Is Avandia safe?

Bottom Line: so far, appears to be safe.

So, what's the issue?

A recent study was done that lumped together a number of separate studies (this is called meta-analysis), and it suggested that people on Avandia may have more heart attacks or heart failure than people who don't take Avandia. (Bear in mind, that the manufacturer and the FDA are involved in looking at the safety of the drug, but are not felt to have been at fault in some way.)

Problem is, meta-analysis is kind of a forced apples-orange comparision and is known to produce conclusions that have to be carefully considered.

So far, investigations looking specifically at whether Avandia carries an increased risk of heart disease do not show an increased risk. Naturally, these findings will be made public as they are concluded.

In the mean time, it's worth bearing in mind that poorly controlled diabetes itself carries a very high risk of heart attack. Because the question of drug-related heart risks is inconclusive, it is probably better to use Avandia to keep your diabetes under good control.

[This posting is for general information, and is not a substitute for individual assessment or advice!]

NEWS: Hantavirus

An El Dorado County woman was recently diagnosed with a hantavirus infection, and has recovered. Local doctor's offices have been notified today by the Department of Public Health, and further information from the Centers for Disease Control (CDC) have been distributed by Marshall Medical Center.

Please bear in mind that this is a rare disease and an avoidable one.

This virus occurs in wild rodents such as mice and rats. It can be inhaled by humans because the rodents excrete it in their urine and droppings.

The most frequent symptoms are pretty non-specific: fever, chills and muscle aches. Shortness of breath, chest pain and cough are not common, but are serious as the virus can cause a serious lung infection.

Rashes, bloodshot eyes reddened throat, and fluid swelling are unlikely to be from hantavirus.

To prevent getting exposed to hantavirus:

• Avoid areas (especially indoors) where wild rodents are likely to have been present.
• Before cleaning an enclosed cabin, shed, trailer or similar area open the doors and windows and air it out for at least 30 minutes before entering.
• Don't touch live wild rodents.
• Wear disposable plastic gloves when handling dead rodents or cleaning areas.
• Spray diluted bleach on areas soiled by rodent droppings or urine and on dead rodents. Use one part household bleach to 10 parts water.
• Wear plastic gloves and a wet sponge or mop to clean the area. Do not sweep or vacuum.
• Place dead rodents and waste in double plastic bags. Seal each one tightly and discard in trash.
• Wash your hands thoroughly afterwards.
• Deter rodents by removing rubbish, discarded junk, stacked wood. Block mouseholes. Tightly seal food containers.
• If large numbers of rodents are present, contact a pest control service to remove them.
  

Blood Pressure

Your blood pressure is considered to be one of your "vital signs" because increases or decreases in it can give doctors and nurses clues to underlying problems like infections, injuries, heart attacks and so forth.

It is measured in the resulting rise in a column of mercury in millimeters, abbreviated as mm Hg. The first higher number is the systolic pressure, which is the pressure in your arteries when your heart is pumping. The second lower number is the diastolic pressure, which is the "standing" pressure in your arteries when your heart is filling. (There has to be some positive pressure then in order for blood to flow up against gravity to your brain, and against resistance to reach your hands and feet.)

On a chronic ongoing basis, your blood pressure should be lower than 130/85. We find that risk of heart attack and stroke starts to get higher above this. Specifically, there is a doubling in risk of heart attack and stroke for every 20/10 in chronic blood pressure over 120/80. Lower than 110/60 (again, assuming you are not on heart medications) is not healthier.

By chronic, I mean at rest on a day to day basis and not with exercise or on heart medications. Your blood pressure normally changes throughout the day and may vary with activity, exercise, time of day, diet, stress or illness.

We used to think that if your blood pressure went up just in the ER or the doctor's office that this was just due to understandable anxiety. However, we now know that this lability or rapid changability in your blood pressure is just as dangerous to you as sustained high blood pressure.

Keeping your blood pressure under control is important because high blood pressure almost never causes symptoms. Therefore, you may only find out that your blood pressure is high through having a heart attack or stroke unless you are having it checked.

Fortunately, the benefits of having or getting your blood pressure to less than 130/85 are just as good with medications as without them. More on that...

Long-term care insurance

I'm posting about this because I get questions about this regularly, and it's a complicated matter.

Long-term care insurance is a kind of medical or health insurance you can buy that covers medical equipment, care or therapy for long-term conditions such as a stroke, dementia or cancer. It particularly covers care you might need at your own home, and not at a doctor's office, in the hospital or in a nursing facility. Most people consider buying it in addition to their health insurance in order to be able to receive medical care for a long period of time in their home, and to avoid having to go to a nursing home to receive such care. (What may be covered by this insurance is coming right up.)

In other words, this kind of insurance is very helpful in situations where you could be ill enough to need help at home or in recovering further, but could not otherwise afford it and are then left with no choice but a nursing home.

When to buy it is a judgement call. You want to already have it before you need it, so you don't want to wait overly long. At the same time, it's a very expensive insurance so buying it too early can be needlessly expensive. Having pre-existing medical conditions can make it more expensive, while buying it at 40 years old could even mean the insurance company is no longer financially solvent by the time you are old enough to need it! Look at your age, whether or not you smoke, your health and also your family medical history. Also consider your personal finances and the credit-worthiness of any insurance company you are considering.

If you are already on MediCare, examine some of the supplement plans which include long-term care coverage. You may find the coverage to be worth any increase in costs to you.

Read the fine print! Is skilled therapy (such as physical, occupational or speech therapy) covered? Is Durable Medical Equipment (DME such as hospital beds, wheel chairs, etc.) covered? When and for how long is coverage provided? Does it cover unskilled caregivers (someone to come in regularly to help you dress, have a bath, eat or just to be there to make sure you are okay)? How does it coordinate benefits with your other insurance(s)? Where does it provide coverage: hospitals, rehabilitation centers, your home?

Often, the need for coverage includes being unable to perform some of what are known as Activities of Daily Living (ADL's). There are six of them: bathing, toileting, dressing, feeding, continence and transferring (moving). You would like for coverage to start if you are unable to independently perform as few as 1-2 ADL's, especially transferring and continence. These two ADL's are the hardest for spouses, friends and family to manage for any length of time.

So, bottom line:

• Long-term care insurance can turn out to be extremely helpful to you should you be so unfortunate as to ever need it.
• It's usually very expensive.
• Comparison shop wisely with an eye to when you buy it, its affordability to you, the financial viability of the insurer, and whether it will help you as much as possible when you need it.
  

Preventing Heat-related Illnesses

It is definitely Summer now!

With all this sun and high temperatures, it can be easy to get sunburned or develop heat-related problems like heat exhaustion.

Avoid staying out in the sun too long; wear a hat, sunglasses and protective clothing.

Drink enough fluids to urinate every hour or two and to produce clear or light yellow urine.

Also, have a meal or some salty snack foods to replace salts you lose in your sweat. Do not use salt tablets: overly rapid changes in sodium or potassium levels can interrupt heart rhythm and can even be fatal.

Sunscreens that contain micronized zinc oxide are the best at preventing sunburn and also skin cancers. Remember to reapply sunscreen every 3-4 hours and after swimming.

If you don't have air conditioning, take advantage of air conditioning elsewhere by going to a movie or visiting the library. Or, enjoy a swim at the local pool!

CalPERS: the continuing saga

So far, press coverage (Sac Bee, Sac Business Journal, CalPERS press releases) consistently states CalPERS's withdrawl of Blue Shield EPO from four rural counties including El Dorado.

The pickings have become slimmer with their dropping of Western Health Advantage (WHA). This makes no difference to me, since WHA is another HMO option like Kaiser.

Happily, the plan rates for 2008 are a small increase when compared to every previous year and the rates for Blue Cross PPO PERSChoice and PERSCare are not much higher than for Kaiser.

Specifically, keeping your medical care local (my office, specialists, Marshall ER and Hospital, labs and XRay) can be done. Kaiser is not your only remaining choice. PPO's via Blue Cross allow you to get medical care where you want to (like with the Blue Shield EPO). They are a little more expensive than Kaiser, but not a lot.

If you decide that the extra buck is worth the extra bang, I am happy to continue to be your doc.