Archive for the ‘General’ Category

There are times we need to see how things are working and other times we need to know what things look like. See the different tests called “heart scans.” They are ranked by complexity and cost and separated into two categories (physiologic and anatomical)

A)Physiologic (how things are working) An EKG looks at the electricity going through your heart and sees what has happened, but rarely predicts the future. Scans often do.

1) Treadmills Pros: These see how the heart responds to stress. They show how long people can run compared to others, how fast the heart beats compared to other people at the same level of stress, they show if the heart beat becomes irregular under stress, and the doctor and computer look for signs of strain in the EKG (ST segments) under stress. This is probably the best bargain of all the tests. They predict really well who will and who won’t have a heart attack in the next year or two. They are done at SBFMG offices.
Cons: There must be about 80% blockage in the coronary arteries before these show a strain pattern and some people can’t walk fast or long enough to perform the test. As with all tests, there are no guarantees, only predictions with treadmills.

2) Echocardiograms (Echos or ultrasounds of the heart): Using dopler techniques the doctor can see blood flow through valves and the aorta.
Pros: Excellent to see how valves and muscles work and whether they are stressed by blood pressure, age, wear and tear or diseases. No x-ray, needles or dyes are used and they are done at SBFMG several days per week. They are usually covered by insurance as “diagnostic” to monitor a problem such as a murmur.
Cons: Moderately expensive and don’t’ see coronary arteries (too small) so little value in predicting heart attacks

3) Stress Echos: Pros: more sensitive (more likely to find blockage of arteries) in predicting heart attacks than regular treadmills, done at cardiologists’ offices rather than hospital, have no x-rays, dyes, or needles. Usually covered by insurance if you fail regular treadmill
Cons: Expensive, requires cardiologist, requires fast walking

4) Nuclear studies (like Cardiolyte tests): Pros: can be performed either with exercise or IV chemicals to make heart work as if you were running. They are more sensitive than plain treadmills in predicting heart attack risks. Insurance usually cover if you fail a regular treadmill. It lights up areas of heart if adequate blood supply exists through the coronary arteries instead of looking at the arteries themselves.
Cons: Usually done in a hospital, requires injection of trace amount of radioactive substance (less than most common x-rays), and very expensive

B)Anatomical (what thinks look like, not how they work)

1) CIMT (Carotid Intima-Medial Thickness). Pros: Using ultrasound the carotid arteries in the neck are measured for hardening compared to people in same age group. Done at SBFMG. Inexpensive at $295, but not covered by insurance as it is considered a “screening” test. It is different from inexpensive blood flow tests that take only a few minutes to check for stroke risk. It is the up and coming test used by universities to see if medications to prevent heart attacks are working. No pain, x-ray or needles.
Cons: Looks at neck not heart arteries and, therefore, doesn’t make sense that it predicts the relative risk of heart attacks (it does!) Gives percentile, not percentage of blockage (on a scale of 1 to 100, we know where you would stand relative to a problem, not what percentage each of your own arteries are blocked)

2) EBCT (now replaced by 64 slice CT scanner) Pros: Using x-rays the coronary arteries, which when blocked cause heart attacks, can be seen without dye or needles. It is inexpensive (about $395, but not usually covered by insurance) and “makes sense” because is looks directly at the heart’s arteries.
Cons: Only the calcium can be measured. It takes a few years of plaque being present before you can see the calcium deposits. The inside diameter, or amount of blockage, can’t be seen. As with CIMT a computer calculates what “percentile” (not percentage of blockage) the patient’s arteries are in and allows the doctor to determine if you are high, medium or low risk for a heart attack compared to others your age.

3) Echocardiogram (also described in physiology section) sees anatomy of muscles and valves, but not the coronary arteries

4) CT Coronary Angiogram: Pros: this adds intravenous dye (contrast) to the scan in #2 and allows us to find what percentage of blockage exists in the arteries. The arteries themselves are not punctured and it takes only an hour or two. Recent studies (i.e. Mayo Clinic) show it correlates really well with a conventional angiogram (#5)
Cons: It requires contrast (dye) to be placed in your veins and you could be allergic (rare). You must have a blood test first to be sure your kidneys are working well enough to get rid of the dye. It is rarely covered by insurance, costs at least $1,200 at current centers and has x-ray exposure.

5) Angiogram: Pros: this is the “gold standard” to see the anatomy of your coronaries and is needed to see if and where stents should be placed. It sees exactly how much blockage you have in your coronary arteries. It is almost always covered by insurance
Cons: requires all day in hospital, artery in groin is punctured (risks bleeding) through which a tube is maneuvered up to your heart to place the contrast right into the coronary openings. Allergic reactions, bleeding, x-ray exposure are all risks involved, but bleeding requiring transfusions is rare.

No matter how old you are, you need to take care of your teeth and mouth. When your mouth is healthy, you can eat the foods you need for good nutrition. You will also feel better about smiling, talking and laughing. Teeth are meant to last a lifetime. By taking good care of your teeth and gums, you can protect them for many years.

Tooth Decay
Teeth are covered in a hard, outer coating called enamel. Everyday a thin film of bacteria builds up on your teeth. Over time the bacteria can cause holes in the enamel. These holes are called cavities. Brushing and flossing your teeth can protect you from decay, but once a cavity appears, a dentist has to fix it.

Gum Disease
Gum disease begins when plaque builds up along and under the gum line. This plaque causes infections that hurt the gum and bone that hold teeth in place. Sometimes gum disease makes your gums tender and more likely to bleed. This problem, called gingivitis, can often be fixed by daily brushing and flossing.

To prevent gum disease:

• Brush your teeth 2 times per day with fluoride toothpaste
• Floss once per day
• Visit your dentist regularly for a checkup and cleaning
• Quit smoking. Smoking increases your risk for gum disease.

Oral health problems to report to your dentist

• Red, tender or swollen gums
• Gums that bleed when you brush or floss
• Gums that begin pulling away from your teeth
• Loose teeth
• Changes in the way your top and bottom teeth align with each other
• Unusual sensitivity to hot or cold

Cholesterol is one of the main contributors to heart and vascular disease in the world. The Framingham Study showed us several decades ago that there was a link between high cholesterol and heart disease. High cholesterol remains one of the major risks for heart attacks and stroke. Although it appears to be mostly the bad cholesterol (LDL) or a lack of the good cholesterol (HDL) that leads to artery hardening, the total cholesterol remains the number most people think of when discussing the this issue.

Unfortunately, most of the cholesterol in our body is made by our liver rather than related to the amount of cholesterol we eat. Foods high in saturated fats (usually fats from animal products) are the main building blocks of cholesterol. Our genetic makeup triggers the production of the total amount and the sub-components. Although we don’t have control over what is in our genes, we have new medicines that can block the production in our liver or reduce our absorption from our intestines. Many products are made for this problem, but none work as well as “statin” drugs like Lipitor, Zocor, Crestor, Mevacor, or Pravachol. This group of drugs not only reduces cholesterol more effectively that other groups or diet, but there are added reductions in heart attack rates not fully explained by the cholesterol reduction alone. Generic forms of these drugs are often available and work about as well as the brands they replace. The differences among these are potency and small differences in outcome, but they all work really well.

For reading more on The Web about treating, testing, and evaluating your cholesterol SBFMG recommends WEBMD.COM and the NCEP (National Cholesterol Education Program) sponsored by The National Institute of Health and The American Heart Association.

Immunizations are one of the most effective ways to prevent serious illness in children and adults. Pediatric immunization programs in the US have been quite successful in reducing the number of children affected by a range of highly contagious diseases, including Measles, Mumps, Rubella, Diphtheria and Polio.

Hepatitis B
Inflammation of the liver (hepatitis) can be caused by toxic drugs, chemical agents and certain viral infections including Hepatitis B virus (HPV). Although Hepatitis B infection often resolves or causes no symptoms, HBV can cause chronic liver disease that leads to progressive scarring (cirrhosis) or liver cancer. HBV is transmitted by contact with an infected individual’s body fluids. It can be transmitted from an infected pregnant woman to her baby.
Hepatitis B vaccine is recommended for all children beginning at birth but can be started at a later time. It requires 3 doses.

Hepatitis A
Hepatitis due to infection with Hepatitis A virus (HAV) is one of the most common viral infections in children and adolescents in the US. HAV infection often causes few or no symptoms in younger children. By contrast, infection in adults can vary in severity from mild flu-like illness to rapidly progressive severe liver disease. HAV is found in the stool of infected individuals. A person can become infected with HAV by consuming contaminated food or water or by touching the mouth, nose or eyes after touching a contaminated surface.
Hepatitis A vaccine is recommended in all children 12-23 months. Older children and adults also can consider being immunized. In all age groups, 2 doses of the vaccine are required at least 6 months apart.

Diphtheria, Tetanus, Pertussis
Diphtheria is a highly contagious disease caused by a bacterial toxin. It is usually transmitted via droplet particles that are coughed or sneezed into the air. The toxin can lead to damage of the kidneys, brain, nervous system or heart.
Tetanus is an infection cause by a bacterial toxin. Bacteria reside in the soil and intestinal tracts of certain mammals. It enters the body through an open wound, multiplies and produces a toxin that can affect nerves controlling muscle activity. A common symptom of tetanus infections is stiffness of the jaw muscles (“lockjaw”).
Pertussis, or whooping cough, is an upper respiratory infection caused by a bacterial organism that is highly contagious. It spreads easily and can cause serious illness, especially in infants.
Combined DTaP is recommended for all children in the US. A total of 5 separate doses are recommended. The first 3 doses are at 2 months, 4 months, and 6 months. The 4th dose is at 15-18 months and the 5th dose is at 4-6 years. Subsequent doses are recommended at 10 year intervals throughout life.

Polio
During the first half of the 20th century, Polio was a major cause of serious illness and death throughout the world. It is still a significant health problem in some developing countries. Primary signs of Polio include muscle weakness, pain and fatigue. Ultimately, the illness can lead to paralysis and even death.
Vaccination of all children is recommended to avoid new outbreaks.
IPV series in the US consists of 4 doses. The first 2 doses are given at 2 and 4 months. The 3rd dose is given at 6-18 months and the 4th dose at 4-6 years.

Rotavirus
Rotavirus is the single most important cause of severe diarrhea and dehydration in infants and young children. Immunization against Rotavirus is recommended for all infants in the US.
The vaccine is in a liquid form and is given by mouth. Three doses are recommended at 2, 4, and 6 months. The third dose should be given by 8 months.

Haemophilus influenzae B (Hib)
Until the mid-1990s, Hib was the most common cause of bacterial meningitis in children. It was also responsible for other serious bacterial infections, including skin, throat and joint infections. Despite its name, Hib is not actually related to the influenza virus.
The vaccine is given at 2, 4, and 6 months and a booster at 12-15months.

Pneumococcal
Streptococcus pneumoniae can cause serious infections, including meningitis and pneumonia that can be fatal in young children;
Children receive a total of 4 doses at 2, 4, 6, and 12-15 months of age.

Influenza
Commonly known as flu, influenza is a highly contagious viral infection that occurs in outbreaks world wide.
Annual immunization against influenza is recommended for all children ages 6 months to 18 years.

Measles, Mumps and Rubella (MMR)
Measles, Mumps and Rubella are illnesses that may be transmitted by airborne droplets released during coughing or sneezing.
Measles (rubeola) is a highly contagious viral illness of the respiratory tract that primarily affects children. It causes a distinctive rash, fever, and cough and may result in complications including infection of the middle ear, lungs and brain.
Mumps is an acute, usually mild viral infection of childhood that causes painful swelling of salivary glands. Mumps complications can develop including inflammation of the brain (encephalitis), protective membranes of the brain (meningitis), and in males after puberty, swelling and tenderness of one or both tests (orchitis).
Rubella (aka German measles), a mild viral infection, causes fever, swelling of lymph nodes in the neck and a distinctive rash. However, it can cause severe birth defects if a woman becomes infected during early pregnancy.
The first MMR vaccine is given at 12-15 months and the second at 4-6 years.

Varicella (chicken pox)
Varicella is a highly contagious viral illness caused by infection with Varicella Zoster virus. The disease causes fever, sore throat and a distinctive, itchy rash with fluid filled blisters that later form scabs. It is transmitted via spread of airborne droplets or direct contact with skin lesions. Complications include bacterial infections of the skin, pneumonia or less commonly inflammation of the brain.
The vaccine is recommended at 12-18 months and at 4-6 years.

For those of us with a relative who has had a heart attack or stroke, or for those of us who may worry we may be at risk for the same, there is a now a test available to help determine our risk. Carotid Intima Media Thickness (CIMT) is an ultrasound protocol that has been around as a research tool for over 20 years and in clinical practice since 2002. This is a simple non-invasive test that takes 10 – 20 minutes and involves measuring the thickness of the two innermost layers of the common carotid artery. The thickness of these two layers has been shown to correlate very well with cardiovascular risk.

You may ask “Who says that this is a good test and why?” Well, The American Heart Association and the American College of Cardiology have recommended this test for those of us with cardiovascular risks. Many research studies have been conducted using this technique. There is an accepted opinion that with CIMT there is a 96% correlation with the amount of disease found in the common carotid artery and with the disease found elsewhere in the body, such as the arteries in the heart and brain. Furthermore, it is equally predictive in men as in women. Large trials following populations with heart disease as well as outcome studies suggest CIMT can be used as a surrogate end point or marker to help predict clinical events such as a heart attack or stroke.

Who should consider getting this test? Any person with a family history of coronary heart disease or heart attack, stroke, tobacco use, high blood pressure, diabetes, elevated LDL cholesterol, low HDL cholesterol, elevated triglycerides or the Metabolic Syndrome may want to consider having this test. Generally, we suggest this test for those of us at risk and over the age of 40. CIMT may also be used monitor life style changes and treatments suggested to modify cardiovascular risk.

Autism spectrum disorders (ASDs) are a group of developmental disorders that cause lifelong difficulties with socializing, communicating and behavior. The term “spectrum” refers to the fact that some people have a few mild symptoms while others have severe symptoms. It affects 1 in 110 children.

How does autism develop?
It is not clear how or why autism develops. The general consensus is that autism spectrum disorders are a genetic disorder that affects brain development and impairs the development of social and communication skills.
There have been concerns within the general public about the safety of vaccination for children. These concerns include a relationship between vaccines and autism. Despite this concern, there is no scientific evidence that receiving these vaccines causes or increases the risk of developing autism. Studies that raised this possibility had significant weaknesses in their design.
Environmental factors such as toxic exposures before or after birth, complications during delivery and infections before birth may be responsible for a small percentage of cases. In children with a genetic predisposition, environmental factors may further increase the child’s risk of developing autism. It is not currently possible to test a child’s genes to determine if he or she is at risk for ASD.

Symptoms
Symptoms begin before the age of 3 and last throughout a person’s life, although symptoms may improve over time. Some children with an ASD show hints of future problems within the first few months of life. In others, symptoms might not show up until 24 months or older.
A person with an ASD might

• Not respond to their name by 12 months
• Not point at objects to show interest (point at an airplane flying over) by 14 months
• Not play “pretend” games by 18 months
• Avoid eye contact and want to be alone
• Have trouble understanding other people’s feelings or talking about their own feelings
• Have delayed speech and language skills
• Repeat words or phrases over and over
• Give unrelated answers to questions
• Get upset by minor changes
• Have obsessive interests
• Flap their hands, rock their body or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look or feel

Diagnosis
Diagnosing ASD can be difficult since there is no medical test, like a blood test, to diagnose the disorders. Doctors look at the child’s behavior and development to make a diagnosis.

Treatment
Currently there is no cure. Research shows that early intervention treatment services can greatly improve a child’s development. Early intervention services help children from birth to 3 years learn important skills.

If you think your child might have an ASD or you think there could be a problem with the way your child plays, learns, speaks, or acts, contact your child’s doctor and share your concerns.

Cardiovascular Disease is very common in Western Societies and affects the majority of adults past the age of 60 years old. Cardiovascular Disease can be divided into four major areas or diagnostic categories:
1. Coronary Disease – may cause heart attacks, angina or heart pain, heart failure, and sudden death.
2. Cerebrovascular Disease – manifests as strokes or mini strokes called TIA’s.
3. Aortic Atherosclerosis – may cause aneurysms or a weakening of the walls of the thoracic and abdominal aorta.
4. Peripheral Arterial Disease – manifests by leg cramps with exertion and poor leg circulation.

The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults has determined the following to be the risk factors for Cardiovascular Disease:

Positive Risk:
Age – males 45 and over and females 55 and over and also females with premature menopause without estrogen replacement.
Family history of premature coronary heart disease – heart attack or sudden death before 55 years old in a male 1st degree relative or before 65 years old in a female 1st degree relative.
Current cigarette smoking.
High Blood Pressure: >140/90 (current recommendations state this should be <120/80.
HDL cholesterol < 40mg/dl. Negative Risk: HDL cholesterol >60mg/dl.

Many other factors are involved such as elevated LDL cholesterol, lifestyle factors such as exercise, diet, alcohol, and stress. Talk to your doctor to better determine your risk and formulate a plan to correct as many risk factors as possible.

Diabetes is very common. The estimated prevalence in the USA is about 7.5% of the population, and this is rising with the increased prevalence of obesity in the Baby Boomers and younger populations. Diabetes, if not managed, is associated with severe multi-system complications such as heart attack, stroke, end-stage kidney disease requiring dialysis, retinopathy, , blindness, foot ulcers and amputations. These complications alone currently account or about 14% of the US health care expenditures.

Diabetes is a disease that simply needs to be controlled. With tight control, most if not all of the complications can be avoided. The following are the recommended “tune ups”:

Ophthalmologic Exam – This should be done at the time of diagnosis and then yearly. For Type I Diabetes which may be diagnosed in childhood, within 5 years of the diagnosis or age 10 (which ever comes first), then yearly.

Foot Examination – This should be done yearly. Advice about prophylactic foot care includes avoiding going barefoot – even at home. Test water temperature prior to stepping into a hot bath. Trim toe nails to the shape of the toe and do not cut the cuticles. Wash and check feet daily. Shoes should be snug and not too tight and customized for misshapen feet or if ulcers are noted. Socks should fit and be changed daily.

Fasting lipid profile – Yearly, unless there are abnormalities. If abnormal and/or on medication, labs are done as often as every 3 months.

HgbA1C – Every 3-6months, depending on how well controlled the Diabetes is. In general the goal is an AIC of <7%.

Urine Microalbumin – Yearly

Serum Creatinine – This kidney function test should be done initially and as often as every 3 months depending on medications and renal function.

Blood pressure should be checked on every visit and should be kept below 130/80 and below 120/75 if there is kidney impairment.

There is a lot of great information on a web site made for docs and parts of this may be accessed without joining – check it out @ http://www.uptodate.com/patients

Programs promising overnight results in weight loss can be very tempting! However, if it sounds too good to be true, it usually is. Weight loss takes effort, support and determination. Once you’ve lost weight, support for weight maintenance is just as important as losing it in the first place.

SBFMG’s Internist, Dr Tanya Arvan, is a member of the American Society of Bariatric Physicians

• Bariatric medicine is the art and science of medical weight management. The term is derived from the Greek word barros, meaning heavy.
• Bariatric physicians, or bariatricians, practice weight loss management by reducing body fat using an individualized approach designed specifically for the patient.
• If appropriate for the patient, bariatricians will work closely with surgeons who perform weight reduction surgeries.
• Physicians perform an initial patient consultation to determine treatment based on each patient’s history, physical examination, laboratory work and other appropriate testing, as needed. Other associated medical conditions are evaluated, and physicians determine if patients are ready to lose weight.
• Bariatricians use medical (non-surgical) methods for weight loss including dietary modification, activity/exercise prescription, psychological support, and medication (when appropriate).
• A variety of prescribed diets are designed to reduce hunger while you lose weight.
• Physicians review the potential benefits and risks of any medications that may be used during treatment.
• In many cases, with appropriate weight loss, previous medications used for other related conditions can be decreased or eliminated.
• Bariatricians are dedicated to supporting your weight management efforts by providing an ongoing maintenance program to suit your needs.
• The goals of becoming healthier and looking better are definitely achievable when a program designed by a skilled professional is implemented

Vaccinations are not just for kids!

Vaccines save thousands of lives yearly and make life better by preventing the chronic conditions associated with some viral and bacterial illnesses.

The following are a list of the most common vaccines suggested for adults:

Seasonal Flu Vaccine – This is given yearly and is formulated every year to cover for the expected strain that year. One does not get the Flu from getting a flu vaccine, and if you feel a little achy it is probably a result of a good immune response on your part – a good thing.

Pneumococcal Vaccine (Pneumovax) – The adult form of this vaccine if formulated to give us immunity against 23 of the most virulent or disease causing types of the Pneumococcal bacteria. This bug is responsible for many deaths due to pneumonia, meningitis and sepsis or blood infections which may attack us after a bout of flu or in a weakened immune state. It is recommended for any adult age 19 and up with asthma or who smokes. Also this vaccine is given for any adult 50 years or older with liver problems, alcoholism, diabetes or cancer and some immune disorders. Finally, when you hit 65 and over one should have this on board. Many of us docs like to revaccinate once after 5 years. Check with your doctor for the timing of this vaccine if you are about to undergo chemotherapy or are on immunosuppressant medication.

It is estimated that 50,000 to 70,000 adults die from the above 2 preventable diseases each year.

Shingles vaccine (Zostavax) – Zoster, or Shingles, is caused by the same virus that causes chickenpox. After having chicken pox, this virus lives in the body for decades near the spinal cord. It seems to wait for times following great stress to attack us later in life. The older you are when you get Shingles, the more it hurts and the longer it lasts. It is estimated that 20% of all adults will get Shingles and most cases are reported in individuals 50 years or older. Zostavax is recommended for adults 60 years and older, but is not given to patients with TB, HIV, those receiving chemotherapy, having cancer of the blood or bone marrow, or allergies to the components of the vaccine. Most complications occur in those people aged 60 years and older, thus the recommendation to start at 60. It is a one time only shot and is very effective at preventing an outbreak of Shingles. In those that get the vaccine and later develop Shingles anyway, their disease course and complications will be much less than if they never received the vaccine.

Tetanus, Diphtheria and Whooping Cough (Adacel) – This is a new version of the old Tetanus Shot. It is very effective and should be given every 10 years for tetanus prophylaxis, but may be given as frequently as a 2 year booster if covering for diphtheria exposures and some dirty wounds.

Meningococcal Vaccine – This vaccine is for a very bad bug with a high killing rate. It is recommended for any young adult going to college or going into the military. It is also suggested for travelers the “Meningitis Belt” or Sub-Saharan Africa. Individuals without a spleen should also get this vaccine. Check with your doc for other indications.

Hepatitis B – This is now standard to all school age kids, and is recommended for adults over the age of 18 who have liver disease or are taking care of an individual with chronic Hepatitis. This vaccine is given as a series of 3 shots over 6 months.

Hepatitis A – This vaccine course is a series of two shots given over 6 months and is suggested for any world travel except it is not needed if traveling to the USA, Western Europe, New Zealand, Australia, Canada or Japan.

Measles, Mumps and Rubella (MMR) – This is recommended as a one time shot for anyone born after 1957 without evidence of vaccination or prior infection. This vaccine may also be given for International travel, college bound adults or health care workers.

Polio Vaccine (IPV) – The last cases of polio in the USA were reported in 1978 and 1979 in an unvaccinated religious community. 85 % of reported cases currently are found in parts of Africa, especially Nigeria and Namibia, and from India. This vaccine is not needed for adults living in the USA but may be given to world travelers. There are a few rare indications for this vaccine your doc will know about such as lab workers and adults with children who are given the older OPV vaccine.

Human Papillomavirus Vaccine (HPV) – Gardasil – Current recommendations are for women aged 9 to 26 years old. Recently, the FDA approved its use in boys and men 9 years to 26. The intent of this vaccine is to prevent cervical cancer in women. It is effective against various strains of the Human Papillomavirus (HPV). HPV is also implicated in other human malignancies such as head and neck and lower GI malignancies,. Therefor, we may see a broader indication for this vaccine in the future. It is a series of 3 shots given at 0, 2 and 6 months.