Category Archives: Dr. C “Comments”

Emergency Care: Flying Intervention Team Use In Acute Ischemic Stroke

In a nonrandomized controlled intervention study published in JAMA, researchers in Germany assessed whether deployment of a flying interventional team, consisting of a neurointerventional radiologist and an angiography assistant, was associated with a shorter time to endovascular thrombectomy for patients in rural or intermediate population areas in Southeast Bavaria.

This video explains the study design. Click https://ja.ma/FIT for full details.

COMMENTARY:

Stroke prevention by a healthy lifestyle, including a good diet, regular exercise, and sleep is of course preferable to treatment.

However, stroke still claims more than 100,000 lives per year in the United States, and is a major factor in disability.

Recognition of a stroke is the first crucial step, and has been discussed in DWWR previously; FAST is the Menmonic and guiding principle. Ask the patient to smile, and it may be assymmetric, with one side drooping. Ask the patient to raise both arms, and one may drift down. Ask the patient to repeat a simple sentence, and he may be unable to do so. And above all be speedy, since time is of the essence, and treatment must take place within a very few hours.

Modern medical centers in large cities frequently have a team dedicated to treating stroke. The patient goes for a CT or MRI while  the Catheter team assembles. An intravenous clot dissolver, tPA, is often used, or possibly a catheter is inserted into an artery and guided to the  proper location. Sometimes the clot is mechanically removed as in the accompanying video.

The helicopter stroke response team featured in the posting is one aspect of the speed that is so essential; any delay will result in death, sometimes permanently, of brain cells.

Acute Heart attack treatment is basically similar to stroke, and was the pioneering venture into the interventional radiology described above. Also, the heart may be the source of the clots that lodge in the brain, especially from atrial fibrillation.

Please enjoy the following video which shows how mechanical clot removal is achieved.

—Dr. C.

Varicose Veins: Symptoms And Treatment (Harvard)

Can you prevent varicose veins?

Even if you have a family history of varicose veins, they aren’t always inevitable, says Dr. Sherry Scovell, a vascular and endovascular surgeon at Harvard-affiliated Massachusetts General Hospital. Three simple strategies can help to prevent them.

1. Get moving. “Leading an active lifestyle is probably the most important thing that you can do for prevention,” says Dr. Scovell. Exercise, particularly walking, induces calf muscle contractions that keep blood flowing efficiently. “The calf muscles act like a heart for the veins,” she says. People sometimes believe that if they stand more and sit less, they can prevent vein problems. But that’s not true if you’re mostly standing still. “It’s better to move as much as possible,” says Dr. Scovell. Exercise also helps you maintain a healthy weight, which can keep varicose veins at bay.

2. Put your feet up. Give your legs a break by elevating your feet at the end of the day, and even during the middle of the day if you’ve got some spare time. This can relieve pressure on the veins to help keep them healthy.

3. Pull on compression stockings. These garments fit snugly on your legs, squeezing them slightly to help keep blood moving. People sometimes think they’re unfashionable and are reluctant to wear them. But today’s stockings don’t resemble old-fashioned versions, says Dr. Scovell. Compression stockings come in numerous styles, including calf-high tube socks, dress socks, and tall stockings that look like tights. “They make them in so many cool colors and patterns,” says Dr. Scovell. “They can be fashionable and still help your veins at the same time.” You can purchase over-the-counter compression stockings at a drugstore or get medical-grade options through your primary care doctor or a specialist.

COMMENTARY:

Varicose veins entered my vocabulary when I noticed that my feet were different in their coloration; my left foot was darker than my right, and had a bruise-like discoloration at the heel. Some enlargement and irregular “snaking” of my veins was also apparant at that time.

I went to see a vascular surgeon who performed an ultrasound on my veins, and informed  me that my popliteal valve, the one in the vein behind my knee, wasn’t working. This caused a constant column of blood, unchecked by a valve, to enlarge my veins.

I have been wearing compression stockings ever since, to slow down the enlargement of those veins.

My right leg has done better than my left, but still has a few varicose veins.

The compression stockings are hard for me to put on my legs, especially since I have arthritis in my hands. However, by learning a few tricks, this is not an intolerable burden.

First, you have to select your stockings. Jobst was the brand first suggested to me, and I used them for years. Recently, my big toe has been starting to cross over the second toe, a condition called “scissor toe”. The jobst stockings had toes in them, like most stockings, and I thought the compression acting on the toes was partially responsible for the scissor toe. Jobst has no open toe option that I can find. After going through several different brands, I settled on Sigvaris open toe. The label states the number of millimeters compression that is provided. More than 30 mm would be best, but 20-30mm. Is the tightest that my fingers will allow. More commonly I use 15 to 20, because after I swim the skin is wet, and wet skin simply gives too much friction to allow my painful hands to get the stockings on.

In the Harvard article, walking is also suggested, since the calf muscles act like a pumping mechanism on the deep veins to get the blood back to the heart. I learned from the article that the deep veins return 80% of the blood, and the superficial varicose veins only 20%, making them expendable. There are a number of different options for getting rid of the varicose veins, “sclerosing” them, including thermal and chemical treatments.

I walk a lot, going along with another suggestion from the article, although I don’t usually prop my legs up; I’m too busy running around to make propping a viable option.

Preventative treatment, such as I’ve been discussing, certainly beats having edematous legs with ulcers, such as I see in many older people.

—Dr. C.

Health: Four Tests For Chronic Inflammation

These are four of the most common tests for inflammation:

  • Erythrocyte sedimentation rate (sed rate or ESR). This test measures how fast red blood cells settle to the bottom of a vertical tube of blood. When inflammation is present the red blood cells fall faster, as higher amounts of proteins in the blood make those cells clump together. While ranges vary by lab, a normal result is typically 20 mm/hr or less, while a value over 100 mm/hr is quite high.
  • C-reactive protein (CRP). This protein made in the liver tends to rise when inflammation is present. A normal value is less than 3 mg/L. A value over 3 mg/L is often used to identify an increased risk of cardiovascular disease, but bodywide inflammation can make CRP rise to 100 mg/L or more.
  • Ferritin. This is a blood protein that reflects the amount of iron stored in the body. It’s most often ordered to evaluate whether an anemic person is iron-deficient, in which case ferritin levels are low. Or, if there is too much iron in the body, ferritin levels may be high. But ferritin levels also rise when inflammation is present. Normal results vary by lab and tend to be a bit higher in men, but a typical normal range is 20 to 200 mcg/L.
  • Fibrinogen. While this protein is most commonly measured to evaluate the status of the blood clotting system, its levels tend to rise when inflammation is present. A normal fibrinogen level is 200 to 400 mg/dL.

Commentary:

Inflammation is an essential, evolutionarily conserved mechanism that our bodies have developed for excluding infections, toxins, and damaged or cancerous cells.

Acute inflammation in response to infections is almost always beneficial, except where it is disproportionate to the danger that it fights; the common cold is  probably innocuous, but we develop symptoms from our bodies’ response. Covid has been found to incite disproportionately severe inflammation, which can lead to severe disease, and the need for corticosteroids.

Chronic inflammation is a different animal, and is usually undesirable. Sometimes it is due to an infection, such as tuberculosis, which won’t go away. Sometimes the bodies immune system develops a disordered communication system, and fights its own cells, called auto immunity.

Chronic inflammation can also be caused by obesity, chronic stress, cigarette smoking, alcohol in excess, and cancer, which can also be CAUSED BY chronic inflammation.

Chronic inflammation is also associated with Alzheimer’s, heart disease, rheumatoid arthritis, and type two diabetes. Asthma is a chronic inflammatory disease of the airways. IBD, inflammatory bowel disease, is a chronic inflammatory disease of the intestinal tract.

The symptoms of chronic inflammation very widely depending on the area involved. Abdominal pain, chest pain, joint pain, skin rashes, fatigue, and fever are some of the symptoms.

You can reduce your likelihood of chronic inflammation by maintaining normal weight, having regular exercise, eating a diet rich in natural vegetables and fruits (antioxidants),  avoiding alcohol and cigarette smoke, and by reducing or handling your stress.

—Dr. C.

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TREATING DEPRESSION: DEEP BRAIN STIMULATION (UCSF)

UCSF Health physicians have successfully treated a patient with severe depression by tapping into the specific brain circuit involved in depressive brain patterns and resetting them using the equivalent of a pacemaker for the brain.

COMMENTARY:

UCSF is my medical alma mater, and I am proud to comment on their info graphic about need-driven deep brain stimulation (DBS). This is not only a good idea, it should spearhead a personalized wave of the future.

Your body’s metabolism is a great balancing act, and needs to be kept on an even keel, to maintain the stability of your internal environment. What is “good” at one time may be deleterious at another.

Good illustrations of this are insulin and thyroid hormone. Both too little and too much is deleterious.

Likewise, the need for DBS varies.. This was recognized by the designers of feedback-driven DBS. The amygdala is overactive when the depressive wave is greatest, triggering the deep brain stimulation. As the depressive wave lightens, the stimulation diminishes or stops.

Engineers are quite attentive to this idea.  A similar feedback mechanism is used by implanted heart stimulators, or “ defibrillators“. if the heart slows down excessively, there is stimulation of the atrium to restore the proper rate. If the ventricle is ineffective, and fibrillates, it is given a shock which acts like rebooting your computer.

Chronotherapy, the administration of medication depending upon the time of day, is a kindred idea, illustrated by asthma. Wheezing attacks peak at night, when adrenaline and cortisol ebb, and so should the blood levels of the anti-asthmatic medication, theophylline.

Another illustration is the medication omeprazole, a proton pump inhibitor that reduces stomach acid. Reflux of this acid into the esophagus increases when you are recumbent and sleeping.. The need for the antacid is therefore greatest at night.

It is estimated that the effects of at least 50% of all medications would  benefit by attending to the diurnal cycles. If your symptoms cycle with the sun, ask your doctor about your medications.

—Dr. C.

Covid-19: Patients Dying In Name Of Vaccine Freedom

In the video above, Alexander Stockton, a producer on the Opinion Video team, explores two of the main reasons the number of Covid cases is soaring once again in the United States: vaccine hesitancy and refusal.

“It’s hard to watch the pandemic drag on as Americans refuse the vaccine in the name of freedom,” he says. Seeking understanding, Mr. Stockton travels to Mountain Home, Ark., in the Ozarks, a region with galloping contagion and — not unrelated — abysmal vaccination rates. He finds that a range of feelings and beliefs underpins the low rates — including fear, skepticism and a libertarian strain of defiance.

This doubt even extends to the staff at a regional hospital, where about half of the medical personnel are not vaccinated — even while the intensive care unit is crowded with unvaccinated Covid patients fighting for their lives. Mountain Home — like the United States as a whole — is caught in a tug of war between private liberty and public health. But Mr. Stockton suggests that unless government upholds its duty to protect Americans, keeping the common good in mind, this may be a battle with no end.

COMMENTARY:

I am a Doctor Who has studied the miracle of MRNA Covid vaccine, and who knows that it cannot get into the nucleus of any of my cells or long remain in my body.

I have studied the transmission and pathogenesis of Covid, and know how it works. The knowledge that it could affect my thinking, memory, my very essence, and the fact that it could last indefinitely after the initial illness has certainly made me a believer.

There is an element of truth in the concerns of anti-vaxers and anti-maskers. Unfortunately the problem is not black and white. No vaccine is 100% safe, although the mRNA vaccines come close. There is some worry about clotting problems with a few people, particularly the young. This risk is measured in terms of problems per million people getting the vaccine, and is vanishingly small compared to the alternative of exposing yourself to the ravages of Covid.

An intelligent friend of mine who is a nurse has auto immune disease, and vaccines tend to hit her hard. Unfortunately the fact that she is a nurse and is exposed a lot to the public make her more likely to get Covid, and her auto immunity would render her much more likely to have complications, should she get it. She has received her first injection of Covid vaccine, and had a lot of fatigue, headaches and symptoms that were relatively self-limited.

Masks are mainly useful in protecting other people from the mask-wearer and only slightly helpful in protecting the mask wearer from other people. Also, I have read a long article about some subtle disadvantages of forcing children to wear masks although I think it’s still a good idea, particularly when Covid is common in the community.

The main problem is that Americans have freedom of choice without the knowledge to weigh the benefits and hazards of receiving the vaccine, versus the hazards of getting the disease.

There are times when we should unload the making of such statistical decisions on people who know more about the vagaries of disease.
In my opinion, the states which allow hospitals to require their healthcare workers to receive vaccination, and allow schools to require their students and teachers to receive vaccination are in the right. Currently, there are less problems in those states.

Covid is certainly a nasty disease, and even doubly vaccinated people can be spreaders. As an elderly vaccinated person, I still treat everybody as if they are infected, and require masks when visitors come. When inside, I sit by an open door, with a fan behind me blowing air in the other direction.

At the age of 89, I cannot afford to get Covid-19.

—Dr. C.

HARVARD STUDY: VITAMIN D LOWERS THE RISK OF YOUNG-ONSET COLORECTAL CANCER

COMMENTARY:

Vitamin D has many beneficial effects, but my comments will be restricted to the effect of vitamin D on cancer.

Interest in this association was started by the observation that certain cancers are less common near the equator, where there is more sunlight exposure, and therefore more natural vitamin D generation in your skin.
The most information on cancer in humans Is available on colorectal, breast, prostate, and pancreatic cancer. Colorectal cancer, highlighted DWW our posting, is the only cancer that apparently is affected by vitamin D.

Several studies have suggested that vitamin D can decrease cancer cell growth, stimulate cell death, and reduce cancer blood vessel formation. Increasing cell death, or apoptosis, is what interests me the most, since this is one of the factors which increases inflammation in aging.

The infographics stated that only 300 international units of vitamin D is necessary to produce a 50 Percent reduction in cancer, and that a healthy diet generally supplies this.

I personally take 5000 international units vitamin D. This produces a blood level of about 60 ng/mL, and what the NFL recommends to keep their players healthy, and well within the maximum recommended level of 120 ng/milliliter.

Excessive vitamin D can produce an elevated calcium blood level, and mine is within normal limits. I take the higher dose because of vitamin D’s other effects, such is benefiting the immune system in a time of Conid-19.

I suggest that you get a vitamin D blood level, and also a calcium blood level if you elect to take more of this useful vitamin.

–Dr. C

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SCIENCE: CLEANING INDOOR AIR WILL IMPROVE HUMAN HEALTH AND COGNITION

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COMMENTARY:

Joseph Allen, the “air investigator”, was apparently on board early in the COVID-19 epidemic, stressing the importance of suspended  air particulates, less than 2 microns in size, causing transmission of the disease.

His article in Science: “clean indoor air will improve human health and cognition” is well worth reading, or at least inspecting the info graphic. As a practicing allergist, I was aware that inside dust mite particles and mold spores made allergies worse. We had a service where we would go into homes and sample the air. An excess of certain Indoor mold spores, compared with those outside, would indicate a “problem home”. We would then try to find the water leakage source that produced the molds.

I also had a patient who could not tolerate a new house, with its carpets and other artificial materials. The only place where she felt better was in an old seaside house 100 miles south of San Francisco. I thought there were some psychological factors, but who knows? Volatile organic compounds, VOCs, probably affect some people more severely.

Beginning shortly after the energy crisis in the 80s, the “sick building syndrome”, characterized by headache and fatigue in certain buildings, was on the news. The eventual solution was to create better ventilation, with a reduction of CO2 and VOCs in those buildings. In addition, federal agencies began banning certain artificial  fabrics that out-gassed VOCs.

There was eventually less talk about sick building syndrome, except for the occasional air system which was contaminated with Legionella bacteria.

The present article stresses accumulation of CO2 and VOCs In the stale air in the individual home or office as a cause of diminished attention and productivity.

CO2 monitors still cost about $200, and so I think I am going to just try to increase the ventilation in my office, where I get sleepy in the afternoon, by opening the windows and sliding doors. I wonder about  the indoor CO2 in Scandinavian winters, where depression is increased.

—Dr. C.

VIEWS: IS U.S. HEALTHCARE SYSTEM BROKEN? (HARVARD)

Here’s a question that’s been on my mind and perhaps yours: Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all.

Below are 10 of the most convincing arguments I’ve heard that our system needs a major overhaul. And that’s just the tip of the iceberg. Remember, an entire industry has evolved in the US just to help people navigate the maddeningly complex task of choosing a health insurance plan.

The cost is enormous

  • High cost, not highest quality. Despite spending far more on healthcare than other high-income nations, the US scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality. And for all that expense, satisfaction with the current healthcare system is relatively low in the US.
  • Financial burden. High costs combined with high numbers of underinsured or uninsured means many people risk bankruptcy if they develop a serious illness. Prices vary widely, and it’s nearly impossible to compare the quality or cost of your healthcare options — or even to know how big a bill to expect. And even when you ask lots of questions ahead of time and stick with recommended doctors in your health insurance network, you may still wind up getting a surprise bill. My neighbor did after knee surgery: even though the hospital and his surgeon were in his insurance network, the anesthesiologist was not.

Access is uneven

  • Health insurance tied to employment. During World War II, healthcare was offered as a way to attract workers since employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to healthcare.
  • Healthcare disparities. The current US healthcare system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable healthcare disparities for people of color and other disadvantaged groups.
  • Health insurers may discourage care to hold down costs. Many health insurance companies restrict expensive medications, tests, and other services by declining coverage until forms are filled out to justify the service to the insurer. True, this can prevent unnecessary expense to the healthcare system — and to the insurance company. Yet it also discourages care deemed appropriate by your physician.

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Dr. C Commentary:

Please refer to the DWWR Posting on “concierge doctors” for my rant on the current healthcare system, which I will not repeat.

The truth is more nuanced. All countries are having trouble of one sort or another with their healthcare systems. This is due to the inherent expense of today’s top flight medicine. The very best care requires costly high technology and drugs that are intrinsically hard to produce. And you have to know where to look. I am very thankful for my medical degree, and that I have kept up with current advances.

You would probably need a Government entirely of physicians to develop the willpower to do something for health, which always starts with PREVENTATIVE MEDICINE, A hard sell, given that you must spend money and effort to block something which will probably, but may not always, occur.

There is low hanging fruit. Why are sugary drinks not heavily taxed, since they produce obesity which causes a lot of costly medical disorders, such as diabetes, inflammatory diseases, and cancer, but not everybody all the time?

Why is efficiency of telehealth not more widely embraced, but stymied by moneymaking lobbiests and lawyer powered difficulties, in addition to Patient’s and doctor’s old habits?

And then there are the jealously guarded  American freedoms to do stupid things, such as avoid vaccines and masks, even in a prodigiously expensive and dangerous Covid  epidemic.

Given human nature, a complete solution would seem to be impossible, and we should content ourselves with minor victories wherever they can be attained.

Embrace sleep, diet, and exercise, and KEEP HEALTHY.

–Dr. C

TeleHealth: Weill Cornell ‘Center For Virtual Care’ Expands Training Courses

The new eCornell course, which features a curriculum in-line with the Association of American Medical College’s Telehealth Competencies, offers instruction on how to harness the digital health medium to effectively create a therapeutic patient-provider encounter. Students learn essentials including verbal and nonverbal communication strategies to convey empathy and compassion, how to overcome technical challenges, and how to conduct remote patient exams.

Digital health and the tools for patients to virtually reach their health care providers have quickly become a mainstay of medical care during the COVID-19 pandemic. Weill Cornell Medicine’s Center for Virtual Care is positioned at the leading edge of this health care delivery transformation. Leveraging their years of experience with video visits, the center’s experts train providers how to best use it to give their patients comprehensive, compassionate care.

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DR. C Comments

Telehealth offers significant advantages to both patient and doctor. It should be a welcome and valuable addition to the medical profession in its desire to deliver comprehensive care to patients. However, Telemedicine faces a number of barriers both from the medical side and the patient side, not to mention insurance, lawyers, and government.

A good video was posted from Cornell, which aims to get doctors to develop a set of behavioral skills which will make telemedicine more personal. Of course, training should be extended to peripheral sensing devices that will enhance the ability of doctors to gain information at a distance, as well as familiarization with a user-friendly electronic system to navigate.

Patients also need a special course in how to become more Competent in the technical aspects of telemedicine,  sensors and other challenges. Since  Telemedicine visits occur at widely spaced intervals, even an intensive training course might find the patient unfamiliar with the system at the time of need.

Recently, I signed up for a zoom consultation At UCLA medical Center. It was very helpful to have a knowledgeable person on the phone directing me through the maze that got me signed up to “my chart”, The electronic system that UCLA uses. Even though I took Notes, when it is actually time to get into the system and  go to the virtual waiting room of my chart, I may well have difficulty.

And that’s just one system. It seems as though doctors offices, different medical systems, and different health plans all have their own unique electronic systems which are enough different to be confusing to the patient.

I can only hope that the newer generations, having grown up using these electronic devices, will have enough facility to easily interface with their doctor electronically. Until the older generation passes on, however,  there will be ongoing challenges.

AMERICAN DIET: THE COVID SURGE IN SNACKING (VIDEO)

With Americans stuck at home, snack food has become a valuable commodity for the pandemic stressed consumer. North American sales of savory snacks like chips, popcorn, and pretzels climbed to $56.9 billion in 2020. In stressful times, people turn to snacking for comfort and Covid-19 has transformed kitchens across the U.S. into giant vending machines. So, has Covid-19 put an end to the shift to healthier snacks?

DR. C’S COMMENTS:

Snacking with its  concomitant weight gain has increased with Covid. Of course Snacking didn’t originate with Covid, and it has long been common in Overweight people.  Snacks are engineered to taste terrific, which means containing a lot of fat, sugar, and salt, easily be over done. Good nutrition  is an afterthought to snack companies.

The Small volume of snacks, eaten frequently, Does not cause the satiation that comes with regular meals.

In my opinion, one of the major mechanisms by which TIME RESTRICTED EATING causes weight loss is by its prohibition of snacks. In the narrow window of time that you’re allowed to eat, you are hungry and eat regular food which tends to be of higher quality. Your stomach is full. You feel full and are not tempted to snack. Sugary drinks and snacks are bad for health.