Sexual Intercourse After a Heart Attack

Evidently, this is an issue that often goes unaddressed with patients (not by me, I think).

Patients who have had a heart attack are usually and rightly concerned about what they can safely do, and how hard they can push their own bodies without harm. Their partners and family may be equally concerned about whether physical activity including sexual intercourse could be dangerous or harmful.

For most patients, sexual activity is perfectly safe within the few weeks after going home from the hospital assuming you feel generally up to it.

This frequently asked question list is helpful and reasonably specific, and notes that sexual activity (in terms of demand on your heart) is moderate and falls in between showering and gardening in terms of metabolic demand.

[Do note that if you use medication for erectile dysfunction (Viagra, Levitra, Cialis) you should not use them with nitroglycerin- containing heart medications (such as Imdur, IsMo, sub-lingual nitroglycerin) because sudden decreases in your blood pressure could result.]

Allergies

'Tis the season!

If the last few weeks of yellow-green pollen on everything has also been marked by itchy watery eyes, itchy runny nose and sneezing then you are very likely allergic to it. This is often referred to as "hay fever" and is technically known as seasonal allergic rhinitis.

If you notice this all year 'round, you may also be allergic to other things such as molds, dusts or animal danders.

Happily, there are a lot of things you can do to improve your symptoms.

First, try to avoid pollens by wearing a mask for mowing or brush clearing. Wash your face and hands when you're done. Try to sleep with the windows closed.

Over the counter medicines can be very helpful .

Anti-histamines such as Benadryl, Zyrtec and Claritin help by blocking the effects of histamine released in the allergic reaction. Remember, the more it works for allergy, the more potential there is for drowsiness. You may have to try different ones to strike the best and safest balance.

Decongestants such as Coracedin and Sudafed can help but can also raise your blood pressure. If you already have high blood pressure or take medication for that you should at least check your blood pressure after taking decongestants. If it's higher than your usual, you probably should avoid these.

Be careful of decongestant nose sprays such as Afrin and Neo-Synephrine. They are very effective, but addictive if used for over 3-5 days in a row.

Prescription nose sprays such as Flonase and Nasonex are easy to use, well tolerated and the single most effective kind of medication for relieving symptoms. If you are using them, remember that they have to be taken every day in order to prevent allergy symptoms.

Hopefully, this will help relieve the bothersome symptoms of hay fever for the season. If not, let us know so we can work on this with you.

Chicken Pox outbreak

We are seeing chicken pox within the last week or two here in El Dorado county, as also noted in the Friday 5/14/10 Mountain Democrat (sorry, their website is subscription only).

This is a common viral illness that generally shows up as a mild illness with feeling generally ill, itching, and fever up to 102 degrees for up to 2-3 days. More severe disease can result in pneumonia or other complications.

People at moderately higher risk of more severe disease includes:

• people 13 years old or older
• people with chronic skin disease such as eczema or psoriasis
• chronic lung disease
• patients who take steroids chronically as inhalers or pills

Folks at higher risk of severe disease include:

• newborns
• pregnant women
• patients on steroid pills daily
• patients with supressed immune systems (HIV/AIDS, chemotherapy, organ transplant medicines)

Mind you, if you've already had chicken pox before you are extremely unlikely to get it again.

For the most part, the illness is treated supportively with soothing compresses, rest and over the counter medicines such as Tylenol. It generally goes away in a week or two. As it can easily spread through touching pox lesions and/or coughing or sneezing we generally recommend staying at home and avoiding school or work or social gatherings until the pox lesions have scabbed and the scabs have come off and there is no more coughing or sneezing. It is not necessary to see us in the office for this, as risk of spread to other patients is high.

Certainly, feel free to call if you are concerned about more severe illness or risk for severe illness.

The chicken pox vaccine has, over the past decade or more, been a routine part of childhood vaccinations and is generally given at 15-18 months of age. More recently, a second dose has been recommended for better vaccine response. Please contact the county department of public health about this if you feel you may need a second vaccine.

High Deductible Health Insurance Plans

The impact of the recession on our local economy has been severe, especially considering the number of folks who have been affected by the loss of jobs in construction,and the number of state employees affected by furlough programs.

I think one of the tough choices folks are having to make is in choosing health plans that are lower in monthly premiums, but leave a lot of out-of-pocket costs to the patient in terms of annual deductibles, coverage only of generic medicines and/or coverage only of preventive care (or everything but - such as only ER and hospitalizations).

These high-deductible plans (so called "crash and burn" or catastrophic coverage plans) are attractive insofar as the monthly cost in premiums is lower or at least manageable.

The problem is that these plans were never really geared for families or for patients over about 30- 35 years old. These plans have been around for quite a while, but the target market was always young healthy employees just out of school and off their parents' insurance who rarely got sick and would typically just need annual Pap smears and coverage of emergencies or catastrophes such as car accidents and traumatic injuries, or unexpected severe illnesses needing hospitalization.

These plans were never really intended for folks living in what the insurance industry calls "elephant country"- the age at which you are actually increasingly likely to need the insurance for sudden problems like heart attacks, strokes or cancers, or for chronic problems like high blood pressure or diabetes. For families or for patients over 30- 35, you can actually end up either spending more money out of pocket in a year than you would have by having a more comprehensive insurance plan, or you can find yourself doing without necessary medical care. Or both.

Please look closely at these kinds of health insurance plans; it's really important to look beyond the monthly premium and also look at the possible costs to you of medicines, physicals, appointments or tests over the year and whether you have the reserves to handle the cost of these or not. The situation you'd like to avoid is where you use the catastrophic coverage for a medical catastrophe that could have been avoided or prevented.

Otherwise, please let us know if you have such a plan. We are happy to work with you in any way we can in order to provide the best medical care, but we have no way to know whether anything we prescribe for you or recommend to you represents a problem for you unless you let us know!

Wandering in Dementia Patients

As our population ages, dementia (the gradual loss of higher brain functions such as memory, orientation and attention) will be an increasing problem.

Wandering away from home is one of the most frustrating and potentially dangerous problems family and caregivers can face. Institutions such as nursing homes have secured doors and staff to prevent this. In your own home, this can be much more difficult.

Evidently, searching for wandering dementia patients is very difficult and very different from usual search and rescue since the demented person may not act logically and may actually try to evade rescuers.

Fortunately, there are some simple things you can do to prevent this in the above link, and also here.

Osteoporosis

Osteoporosis falls into one of those medical conditions in which you don't feel anything wrong until there's a problem, but if you develop a problem it's serious and already too late. On the other hand, it's happily also detectable and preventable.

Also known as "brittle bone disease", osteoporosis refers to a loss of bone strength. This does not cause pain in its own right, but it does mean that a simple fall to the ground can result in painful or disabling fractures. We are especially concerned about hip fractures because even though they can be surgically repaired, half of patients who sustain a hip fracture have died or are permanent nursing home residents within the following six months.

On the positive side, there's a lot that can be done to detect osteoporosis early on, and to prevent it from harming you.

Testing can easily be done to detect osteoporosis before fractures or loss of height occur. Indicators of higher risk to have low bone density include:

• smokers
• body weight under 154 pounds
• family history of osteoporosis
• physical inactivity
• alcohol use
• post-menopausal women older than 65, or older than 60 with another risk factor

The most accurate and reliable test for osteoporosis is the DXA (dual X-ray absorptimetry) test. Heel ultrasound is not accurate, and should not be used as the only basis to rule in or rule out osteoporosis. Save your money, if this is offered as part of a low-cost "health screening". (When's the last time you heard of a doctor or ER talk about ordering a bone ultrasound?)

The arm emits a low-dose beam of X-rays through several specific sites such as the wrists, spine and hips. The table can detect how much of that known amount of X-ray is getting through to the table. The more dense your bones are, the less makes it through to the table. Then, a detailed result can be generated showing density of your bones at these various points in comparison to other patients of your age.

Long story short, if your bone density is among the lowest ranking it does actually relate to markedly higher risk of a simple fall resulting in a serious fracture.

If this is the case, then it's a good idea to get proactive about maintaining or improving your bone density in the interests of not sustaining a fracture as well as avoiding loss of height or a humped curvature of the spine (the so-called "widows' hump").

Exercise does help:

• High-impact exercises that involve gravity help to stimulate bone formation (lack of this is why young healthy astronauts develop loss of bone density within a matter of a few weeks in orbit). This would mean running, walking and treadmill as examples. While water aerobics and elliptical trainers are excellent for cardiovascular conditioning, they do not increase bone density.
• Exercise that promotes balance can prevent falls (no fall, no fracture). Tai Chi, yoga and dance are particularly beneficial.

Look at your home:

• Most falls occur in your home; it's were you are most of the time.
• Address things that can result in falls, such as loose carpeting or throw rugs, exposed electrical cords, poor lighting or lack of grab bars in the bathroom.

Make sure you are getting adequate calcium and vitamin D by supplementing. This does not increase bone density once you are over 35 years old, but it does ensure that you are getting enough to maintain normal bone metabolism.

• Calcium carbonate, 600 mg, twice a day
• Vitamin D, 400 International Units, twice a day

Prescription medicines do have a role if your bone density is already in the osteoporotic range, since they not only improve bone density but also reduce the occurrence of fractures. The most effective are the bisphosphonates.

• Fosamax and Alendronate are conveniently once a week.
• Fosamax is now generically available as alendronate.
• Unfortunately, the absorption of once a month and once a year treatments such as Boniva is poor and limits their effectiveness.
  

Allergy Season. Again.

Great skiing this weekend, but allergy season is gearing up even as the ski season winds down.

If you are chronically a hay fever or allergy patient, now's the time to prepare.

Sleep with your windows closed, if possible. Wash your hands after coming inside from being outdoors. If possible, avoid being out and about in mid-day since this is when pollen counts are at their highest.

If you usually take a medication that works well for you, don't wait until you're sneezing and weeping continuously to start taking it. Now is a good time to start. Once everything is covered with green pollen, you're already behind the 8-ball.

Remember that as far as pills are concerned, the more effectively they work as anti-histamines, the more likely they are to produce drowsiness.

Over-the-counter Claritin is a pretty good balance of effectiveness versus drowsiness. Zyrtec is "stonger", but more likely to make you feel sleepy and Benadryl even more so.

Avoid decongestant nose sprays such as Afrin, 4-Way or Neo-Synephrine. Use of these for over 3 days in a row can be addictive.

Prescription nose sprays such as Nasonex or generic Flonase are actually more effective than pills alone. However, you have to use them daily for the duration of the allergy season. Otherwise, they are not so effective.

Please see me if you are having allergy symptoms despite such treatment, or if you also have a lot of coughing, wheezing, chest tightness or shortness of breath. This could mean you have asthma and not just simple hay fever.

Health Care Reform

So, I'm getting a lot of folks asking how I feel about the passage of the health care reform bill (H.R. 3590- the Patient Protection and Affordable Care Act), and how I think it's going to affect me and other doctors.

Mind you, these are my opinions based on following these issues for years as a doctor.

If you want to read the actual documents of this bill and of the bill that will proceed through the Senate for the President's signature (H.R. 4872- the Health Care and Education Affordability Reconciliation Act of 2010), this article provides links to the full source documents.

More manageable, plain English 20+ page summaries of these bills (pdf) can be found here and here. This and this are for folks who like FAQ lists.

Generally, I like what I see.

I think it's great that the first things on the table that should occur in the next months include extending coverage for young folks to 26 years old on their parents' insurance, setting up insurance pools for people with pre-existing medical conditions, closing the Part D "donut hole" and covering preventive care for MediCare patients, and doing away with insurance company practices of capping coverage, refusing to insure patients with medical conditions, and stopping your insurance when you become ill.

Do I agree with requiring people to have insurance?
Do. The. Math. Or, consider whether you really feel okay about your taxes and premiums paying for the medical care of a healthy 20 or 30 year old who decided not to pay for insurance and then develops diabetes or has an accident. Did requiring drivers to have insurance cause premiums to go so high that you can't afford to drive? Or, is it better that if you get in an accident and the other guy is at fault that his insurance covers it because he has to have it?

Do I think it's going to bankrupt health care?
No. I believe the Congressional Budget Office.

Will it "cut down on Medicare"?
No. Remember the closing the donut hole part?

Is it okay to pay for this with taxes?
Please. We're talking tax hikes of 3.8% on unearned income of people filing over $200,000/year, or couples filing jointly over a quarter million dollars a year. People in these tax brackets have seen a 300% increase in their earnings in the past 10 years. The rest of the country (adjusted for inflation) has stayed flat over this time. I believe the super-rich can and should afford it.

But, what about my own insurance?
No downside. There's nothing in this law to keep you from staying on your present insurance if you like it. However, you might find it reassuring not to have a $1-3 million dollar lifetime cap on it if you develop and expensive problem like a cancer or a bad car accident. Also, formation of risk-sharing pools in each state should make it possible for you to get your own affordable insurance if you get fired, go to part-time, retire before 65, decide to go into business for yourself, or just don't want to go to Kaiser if the boss decides to change everyone to Kaiser. Bummer.

The government? Involved in health care?
The government already is involved; MediCare, MediCal and the VA. As far as I can tell, the private sector insurances have otherwise had free reign since World War II. I am as frustrated as any doctor with run ins with Medicare, but I also have run its with Kaiser, Blue Cross and Blue Shield. I am perfectly happy to let the government have a go at it. Heck, the seem to do just fine with having a military, enforcing the law and putting out fires. I also must say I've never had a letter or parcel lost by the Post Office.

How do I think it will affect me and my practice?
Dunno, but I remain optimistic. I look forward to not losing patients because they lose their jobs or their boss goes cheap (Kaiser). I look forward to seeing my college students and recent grads without the burden of them having to pay out of pocket. Hey, there's a good chance my own insurance rates will go down and/or that I could more easily retire before 65! Having an influx of available new patients who now have insurance? Sounds good.

Next? More jobs!

The Physical Examination

The physical examination dates back to antiquity, and is useful in assessing a number of clinical findings that can help to establish diagnosis. In other words, examination of a patient's body can help to determine what is happening and what to do.

As I was taught it, examination followed a detailed history-taking which consists of detailed questions and answers about health, symptoms and recent or past events.
I was lucky to attend a medical school (the University of Pittsburgh School of Medicine). This is a very large teaching campus serving half Pennsylvania and also Ohio and West Virginia and had dedicated hospitals for veterans, children, women, ear nose and throat surgeries, eye surgeries and psychiatric patients. As the only medical students in Pittsburgh, we had the entire run of the place to ourselves. Also, the population there is the oldest in the U.S., so you do see a lot of folks. Additionally, the faculty included doctors who were very experienced and gained their experience when good history taking and physical examination skills were nearly all you had. This was before ultrasound, CT's and MRI's. Laparoscopic surgery a new technology at my time.

There are times when the physical exam is not so useful (such as discussing a new diagnosis of high cholesterol or diabetes based on abnormal screening blood tests) and other times where it is crucial (such as sore throat, abdominal pain or shortness of breath).

Unlike in days gone by when doctors rarely asked questions of their patients (such as the 1800's), I find that my teachers were correct: the majority of helping patients relies on accurate diagnosis, and the majority of diagnosis relies on history taking and a targeted examination. I continue to find it useful to elicit a full story, give patients adequate time to explain it and then ask what patients think is actually going on. Not, I admit, great for my schedule but it does help to get it right the first time whenever possible.

I see (h/t to Kevin, MD) this remains a topic of debate amongst doctors, which is not surprising in the context of advances in technology and increasing constraints on time.

This author's reflections on how technological advancement has changed medicine including the social aspects of it really resonates with me, as I see fewer and fewer of my colleagues in the hospital at all due to the trend towards doctors going fully into hospitals or fully into offices and clinics, but no longer both.

• I regret that more and more we seem to distrust our eyes (and almost all of dermatology for example relies on observation, as do a myriad of other diagnoses); we distrust our ears (and the tale the patient might tell us if we only listen long enough) and we distrust our senses. We are putting far too much emphasis on "test results" to tell us what to do next.

• We see too little of our radiology colleagues because we don't go down there as much as we used to. It's a loss--it was great to show them a CAT scan or MRI and give them the clinical context, and then hear their opinion.

• I miss the nurses' station with the chart racks which used to be the social center of each floor of the hospital. Since you can write your note from anywhere (including from Starbucks), we we wind up "talking" to each other through the medical record. We don't develop relationships that are good for coordinated patient care.

• I bemoan the fact that the art of bedside diagnosis is in danger of extinction. The people who invented these skills (beginning a hundred and fifty or more years ago) had to wait for an autopsy to reconcile what they saw or felt or heard on the outside of the body with what was actually going on inside. Now, we can make those correlations in real time; it should have made us superb at the bedside. Instead I worry we will get to a point where if you are missing a finger and show up in a hospital, no one will believe you till they get an MRI, CAT scan and an orthopedic consult.

I think this writer sums up nicely the use of a guided examination in arriving at an accurate diagnosis, which not only allows effective treatment to be started without delay, but also avoids unnecessary tests, radiation exposure and cost to the patient.

We believe that the truth is somewhere in between. We argue that clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

Health Care Reform

On the eve of a vote on health care reform in the House, this link shows a brief summary of the bill's content.



For those with a yen for source documentation, this link is to a pdf file that shows the entire content of the bill.

Sex and the Insulin Pump

This is a well-written article by a professional teacher and writer about the impact of having an insulin pump for Type I diabetes on her feelings of sexuality and self-worth.

The article is of general interest about how chronic illness and particularly medical equipment can affect not just your health, but also sexuality.

As a doctor, it is also a reminder that medical conditions and also their treatments can affect life and also quality of life, which includes sexuality. I admit that I had not considered this in the insulin pump, though the subject often comes up in the setting of arthritis, heart attacks and cancers of the breast and prostate. "Will I spread the cancer by touching her?" "Will "being with him' cause his heart to over-work itself?" These kind of questions may be hard to ask, but they're real questions. They reflect concerns based on anxiety, love and compassion. Nothin' more real than that.

(H/t to boing boing for this link.)

Telemergency Alert Device

A patient's daughter recommended this alert device, based on her use of it for her father who is medically frail and lives alone.

(Disclaimer: this is useful information being passed on, not a product endorsement.)

The idea with alert devices is for elderly folks to have a quick and easy way to summon help if needed (think: Help! I've fallen down and I can't get up!)

The device costs about $148 (see this Amazon link) as a single purchase. Otherwise, there is no installation fee or monthly subscription fee.

You can set up to 5 numbers (including 911 if you wish) that the device will automatically dial in succession if a button is pushed on the base or on a wireless pendant. If no one answers on call #1, the device goes next to call #2, and so on. Thus, you can opt to call family or neighbors as opposed to every call out summoning the fire department.

The only potential drawbacks that have been pointed out are that the button can be activated fairly easily (as in rolling onto it in sleep), and that the device will leave a message on a message machine and stop calling further numbers. Perhaps setting calls to go to cell phones is better.

Popular Health Supplements

Hmmm, this looks interesting.

This link is to a graphic representation of data around health supplements as a "bubble race". The higher the bubble, the stronger the evidence showing that it works. The bigger the bubble, the more popular it is (in terms of Google searches).

Hormone Replacement Therapy: better to wean slowly or stop cold turkey?

Ever since the publication of the findings of the Womens' Health Initiative earlier in the last decade,
it has generally been appreciated that hormone replacement should be reserved for alleviation of intractable menopausal symptoms and only for as long as necessary to do so.

On the other hand, it has been unclear whether stopping hormone replacement can be sudden or whether it should be done gradually.

A recent medical study suggests that there may not be much difference between the two approaches.

Women who suddenly stopped taking hormone replacement had the same number and severity of hot flashes as women who took their usual doses every other day for a month and then stopped.

Interestingly, almost half the women went back on to hormone replacement because of the severity of hot flashes within a year of going off them.

I think the take-home message is that hormone replacement is reasonable to use to alleviate significant hot flashes and menopausal symptoms. In order to establish whether you still need to be on them, it's okay to just stop them and consider restarting them if the symptoms return and are not tolerable. Remember that the earliest signs of harm from use of hormone replacement took over 5 years to manifest in the Womens' Health Initiative study, and also that there are alternatives to hormone replacement that you may prefer.

An Inspiration in Tough Economic Times

Ralph Bakshi is a cartoonist and cartoon animator (remember Fritz the Cat, Wizards, Lord of the Rings?) who in this YouTube video is responding to a question at a comics convention as to advice for young up-and-comers in a tough industry during this economic downturn.

His answer is like Babe Ruth taking it out of the park.

The answer addresses the opportunities in times of crisis for animators, but really speaks to anyone with some creative talent, a marketable idea and the drive to take the entrepreneurial bull by the horns.

This is recommended viewing for anyone considering making a go of a long cherished idea that has been on the back burner until now.

Kidney Stones

Kidney stones are a relatively common, and potentially quite painful problem.

They occur through the formation of crystals from dissolved chemicals in the urine. These form in the kidneys, and can be passed down through the ureters to the bladder. If they are small enough to get out of the bladder, but big enough to get stuck partway down (4-6 mm across) that's when the problem gets very painful. Painful as in more painful than childbirth (so says every female patient I have ever had who has a basis for comparison).

Kidney stones have a 10-15% chance of occurring in any given person's lifetime, though this varies with a number of factors:

• Stones are 2-3 times more likely to occur in men than in women.
• Whites have more stones than Hispanics, Blacks and Asians.
• Stones are uncommon in people under 20 years old, and the occurrence peaks between 50-70.
• Stones are more common in hot, dry climates. Also, heat exposure and dehydration are risks.

80% of stones are made of calcium (which happily means that they show up on plain old X-Rays), and 80% of these calcium stones are made up of a chemical called calcium oxalate.

So, for the good news- there are things you can do in order to prevent these stones. (h/t to my urology colleague Dr. Kash Desai for many of these):

• Hydration: drink 6-8 glasses of water a day, avoid sodas, salt and caffeine from your diet.
• Avoid high-protein and high-salt diets.
• Avoid excessive cheese and dairy intake.
• Lemonade is good: 8-10 ounces of lemon juice in 64 ounces of "reverse osmosis" water such as Aquafina, Dasani or Alhambra.
• Orange juice, or any other citrus juice is good. (Remember, you should not drink grapefruit juice at all if you take a statin cholesterol medication.)
• Vitamin B-6, 50 mg a day.
• Calcium supplements are OK, but should be calcium citrate with Vitamin D and magnesium (and not calcium carbonate such as Tums, Rolaids or "natural" calcium).
  

Sports Injuries in Girls

3 million girls now participate in high school sports. This is a 940% increase since the Title IX Equal Opportunity in Education Act was passed in 1972; how cool is that?

A recent study reveals some very interesting findings about injuries in our young female athletes.

The bottom line of the study is that girls have a higher risk of certain specific types of injuries than boys, but a lower overall injury rate than boys.

Specifically,

• The most popular high-school girls' sports are basketball, track, volleyball, softball and soccer.
• Overall, girls had half the injury rate of boys.
• In girls, injury rates were highest in soccer.
• The most common injuries were knee and ankle. These comprised 60% of all injuries in young female athletes (which is to say 99 injuries/100,000 athletes).
• This was a 30% higher rate of knee injury than in boys. ACL (anterior cruciate ligament) ruptures were seen to be three times more frequent in girl soccer and basketball players than in their boy counterparts. Girls also had higher rates of surgical repair than boys.

On the other hand,

• Traumatic brain injury involved only 11/100,000 girl athletes: a much lower rate than in boys.
• Basketball had the highest rate of concussion in girls, at a rate topped only by boy's football and boy's soccer. (Girl's track and girl's soccer were next highest.)

Interestingly, cheer-leading had the highest rate of catastrophic injury in girls. I guess I don't find this completely surprising as I do a lot of sports physicals for our local athletes.

Overall,

• There is no "injury epidemic" in girls' sports.
• The increased number of injuries seen corresponds to the greater number of girls competing.
• Other studies show that knee and ankle injury rates in girls improve with specific warm-up exercises and use of protective gear such as knee pads.

(Ed. If you are proud of your athletic potential-sports-scholarship daughter, niece, grand-daughter or neighbor, thank the federal government for Title IX.)

Discussing End of Life Care With Your Doctor

This article in the L.A. Times is pretty interesting, insofar as it's one of those studies where you would think the result would be obvious. Not.

The study, published online Jan. 11 in the journal Cancer, surveyed 4,188 physicians about how they would talk to a hypothetical cancer patient with four to six months to live. A majority of respondents (65%) said they would discuss prognosis, but only a minority said they would discuss do-not-resuscitate status (44%), hospice (26%) or preferred site of death (21%) at that time. Rather, they would wait until symptoms were present or until there were no more treatments to offer.

I must say, I'm pretty surprised about this. I think the time to have this discussion is before a crisis, and not at the time of crisis. Admittedly, these kinds of discussions are incredibly time-consuming but they are also necessary in order for everyone involved to have a chance to think and talk about what is wanted and what is not. Certainly, the time has to be right for the discussion. It's just that the right time is not at the end of the line.

For that matter, a cancer diagnosis is not the only kind of medical problem where this issue is relevant. It applies equally where a medical problem is very likely to be fatal in the near future, and where it is best for patients and their families to discuss their own preferences and choices for the future.

Does losing weight help with my blood pressure?

Yes; yes it does!

This is particularly nice to know at this time of the year when many people gain 7-8 pounds over the holidays. The trick is to lose this rather than gaining 7-8 pounds every year that you never lose.

On average, losing 10 pounds (no matter how much you presently weigh) results on an 8-10% reduction in you blood pressure.

This may not sound like much, but it's about what you would see with starting doses of prescription blood pressure pills.

Take home message: losing 10 pounds is as helpful as starting a blood pressure medication. Which one sounds better?

Holiday Schedule

We will be out of the office spending the holidays with our families during Thanksgiving (11/26 and 11/27), on Christamas (12/24 and 12/25) and on New Year (12/31 and 1/1)!

These happen to fall on Thursdays and Fridays, so we will be enjoying a few well-deserved long weekends during this season.

Please plan accordingly, particularly with respect to any medication refills or prescriptions you may need.

We wish you and your loved ones the best for the season and the new year!