones, improving the bonding of metal replacements in hip and knee joints. These robots, much like those in a car assembly line, have one specific task.

Robots have been tested as surgical assistants. The “Robo-Nurse” dubbed Penelope was developed to hand instruments to surgeons at the operating table, wipe them clean, and make them available for further use. Penelope was also developed to count instruments, so lost instruments and sponges would be a thing of the past. Robots have provided constant and steady retraction of organs and skin during surgical procedures. Although robots have been tested in this area, they have not received wide acceptance by doctors and nurses to date, and Penelope is currently unemployed. Penelope, welcome to the recession…

Indeed, robots are diligent, precise and consistent. They create high quality products. Unlike humans, they are tireless. They do not take lunch or other breaks; vacations or sick leave; or incur costs for worker compensation or medical insurance.

However, they do cost a lot of money, they break down, and they have no intuition…yet. Human surgical nurses, for example, perform a wide range of critical functions that require advanced scientific training, including monitoring surgical and nonsurgical practice, sterile technique, and the patient’s condition; intervening in the case of an emergency; and advocating for the patient generally. Nurses use critical thinking to save lives. Relieving healthcare practitioners of various tasks does allow them to perform more specialized jobs, but clearly, no combination of metallic parts, microchips, and binary files could replace the empathetic touch or clinical intuition of a human healthcare practitioner. At this stage, at least, robots are not replacing humans, but rather assisting them.

Please contact my robotic assistant with any questions…just kidding!

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Alcohol

Saturday, January 21st, 2012

My wife and I recently returned from a wonderful weekend up in Sonoma County, where we indulged in a little wine tasting. While I’m actually not much of a drinker, learning about wine and winemaking is always fascinating. Upon our return, we’ve plunged into this season of holiday parties, with alcoholic drinks being served at most. All of this has started me thinking about the physiology of how alcohol affects our bodies.

Whether or not we are aware of it, the first sips of an alcoholic beverage result in the immediate impairment of brain function, and the more that we drink, the more that function deteriorates. The rate of deterioration may be affected by how empty or full our stomach is; our gender, age and weight; and race. Certain medicines, such as aspirin, slow the breakdown of alcohol and greatly increase the blood alcohol level. Cognitive abilities such as conduct and behavior are the first to go. There can be a mild euphoria and loss of inhibition. The most vulnerable brain cells are associated with memory, attention, sleep and coordination.

Alcohol affects the heart. Our pulses quicken after very little is consumed. Alcohol is a vasodilator, meaning that it makes the blood vessels relax in order to allow more blood to flow through the skin and tissues. This results in a drop in blood pressure, so in order to get sufficient blood to organs and tissues, the pulse speeds up. After a significant intake of alcohol, the heart develops “holiday heart syndrome,” in which the heart goes into an irregular rapid heart rhythm (atrial fibrillation). This can lead to weakness and shortness of breath, and an increased risk of stroke.

The lungs are involved because alcohol speeds up the breathing rate. However, at higher levels of intoxication, the stimulating affects are replaced by an anesthetic effect, which actually depresses the central nervous system. (Note that as our blood passes through our lungs, a proportional amount of alcohol passes into the air that we exhale. This is why Breathalyzers can accurately detect the blood alcohol level.)

The digestive system is affected. As a rough guideline, it takes as many hours as the number of drinks consumed to burn up the alcohol. Alcohol is absorbed through the stomach and small intestine. Even small amounts can irritate the stomach lining, and larger quantities of alcohol can block absorption of essential vitamins and minerals. Only a few weeks of heavy drinking can lead to pancreatitis.

The kidneys are affected because alcohol is a diuretic. It promotes urine production, which then leads to dehydration. Due to this stimulation, the kidneys are working overtime.

Alcohol affects the skin. It increases blood flow, making us feel warm and look flushed. Since it also dehydrates, it increases the appearance of fine lines.

The destructive effects of alcohol on the liver are well known. Large quantities can lead to both acute and then chronic liver disease. It is in the liver that alcohol is metabolized, and as it breaks down, its by-products (including acetaldehyde) are formed. Some of these by-products are even more toxic to the body than the alcohol. Even a single episode of heavy drinking affects the delicate balance of enzymes in the liver and fat metabolism. Over time, drinking can lead to the development of fatty globules that cause the liver to swell, ultimately leading to cirrhosis.

On top of all of this…is the hangover! Its precise cause is unclear. There are many theories, including hypoglycemia, dehydration, acetaldehyde intoxication, and glutamine rebound. Some symptoms may actually be due to alcohol withdrawal. They include fatigue, headache, body aches, vomiting, diarrhea, flatulence, weakness, elevated body temperature and heart rate, hyper-salivation, difficulty concentrating, sweating, anxiety, dysphoria, irritability, sensitivity to light and noise, erratic motor function, tremors, trouble sleeping, severe hunger, halitosis, and lack of depth perception. Hangovers may include psychological symptoms including depression and anxiety. Symptoms usually begin after the intoxicating effects of alcohol wear off; typically, a hangover is experienced the morning after a night of drinking. Of course, these symptoms vary from person to person, and it’s possible that up to 30% of drinkers may actually be resistant to hangover symptoms.

With long-term heavy drinking, the picture gets pretty ugly. It leads to a drop in testosterone, impotence, testicle shrinking, infertility in both men and women, and permanent damage to the brain by damaging the connections between nerve cells. It is a depressant, and can trigger anxiety and lethargy. It leads to anemia, and is linked to an increased risk of a number of cancers. Drinkers can die from bleeding ulcers, or from swollen blood vessels in the intestine. Eventually drinking can lead to “alcohol dementia,” poor coordination, cirrhosis, and liver and kidney failure.

So as we bid farewell to 2011 and welcome in 2012, let’s remember to practice moderation and treat our body with the respect it needs and deserves. Let me also take this opportunity to remind all of you not to drink and drive.

Happy holidays to you all!

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Vitamine D

Saturday, January 21st, 2012

Lately, when I perform physical exams, I’ve been including Vitamin D levels with the routine lab tests. Very frequently, these levels come back low. Is this important? What does it mean to have a low Vitamin D level, and what impact does that have on our health?

Vitamin D is actually a group of five fat-soluble vitamins known as D1, D2, D3, D4, and D5. Of these, D2 and D3 are the most important to us. Known as the sunshine vitamin, Vitamin D is synthesized in the body from sun exposure, and is also consumed in the diet from food and/or supplements. Vitamin D is well known for preventing rickets in children and osteomalacia (softening of the bones) in adults. Together with calcium, it protects adults from osteoporosis.

Some of us live in areas with very little sunshine, or restrict our sun exposure for health-related reasons. To make up for that, we can increase our intake of Vitamin D-rich foods, including some fish (salmon, mackerel, tuna, sardines), fortified milk and fortified orange juice, beef liver, and eggs. Vitamin D supplements are also readily available, and it is included in most multivitamins. Note that because Vitamin D is a fat-soluble vitamin (as are Vitamins A, E, and K) it is stored in the liver and fatty tissues, and does not need to be replaced every day. Because it is stored, however, it poses a greater risk for toxicity if too much is taken. Nevertheless, I generally recommend that adults take a Vitamin D supplement of 1,000 IU per day.

The beneficial effects of Vitamin D on health are not all clearly proven, but current studies indicate that:

•It is crucial for the absorption and metabolism of calcium and phosphorus, which have various functions, especially that of maintaining healthy bones.

•It plays an important role in immune system regulation. During months of little sunshine when our production of Vitamin D is low, there is a higher prevalence of flu and other viral infections. Many factors may be in play, and researchers are investigating further.

•Researchers have found a correlation between Vitamin D levels and memory function. It may play a role in helping us maintain our mental agility. Stay tuned!

•There may be a correlation between levels of Vitamin D and adolescent and abdominal body fat. This has opened the doors to more studies on using Vitamin D supplements to aid weight loss.

•Low levels of Vitamin D have been linked to more severe asthma attacks in children. Taking supplements has been linked to fewer and milder attacks.

•Various studies link low levels with some cancers, but supplements do not appear to help.

•Low blood levels of Vitamin D are associated with increased mortality in general. Vitamin D3 supplements appear to decrease all causes of mortality, especially in elderly women.

•Also under investigation is the theory that Vitamin D might have a protective effect against multiple sclerosis. Multiple sclerosis occurs at high rates in regions of the world with long periods of little sunlight, and thus far less Vitamin D production in the body.

However, too much of a good thing can be harmful! Vitamin D toxicity, also called hyper-vitaminosis D, is a potentially serious but treatable medical condition. Toxicity comes, not from too much sunlight, but from too many supplements. The body can generally handle up to 10,000 IU (International Units) per day, but sustaining that level of intake for several months may lead to toxic symptoms.

We are more likely to become toxic if we have certain underlying problems, such as hyperparathyroidism. Symptoms of Vitamin D toxicity include nausea, frequent urination, weight loss, poor appetite, constipation, weakness, irregular heart rhythm, kidney stones, headaches, dehydration, fatigue, irritability, and muscle weakness. Treatment includes stopping all supplements and restricting calcium intake in the diet.

I wish for all of us good health and plentiful Southern California sunshine!

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Nutrition Facts

Monday, May 2nd, 2011
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So many of us are keeping a watchful eye on our sodium, fat, or calorie consumption. How do we know what we’re eating? Is there a simple way to understand the contents of the food that we buy?

The Nutrition Labeling and Education Act (NLEA) was passed in 1990, requiring all packaged foods to display nutrition information. These labeling requirements have since undergone multiple amendments, and today, labeling is required for most prepared foods, including breads, cereals, canned and frozen foods, snacks, desserts, and drinks. Labeling for raw produce (fruits and vegetables) and fish is voluntary.

The Nutrition Facts food labels list the percentages supplied based on an average 2,000-calorie (and sometimes 2,500 as well) a day diet. The Daily Values used were originally based on 1968 recommended dietary allowances for each nutrient for men and women of any age, and have been periodically revised to incorporate more current research. However, newer revisions are still necessary.

Here’s an example of the label that appears on most packaged foods:

When evaluating the information on your nutrition labels, keep in mind that higher amounts for vitamins, fiber, and protein are good, but for saturated fats, cholesterol and sugars, lower numbers are more healthful. Remember that most Americans don’t get sufficient amounts of dietary fiber, vitamin A, vitamin C, calcium, and iron in their diets.

How do grams relate to calories? Carbohydrates and protein contain about four calories per gram. Fat contains about nine calories per gram. So, if only grams are listed, multiply four or nine times the number of grams, and the result will be total calories.

Pay special attention to the serving size and the number of servings information listed at the top of the label. All information on the rest of the label is based on a single serving. The serving size tells us the size of that single serving; for example, one serving of chicken noodle soup is considered to be 1/2 cup. This information can be very misleading, as a half-cup of soup (even after it is mixed with water) is not what many of us would picture as a full serving! Note that if a small package of cookies contains six cookies, but the serving size is just two, then the entire package contains triple the calories and other values listed.

It is also important to note that one chicken soup serving is one-half cup of the condensed soup as it comes in the can, and not one-half cup of the soup after it has been mixed with water. Depending on the product, the serving size may be measured or counted before or after preparation. Here, the serving size is before preparation, and since the number of servings is 2.5, you can simply consider that regardless of the amount of water used when preparing the soup, if you consume the entire can, you have eaten two and one-half servings (and that doesn’t include any crackers!).

The middle portion of the Nutrition Facts food label contains information about calories, fat content, amount and type of carbohydrates, and amount of protein. It shows the amounts in grams (g) or milligrams (mg), and the percentage of the daily value (the amount recommended every day) for each of these nutrients.

You will note that trans fats are listed without a percentage next to them. This is because experts have not agreed on a reference value for how much can be safely consumed. These fats raise blood LDL (bad cholesterol) levels, which increase the risk of heart disease. There is no reference value for sugar, either. Be aware that the sugars listed include both naturally occurring sugars (as in fruits), as well as processed sugars. Diabetics and others among us who are concerned about sugar intake should be certain that sugars are not listed as one of the first few ingredients. Processed sugars may appear as corn syrup, high fructose corn syrup, fruit juice concentrate, maltose, dextrose, sucrose, honey, and maple syrup.

We also find sodium information located in this middle section, rather than with the other minerals down at the bottom of the label. You can see that only a single serving of condensed chicken noodle soup has 37% of the daily value for sodium. If you consume the entire can, you will have eaten almost the entire recommended amount of sodium for the whole day!

Glance at the amount of fiber contained, and you may not be surprised to see that chicken noodle soup from a can contains very, very little.

The bottom portion of the Nutrition Facts label displays the vitamin and mineral content. The FDA requires that information on calcium, iron, vitamin A, and vitamin C be included. Food manufacturers may add information about other vitamins like niacin or folic acid if the product contains any significant amounts. This bottom portion is not always present on smaller items, but it is a good reminder of our general needs, based on that 2,000 or 2,500 calorie per day diet.

The information contained on these tiny labels is imperfect. It doesn’t break down our dietary needs by gender, by age, or by particular health condition. It doesn’t address conflicting research and current opinions in the nutrition and health care field. However, if your goal is to use this limited information as a guideline, then it can be a great tool to help find the foods that fit into a balanced and healthful diet.

Read carefully, and eat smart!

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Organ Donor

Tuesday, March 15th, 2011

Every one of us has the opportunity have our organs donated upon our death. How do we make that decision? What factors should we consider? There is a clear need, but bioethical concerns cloud the issue. Interestingly, organized religion poses few obstacles. Let’s explore together.

Organ transplants save lives every day. If a transplant is not possible due to organ condition or match failure, the organ can still be used forresearch or education. Researchers use normal as well as diseased organs and tissues for study, and vast numbers of people benefit from the resulting medical advancements.

The world’s major religions accept the concept of organ donation in at least some form. Most religions, including the Catholic Church, support organ donation on the grounds that it constitutes an act of charity and provides a means of saving a life. Some religions impose restrictions on the types of organs that may be donated, or on the means by which organs are to be harvested or transplanted.

For example, due to their prohibition of blood transfusions, Jehovah’s Witnesses require that organ be drained of blood prior to transplant. Muslims require that the donor provide written consent in advance. Orthodox Judaism considers organ donation obligatory if it will save a life, as long as the donor is considered dead as defined by Jewish law.

A few groups do oppose organ transplantation or donation, including many who follow Shinto practices, and Gypsies.

There is an enormous shortage of donor organs.This could not be truer than with the increasing need for kidneys. Kidney failure is brought on by rising age, diabetes and hypertension, and all three of these categories are growing in size. Spain boasts the highest organ donation rate in the world, with 35.1 donors per million people. This rate compares to 24.8 donors per million in Austria, and 22.2 donors per million in France. The Spanish transplant system is one of the most successful in the world, but it still can’t meet the demand, and 10% of those needing a transplant die while still on the transplant list. Under Spanish law, every death can provide organs unless the donor expressly specified otherwise (while still living!).

Organ donation is becoming an important bioethical issue. For example, prisoners here in the United States are not discriminated against as organ recipients and are equally eligible for organ transplant as the general population. In 1976, the Supreme Court ruled that withholding health care from prisoners constituted “cruel and unusual punishment.” Of course, many are uncomfortable that an organ transplant and follow-up care can cost the prison system up to $1 million, and that an organ transplant to a prisoner may well deprive another citizen of that organ and a possibly life-saving surgery.

Another ethical issue involves whether to give liver transplants to alcoholics who may be in danger of relapse. Should organ transplants be allowed for drug abusers, those with reckless lifestyles, older patients, etc.? With a limited supply of organs to transplant, these become complicated and difficult bioethical social issues.

Because demand for organs far outpaces supply, a black market, often referred to as transplant tourism, exists. Black markets are, by their nature, unregulated, and not surprisingly the rich take advantage of the poor. Those who support a black market argue that the poor are in desperate need of the money. Follow-up studies have actually been conducted on those donors who sold a kidney in countries where organ sales are legal. These studies show that a majority of donors have extreme regret, and if given the chance to repeat the procedure, they would not.

In addition, many study participants reported an actual decline in economic status following the procedure, despite income from the donated organ.

Even more frightening black market cases have involved suspected cases of organ theft, including murder. Supporters of a legal organ market claim that the black-market system encourages such tragedies, and that regulation could prevent them. Opponents claim that such a market could encourage criminals by making it easier to claim that a stolen organ was legal. Needless to say, this issue is far from resolved.

In 1999, eBay was involved in an organ scandal. An auction for “one functional human kidney” reached a bid of $5.7 million before it was blocked by eBay. In the United States, the sale of human organs is punishable by up to five years in prison and a $50,000 fine.

An exciting but hugely controversial new field has arisen with great potential for providing organ supplies: cloning. A cloned organ would run no risk of rejection, since it would be a perfect match. However, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own.

Consider the ethics of cloning an entire person for the express purpose of being destroyed for organ procurement! Currently, stem cell research is investigating using cloned stem cells to grow only a new organ. This research shows enormous promise, despite the bioethical and religious issues still unresolved.

There is simply no replacement for having available a real human body when it comes to teaching and research. I would urge all of us to give organ or full body donation serious consideration. It will truly help in the discovery of cures for many debilitating conditions such as cancer and Alzheimer’s disease, in the development of new medicines, in the study of human anatomy, and in perfecting new surgical procedures.

As a medical student, one of my most important classes was Human Anatomy and Dissection, and I clearly recall that each donation was highly valued, and treated with the utmost humanity, compassion and respect. Many years have passed, and my oldest daughter just finished the very same human anatomy course in her own medical school. She describes a ceremony held before the course began, attended by both medical students and donor families, where the donor families were personally thanked for their amazing and precious gift.

Here are some steps you can take to become an organ donor:

•Register with your state donor registry: www.DonateLifeCalifornia.org/register/

•Sign a donor card and carry it with you until you renew your driver’s license, at which time your decision can be designated on your driver’s license.

•Talk to your family now about your decision to donate. Help them to understand your wish to be an organ and tissue donor, before a crisis occurs.

I wish you and future generations the gift of a long and healthy life!

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Laughter

Thursday, January 27th, 2011

As the cliché goes, laughter is the best medicine. But is it really? Is there evidence to support such a claim?

It turns out that the research is full of good hard evidence that too much stress results in increased levels of ACTH, cortisol, epinephrine, and norepinephrine; the so-called “stress hormones”. This is not normally a good thing. The question remains as to whether humor can decrease stress, positively impact the stress hormones, diminish pain, improve the strength of the immune system, and consequently improve quality of life. This has been a persistent topic of discussion for decades in both the lay and professional medical literature. Certainly, laughing is more affordable than medication, herbs, massage, or lengthy therapy!

Unfortunately there is little conclusive evidence that laughter specifically changes these body chemistries. However, the data is encouraging:

Laughter has been shown to reduce pain, in at least two ways. It serves as a distraction, and causes the release of endorphins, which reduce the sensation of pain.

Laughter may boost the immune system. There appears to be an increase in “killer” antibodies and t-cells – both of which fight infection.

Laughter relaxes the muscles and even tones the facial muscles.

Blood pressure has been shown to decline following bouts of laughter.

Finally, apparently no researcher has found a single harmful effect from laughter. It’s cheap, and available.

So, it is highly likely that laughter boosts immunity, lowers stress hormones, decreases pain, relaxes muscles and lowers blood pressure. Laughter adds joy and zest to life, eases anxiety and fear, relieves stress, improves mood, strengthens relationships, enhances teamwork, helps to defuse conflict, promotes bonding, and likely attracts others to us.

Here are some strategies for all of us to work on during this upcoming year:

•Don’t avoid dealing with your stress. Stress is a major impediment to humor and laughter.

•Laugh at yourself. Share embarrassing moments and take yourself less seriously.

•Laugh more at situations rather than bemoan them. There is often humor to be found even in bad situations. See the irony and absurdity of life!

•Surround yourself with reminders to lighten up. Put up a funny poster, or keep toys on your desk. Choose a computer screensaver that makes you smile.

•Pay attention to children and emulate them. They are truly the experts of play, taking life lightly, and laughing.

•Keep things in perspective. Many things in life are beyond your control. Remember the Serenity Prayer, and that you do not control the behavior of others. I always appreciate my patients’ willingness to carry the weight of the world on their shoulders. It is admirable but unrealistic, unhealthy, and perhaps even egotistical!

Good health and humor to you all, and have a very happy New Year!

I wish you the best of health.

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Water

Tuesday, January 18th, 2011

Doctor, how much water should I drink? I hear this question every day. We all know that enough water is essential for good health, yet everyone’s needs are different. It’s a simple question, with a not so simple answer!

Water makes up about 60% of our body weight and is the principal chemical component in the body. Every system depends on it. Water flushes toxins out of vital organs; carries nutrients to the cells; and moisturizes the nose, ears, throat, blood vessels, and tissues. Minor dehydration will result in thirst, loss of appetite, dry skin, skin flushing, dark colored urine, dry mouth, fatigue, weakness, chills and head rushes. More dehydration leads to increased heart rate, increased respiration, decreased sweating, decreased urination, increased body temperature, extreme fatigue, muscle cramps, headache, nausea, and tingling in the limbs. Once dehydration reaches 10%below normal levels, fluid loss becomes an emergency and can be fatal. Signs include muscle spasms, vomiting, racing pulse, visual changes, painful urination, confusion, difficulty breathing, seizures, and unconsciousness.

We lose water through breathing, perspiration, urine and bowel movements. Clearly, there is some ideal amount of water needed to replace these fluids and keep the system running correctly. The simplest approach is known as the eight by eight rule. Drink eight glasses of eight ounces of water per day. This is based on the replacement method: an adult urinates about six ounces of water per day, and we lose roughly an additional four cups each day through breathing, sweating, and bowel movements. Food accounts for roughly 20% of our total fluid intake, so if we consume about eight cups of water or other beverages a day along with a normal diet, we will typically replace the fluid lost. This is pretty general, but will normally suffice.

Another method is to look at the toilet bowl! If you drink enough fluid so that you rarely feel thirsty and produce about six cups or more of colorless or slightly yellow urine a day, your fluid intake is probably adequate. Since we don’t typically measure our urine output, simply check the color.

Now that we have a general rule of thumb, let’s explore factors that may change our specific requirement. Regular exercise, whether or not we sweat, demands that we drink extra water to compensate for the fluid loss. In general, drinking 1 ½ to 2 ½ extra cups of water should suffice for short bouts of exercise, but intense exercise lasting more than an hour requires more, and if you tend to sweat heavily, even more fluid replacement is required. Sport drinks are more useful than water after heavy exercise.

The environment affects fluid requirements. Hot or humid weather will increase sweating. Spending time in heated buildings causes the skin to lose moisture. High altitudes (over 8,200 feet) may trigger increased urination and more rapid breathing, using up more fluids.

Women who are pregnant or nursing require more hydration. Pregnant women are advised to drink about 10 cups daily and women who are nursing need about 13.

Illness and various health conditions change the formula for fluid replacement substantially. Fevers, vomiting, diarrhea, bladder infections and kidney stones are examples of conditions that require us to drink more. On the opposite end of the spectrum are congestive heart failure, liver failure, and kidney failure, where fluid restriction is often necessary.

Remember that milk, juice, soup, and fruits and vegetables all contain some of the water that we need. Alcohol and caffeinated beverages (some sodas, coffee, tea, etc.) act as diuretics, however, and cause some fluid loss as well.

Is it dangerous to drink too much water? There is actually a condition known as water intoxication, which can be caused by a psychological condition known as psychogenic polydipsia. When too much water enters the body’s cells, the tissues swell with the excess fluid. The result is a potentially dangerous decrease in sodium concentration.

Here are some simple guidelines to help avoid dehydration:

• Drink a glass of water with each meal and between meals

• Hydrate before, during and after exercise

• Try substituting sparkling water or other beverages for alcoholic drinks or sodas

• Work with your physician to determine the proper amount of fluid consumption for your specific needs.

I wish you the best of health.

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Tussis

Sunday, November 28th, 2010

Tussis: It’s Latin for cough; a bodily function we can all relate to. Typically it’s merely a simple reflex due to allergies, a cold, or asthma, but it can unfortunately be one of the symptoms of something much worse, like pneumonia or lung cancer. Coughing can be voluntary or involuntary. It is a sudden and often repetitive reflux, and it helps to clear our large breathing passages from secretions, irritants, foreign particles and microbes.

Allergies account for nearly 90% of coughs. Those with allergy cough typically have clear phlegm and some fatigue, but otherwise feel normal. These coughs are triggered by postnasal drip, and may be seasonal (typically mold in the fall, or pollen in the spring). Alternatively, allergies may be a response to specific exposures such as dogs or cats, and occur throughout the year. It often takes extensive testing to determine which specific allergens are responsible. Asthma, which may or may not be accompanied by allergies, leads to a productive or non-productive cough, often with wheezing and shortness of breath. The airways become overly reactive, inflamed, and spasm, which triggers these symptoms.

Coughing is also caused either by a viral or bacterial infection. This is actually an evolutionary advantage for germs, since coughing helps to spread them! Although a cough is frequently caused by viral or bacterial bronchitis, the most likely infection to cause a cough are the common cold viruses. The common cold resolves in a matter of days to a few weeks, after the viral infection has cleared. However, the infected person may be left with a residual dry, non-productive cough that can last up to six weeks. The irritating cough can cause inflammation, which leads to discomfort, and in turn causes yet more coughing. Helpful remedies include drinking lots of water and other fluids to loosen up the phlegm, gargling with salt water to relieve a sore or scratchy throat, saltwater nasal sprays to decongest, and of course, chicken soup.

Generations of parents have fed chicken soup to their sick children without really understanding why. Now scientists have put chicken soup to the test, and discovered that it does help relieve cold and flu symptoms in two ways. First, it acts as an anti-inflammatory by slowing the movement of neutrophils (immune system cells that aid in the body’s inflammatory response). Second, because it is a warm liquid, it temporarily speeds up the movement of mucus, which helps to relieve congestion and limits the amount of time viruses are in contact with the nose lining.

Over-the-counter cold and cough medications do help to relieve symptoms when a cough is caused by the common cold. Note, however, that acetaminophen (Tylenol) can cause liver damage when taken in excessive doses, so it is dangerous to take Tylenol alongside cold medicines that also include Tylenol. Zinc lozenges have been heavily marketed as a cold-fighting medication, but recent studies don’t support these claims (in fact, intra-nasal zinc may result in permanent damage to the sense of smell). Antibiotics are effective at treating bacterial infections but are of no help whatsoever in fighting a cold virus.

When Gastro esophageal Reflux Disease (GERD) is the cause of a cough, it can be difficult to make the diagnosis. The acidic contents of the stomach come back up into the esophagus and the patient can feel heartburn, a sour taste in the mouth, or a feeling of acid reflux in the chest. Unfortunately, more than half of those with cough from GERD do not have any other symptoms, so doctors sometimes try treating GERD when no other solution has worked.

Other causes of cough include smoking, air pollution, emphysema, lung tumors, heart failure, choking, and medications (a cough is, for example, a frequent side effect of ACE inhibitors, commonly used to control blood pressure). Generally, when more serious diseases cause cough, we find other significant symptoms present as well.

Keep in mind that any persistent cough warrants a proper work-up. Seek the advice of your doctor.

I hope you had a warm and joyous Thanksgiving. Good health to you all!

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Cancer Screening

Sunday, November 21st, 2010

Doctor, do I have cancer? Can you run all of the tests to check?

These are questions I hear regularly. The answers are more complicated than you would think. Science has indeed come a long way in discovering “markers” to follow the progress of cancer treatment in the body, but how much do we know about early detection? What can we do as part of a routine exam to discover hidden cancers?

Tumor markers are substances that can be found in abnormal amounts in the blood, urine, or tissues of some patients with cancer. Different markers are found with different types of cancer, but scientists have not found markers for every type of cancer. Tumor markers are produced by tumor cells, or by other cells of the body in response to the tumor.

However, tumor marker levels are not altered in all people with cancer, especially if the cancer is in early stages. Markers may be used to help diagnose cancer, predict a patient’s response to a particular treatment, or determine if the cancer has returned. To date, researchers have identified more than a dozen substances that appear to be abnormal when some type of cancer is present.

At the present time, the use of tumor markers in clinical medicine is limited. Although an abnormal tumor marker level may suggest cancer, this alone is usually not enough to make the cancer diagnosis. Therefore, this information is usually combined with a patient’s history, other blood tests, x-rays, and biopsies.

After the diagnosis, tumor markers may be measured before a cancer treatment to help doctors plan the appropriate therapy. In some cancers, the level of tumor marker may reflect the stage of the disease. During treatment, decreasing levels of tumor marker can reflect a good response to treatment.

But, in terms of screening for the presence of cancer, tumor makers thus far have limited usefulness. A screening test is a way of detecting cancer early, before there are any symptoms. For a screening test to be helpful, it should have high sensitivity and high specificity. Sensitivity refers to the test’s ability to identify people who have the disease. Specificity refers to the test’s ability to identify people who do not have the disease. Unfortunately, tumor markers are neither sensitive nor specific enough to be used for cancer screening.

For example, prostate-specific antigen (PSA) levels are often used to screen men for prostate cancer, but this is controversial. It is not yet known whether early detection using PSA screening actually saves lives. Elevated levels of PSA can be caused by prostate cancer or by benign conditions, and most men with elevated levels turn out to not have prostate cancer. Further, it is not known if the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments.

Another tumor marker, the CA 125, is sometimes used to screen women who have an increased risk for ovarian cancer. Scientists are currently studying whether measurement of CA-125, along with other tests and exams, is useful to find ovarian cancer before symptoms appear. Thus far, CA-125 is found to be neither sensitive nor specific enough to justify screening all women. At this point, CA-125 is used to monitor responses to treatment of ovarian cancer and check for recurrence.

For now, we doctors spend most of our cancer-fighting efforts working with our patients to eliminate underlying risks that are known to cause future cancers, such as cigarettes, excessive alcohol, too much exposure to the sun, obesity, diet, and environmental exposures. Actual cancer detection more typically happens as a result of listening to a patient’s complaints, performing a physical exam, and then performing tests to confirm any suspicions. But, stay tuned. As science advances, health professionals constantly have more tools at their disposal.

In the meantime, prevention is key. Good health to you all!

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Anxiety Disorders

Wednesday, November 3rd, 2010

If you tend to have feelings of panic, fear, and uneasiness, it’s possible that you are suffering from an anxiety disorder.

Anxiety disorders affect at least 19 million adult Americans, and tend to begin in childhood, adolescence, or early adulthood. They occur slightly more often in women than in men, and appear with similar frequency among whites, African-Americans, and Hispanics.

The many symptoms of anxiety disorders include excessive worry, tension, restlessness, nightmares, irritability, muscle tension, headaches, uncontrolled obsessive thoughts, repeated thoughts or flashbacks of traumatic experiences, ritualistic behaviors, sweating, difficulty concentrating, fatigue, frequent urination or defecation, nausea… and the most common symptom: trouble falling asleep and staying asleep.

We all get feelings of anxiety from time to time. Anxiety is a normal human emotion, and a quite normal and appropriate response to many situations that life throws at us. We may feel anxious or nervous when faced with a problem at work, before taking a test, or when making an important decision. It becomes an anxiety disorder, however, when the response to everyday life events is exaggerated or excessive. The resulting level of distress can interfere with the ability to lead a normal life.

Do not underestimate: an anxiety disorder is a serious mental illness. Worry and fear can be constant, excessive, overwhelming, and even crippling. Anxiety becomes dominant and interferes with health, work, school, social activities, and relationships.

There are many types of anxiety disorders, including:

Panic disorder: People with this condition have feelings of terror that strike suddenly and repeatedly without warning. A panic attack includes sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking.

Obsessive-Compulsive Disorder (OCD): People with OCD are plagued by constant thoughts or fears that cause them to perform certain rituals or routines. The disturbing thoughts are called obsessions, and the rituals are called compulsions. An example is a person with an unreasonable fear of germs who constantly washes his or her hands.

Post Traumatic Stress Disorder (PTSD): PTSD is a condition that can develop following a traumatic and/or terrifying event, such as a sexual or physical assault, the unexpected death of a loved one, involvement in a war, or a natural disaster. People with PTSD often have lasting and frightening thoughts and memories of the event, and may tend to be emotionally numb.

Social Anxiety Disorder: Also called social phobia, this disorder involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others, or fear of embarrassment or ridicule.

Specific phobias: A specific phobia is an intense fear of a specific object or situation, such as snakes, spiders, heights, or flying. The level of fear is usually inappropriate to the situation and may cause the person to avoid common everyday experiences.

Generalized Anxiety Disorder: This disorder involves excessive, unrealistic worry and tension, even if there is little or nothing to justify the anxiety.

The precise cause of anxiety disorders is unknown; but anxiety disorders – like other forms of mental illness – are not the result of personal weakness, a character flaw, or poor upbringing. What is becoming clear is that the tendency to anxiety is likely “pre-wired” in the brain due to genetics. Studies are showing that anxiety disorders tend to run in families, and can be inherited from one or both parents, like hair or eye color.

Anxiety has been associated with chemical imbalances of certain neurotransmitters in the brain. This alters the way the brain reacts to life situations. Other studies demonstrate that people with certain anxiety disorders have changes in the actual brain structures that control memory or mood.

Environmental factors including trauma and stressful events, emotional abuse, the death of a loved one, divorce, change of job or school, or the use of chemicals (such as alcohol, caffeine, nicotine, and other recreational drugs) may trigger an anxiety disorder in people who have an inherited susceptibility.

It is apparent that many anxiety disorders are caused by the interplay between genetics, changes in the brain, and environmental stress.

A diagnosis is made by a doctor’s clinical exam; there are no laboratory tests. The doctor will make sure that the symptoms are not related to some other physical disorder, such as an overactive thyroid. A final diagnosis of anxiety disorder requires a demonstration that anxiety is causing problems in the functioning of daily life for an extended period of time.

Most people gain substantial relief from their symptoms with proper treatment. The most effective treatments usually involve a multi-pronged approach. Eliminating caffeine, alcohol, excess sugar, and eating a balanced diet can be a great place to start. Physical activity helps a great deal; adding yoga, meditation, or aerobic exercise (such as a brisk walk four or five times a week), and focusing on sleep can make a substantial difference. Therapy is often valuable. Medication may be recommended.

For short-term anxiety, there are potent but potentially highly addictive drugs known as benzodiazepines that give the patient a great sense of calm. For longer-term treatment, non-addictive anti-depressant/anti-anxiety drugs include Lexapro, Prozac, and Zoloft. Buspar is also used for chronic anxiety, with no addictive qualities.

Anxiety disorders are difficult to prevent. However, if you feel that you are susceptible, or if anxiety runs in your family, here are some things that you can do to control or lessen symptoms:

•Stop or reduce your consumption of products that contain caffeine, such as coffee, tea, cola and chocolate.

•Exercise daily and eat a healthy, balanced diet.

•Practice stress management techniques like yoga or meditation.

•Speak with your doctor or pharmacist before taking any over-the-counter medicines or herbal remedies. Many contain chemicals that can actually increase the symptoms of anxiety.

•Seek counseling and support after a traumatic or upsetting experience.

May you live a low-stress and healthy life!

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