Swine Flu

DO NOT PANIC, PLEASE!

Swine flu is a flu virus (Type A H1N1) which has been identified in Mexico where it caused 20 deaths, and also in the US, Canada, and possibly New Zealand and Spain where it has caused no deaths.

The reason that the federal government declared a national public health emergency in the face of a new strain of flu is to be able to rapidly move flu medicines from a national stockpile to places it is needed as quickly as possible.

With the exceptions of the deaths in Mexico, Swine Flu is like having the flu: fever, aches, congestion, cough and sometimes vomiting and diarrhea.

It should be treated like the flu:

• stay home
• cover your mouth when you cough or sneeze, discard the tissues in the gargage.
• use Tylenol for fever or aches
• use medicines such as Coracedin, NyQuil or Robitussin DM for cough and congestion
• use Benadryl for nausea or vomiting
• use Imodium/AD for diarrhea

Seeking emergency medical attention is reasonable for unusual symptoms such as:

• chest pain
• difficulty breathing
• unremitting vomiting

To avoid getting the flu,

• Wash your hands frequently with regular soap or waterless hand cleaner.
• Avoid touching your eyes, nose or mouth.
• Avoid visiting ill people, if possible.
• Consider using an N95 respirator mask. These filter out viruses and bacteria from the air you breathe, and can be bought at hardware stores where they are used for sawing and grinding work. These are fiber and semi-disposable, not the big rubber ones with large filter cartridges!

Hearing Aids

Hearing aids, technology and the Baby Boom have finally come together in a "perfect storm" with the happy outcome of really good hearing aids for not much more than the older funkier ones.

The technology around small audio devices, high fidelity, good micro-circuits and batteries has been around for a few years, but the demand has not. Not until recently, that is. With the Baby Boomers finally hitting AARP and MediCare age, there are millions of potential customers for hearing aids that "ain't your fathers hearing aids".

Especially for folks with the most common kind of high-tone hearing loss (more loss at pitches around human speech than at lower pitches), the newer "open-ear" devices are a perfect fit. They are nearly invisible, work well, and don't squeal with feedback even when you use a phone, wear ear protectors, or use a helmet or a hat.

These often cost around $4,000 a pair which is not much above the older clunkier ones. MediCare may cover up to about $500 of this. Make sure the vendor has a reputation for seeing you after the sale for any further fittings and fine adjustments.

I am very impressed that I have had several patients in the past few months absolutely ecstatic over their new hearing aids and the quality of service from their vendors. In fifteen years, I have never heard anyone go on about how happy they were with their hearing aids!

The patients in question had obtained them at All American Hearing in Cameron Park, and the Costco in Folsom. As a disclaimer, I have absolutely no financial ties to either organization and receive no compensation or "kick-backs" from them. (I am, however, a Costco member and am impressed by the quality of the meat and produce selections.)

I have heard every objection to getting hearing aids that there is. Think about it in the same way you would think about LASIK vision correction or a remodel on your home. If the money involved would be worth it in terms of quality (hearing really, really well in this case), then the time to spend that money is when you will be able to enjoy it for a long time. This may also mean while you are still relatively young and still working, since you are still bringing in a paycheck. This is easier than after you retire and are living on a fixed income, and certainly better than waiting until you are so old that you may not get to enjoy them for long.

Hearing what's going on around you, not feeling irritated by having to ask people to repeat themselves and being able to fully enjoy a conversation, a party, music or a dance are not at all over-rated!

EMR- Electronic Medical Records

20%
Percentage of doctor
offices using EMR


70%
Percentage of doctor offices dropping EMR
within 2 years of buying one


$65 Billion
Amount of money
being budgeted
towards national
implementation of EMR

I guess I'm not too hot on the concept of electronic medical records.

As a preamble, let me say that I own several computers, have installed my own wireless networks, enjoy using computers, have tried voice recognition software, and have beta-tested several EMR systems.

Bottom line, they do not save me time or make me more money. In fact, they can cost up to $40,000 to implement and take me longer to document what I do. They do not pay for themselves, and they do not help me to render better medical care than simply keeping and paying attention to a well-organized paper record. Plus, the paper record can still be used even if the power goes out, or the scheduling computer doesn't work.

I also note, that the EMR produced notes from many of my specialist colleagues that are often up to 4-5 pages of not much more useful information than I can get out of one page of well-organized well-written manuscripted notes.

As EMR systems become for comprehensive, they can actually start to make the job harder: for example, not permitting me to list a strong family history of breast cancer on the master Problem List. Like many other features of medical care, a system created by non-doctors and non-nurses may not be particularly effective or easy to use by doctors and nurses.

Also, there is no agreed upon code standards, so none of these expensive systems is capable of interfacing with other systems.

Believe me, I would enthusiastically embrace a system that allowed me to do my work faster, better and more efficiently that was affordable and as universally used as Microsoft Windows. I doesn't yet exist.

Sleeping Pills

A word about sleeping and sleeping pills.

Ambien was a hot new drug for sleep back in the early 1990's, and went generic as zolipedem in the last year or so. If you watch TV or read magazines you would have noticed because you have been blitzed with ads for the competion: Ambien CR, Lunesta, Sonata and Rozerem all sound like the greatest thing since sliced bread. At least, they do on TV.

Granted, older sedatives often taken for sleep (such as Valium, Ativan, Restoril, Serax, etc.) create problems because they render you unconscious, not asleep. This is crucially different, since you are losing up to half of the really deep, restorative sleep and dream sleep when you take these. When this happens for over three nights in a row, daytime problems will follow; such as forgetfulness, irritability, tiredness, depression, moodiness or difficulty concentrating.

When Ambien first came out, it seemed to be the best of both worlds: helping people to sleep, but without the loss of deep sleep and dream sleep.

Unfortunately, it may be that Ambien and the other newer sleeping pills may not help you sleep any better, they may just keep you from remembering your sleep. This may be why some people who take it have been seen to cook, eat or even drive at night without remembering doing so.

Basically, people get needed sleep. Insomnia is often a symptom of another problem such as stress, depression, sleep apnea, pain,urinary problems, drinking or long-established bad sleep habits. The treatment then is to treat the underlying problem, not to be drugged into unconsciousness every night.

To make it easier to sleep well,

• Go to bed and get up at the same time every day, including weekends, vacations and holidays.
• Don't eat or have alcohol or exercise within two hours of bedtime.
• Don't watch TV in your bedroom.
• If you can't sleep, go to another room and read or listen to some music. Do not watch TV or use your computer! The light from the screens stimulates your brain and wakes you up.
• Try taking 2-3 mg of over-the-counter melatonin about 1-2 hours before your bedtime.
• Tylenol PM is OK to use for sleep, unless you find that it causes side-effects or makes you feel groggy in the morning.
  

MRSA- A Lesson in Evolutionary Biology

Methicillin-resistant Staphylococcus aureus (MRSA) simply refers to the development of antibiotic resistance by a common skin bacteria over the last several decades.

"If it bleeds, it leads" news coverage to the contrary, MRSA is not new, not invariably fatal and not incurable or untreatable.

Staph (as Staphylococcus aureus) is commonly known, is one of the common bacteria found in the environment and on any normal, healthy person's skin. Because it is always on your skin, it is one of the most common bacteria to cause skin infection when you get a scrape, cut or some other break in the skin's surface.

Antibiotics used to treat skin infections can lead to the development of antibiotic resistance in surviving strains Staph. Slowly and steadily over the past few decades, strains that resist common antibiotics have become more and more common. This is an expected evolutionary result of antibiotic use.

At this point, MRSA has become a common cause of skin infections. Fortunately, many antibiotics that are inexpensive, safe and generically available work against MRSA (such as Bactrim and Cleocin). This does mean that if doctors suspect MRSA, they may want to use these instead of the usual ones like Keflex or Amoxicillin.

Otherwise, it is not unusual for normal healthy people to spontaneously carry MRSA, and to also spontaneously stop carrying it. Eradication of MRSA from your home and body is technically possible, but really not practical (industrial-strength showers three times a day for a month, anyone?).

Statins: "I heard cholesterol pills are bad for you!"

"Statins" are the most commonly prescribed cholesterol lowering medications, and have been around since the 1980's. The first four are now available generically, and were originally developed based on naturally occurring plant-based compounds. Lipitor was ground-breaking in the mid-1990's because it was more potent ("stronger") and mainly because it was completely synthetic in origin. Crestor followed in the same manner.

They are called "statins" because the chemical names all end in -statin: lovastatin, atorvostatin, pravastatin, etc., etc.

Concerns about rare but severe side-effects in news and magazines fail to make clear the extent of any risks and benefits in taking statins.

Downsides:

• Flatulence (passing gas) is actually the most common side-effect. Not harmful, not associated with diarrhea; just more passing gas. I have, so far, never had anyone stop taking a statin because of this.
• Liver injury. Turns out, increased liver function blood tests turn out to be from the effect that lowering your cholesterol has on allowing solidified fats in your liver to dissolve and return to normal. (so called "fatty liver") This is not a toxic effect on your liver. Unfortunately, warnings that go on drug labels rarely ever go off them.
• Muscle injury. Actual toxic injury to muscle is rare with statins. Rare as in 10-25 times per 10,000,000 (10 million) prescriptions written. That's 1-2.5 in a million. Your chances of being struck dead by lightning are about 1 in 5,000. Please, let's put that in perspective.
• Muscle aching. Here, were talking achiness that is not harmful, and goes away within a few days of stopping the medication. This occurs in about 4% of folks. Mind you, this comes from studies showing 21% of people taking a statin complain of achiness, but 17% of people taking a sugar pill (placebo) do, too. The human mind is a funny thing...

Upsides:

• Reduced risk of heart attack or cardiac arrest by about 31-34%.
• Similarly reduced risk of stroke.
• Reduced risk of Alzheimer's dementia.
• Reduced risk of colon cancer.
• Reduced risk of osteoporosis.

Short story:

• Statins can make you pass gas more often, but can't hurt your liver. Muscle aching is uncommon and actual muscle injury is extremely rare.
• They do reduce you risk of heart attack, stroke, Alzheimer's, colon cancer and osteoporosis.
  

Wal-Mart Pharmacy Changes

As you may know from prior postings on this subject or as a matter of common knowledge, last January Wal-Mart started offering deep discounts on hundreds of commonly used generic prescription medicines at $4/month or $8/3 months.

As of this January, the following changes have been made:

1. 3-month (90-day) prescriptions are $10.
2. New prescriptions have been added at $9/month or $24/90 days:

• Ventolin HFA, the asthma inhaler
• bupropion ER, the equivalent of Zyban for stopping smoking
• alendronate/Fosamax, the osteoporosis weekly pill
• tamoxifen, the breast cancer chemotherapy pill
• several birth control pills

Otherwise, the other medicines are still $4/month.

As previously mentioned, I'm not a big Wally World fan. However, I have to say these prices on hundreds of the most widely used medicines are probably saving lives in a time when lots of folks have to make food/medicines/housing/heating decisions all the time.

The increase from $8 to $10 for 90 days worth is still an unbelievably good deal; particularly with the addition of the aforementioned medicines!

I imagine the reason they continue to offer these discounts is that folks spend an average of $35 whenever they walk in. If you don't want to buy anything else, then don't. But that's a pretty unbeatable deal on medicines if you need them.

Economic Triage

I am borrowing this picture from a newspaper article that talked about something I haven't really seen in print as much as I would expect, which is patients having to not see a doctor because of cost or insurance problems.

Patients canceling, re-scheduling or failing to appear for appointments should not surprise anyone in a full year of the worst economic downturn since the Great Depression with no end in sight.

This article touches on some of the decision-making folks have to face, and also some approaches and resources to stay as healthy as possible.

Certainly, if cost is a problem with medications we are prescribing or tests that we order, do not hesitate to ask. (Believe me, you may find it slightly embarrassing, but you're far from alone.).

If you need to re-schedule a physical or visit due to financial problems, just give us a call in advance. If you are unsure whether this is prudent, it's okay to ask.

We want to see you as often as is in keeping with good preventive health care and treatment of emergencies or with chronic medical conditions. However, the world is presently far from perfect, so let us know if you are having difficulties.

Diabetes control: what if my sugars are too high?

So, having posted a few days ago on good blood sugar goals, an obvious good question is what about if they are higher than goal?

Pills are used to improve blood sugar control and to prevent eventual and inevitable failure of insulin production by your pancreas.

However, diet and exercise are 2-8 times more effective than pills in maintaining normal blood sugars and body weight. A major reason to use pills is that diet and exercise cannot keep your pancreas from eventually needing insulin, and pills can prevent this.

Insulins are used where your body has simply become unable to make insulin for itself.

If sugars first thing in the morning or before meals are over 125, it usually means the meal before this was high in carbohydrates and or that you were not very physically active (such as sleeping or sitting at a desk all day). If you take fast insulins (such as Humalog) before meals, it may mean that the amount you took was too small.

You can get lower sugars in these settings by eating less, being more active or exercising, or by increasing the dose of pills that help to maintain greater insulin responsiveness (such as metformin). If you use insulins and you fasting morning sugars are under 125, but later pre-meal sugars are higher, then increase your fast insulin dose by 1-2 units for the meal before this. For example if your pre-dinner sugar is 155 and you took 5 units of fast insulin before lunch, next time try 6-7 units before the same kind of lunch.

If you are seeing higher than goal sugars after your meals, then try reducing the size of your meals. You may need to increase the dose on pills that help your pancreas to put out more insulin (such as glimiperide, Glyburide, or Precose) or increase your before meal doses of fast insulins.

If you are using long-acting insulins (such as Lantus), then your fasting morning blood sugars are telling you how well your dose is working out for you. The sugar goals for this time are the same as everyone else's: 80-125 is good to go.

If they run over this for over 3 days in a row, then increase the Lantus dose by 2-3 units every 2-3 days until it falls back into this zone and then stay at that dose.

If they are under 80 for 3 days in a row, then go the other direction. Decrease the Lantus dose by 2-3 units every 2-3 days until your morning sugars come back up into the zone, and then stay at that dose.

Rules of thumb:

• Fasting AM sugars reflect overall steady basal insulin activity which maintains normal baseline sugars.
• Pre-meal sugars show how your body is doing with your last meal and activity level since then.
• After-meal sugars are telling you about how much and what you just ate and how well medicines that help with this are working for you.
• Feel free to call or see me if you are concerned about your blood sugar control, medicines, or what to do next!
  

Diabetic Labs: what are those every 3 month tests for?

Every 3 months, you should have a test done called a glycohemoglobin A1c, or glyco for short.

This is a test that tells us what your average (mean, actually, if you are savvy about statistics) blood sugar has been over the prior 2-3 months.

What it actually is is a measurement of glucose (blood sugar) molecules that have become stuck to hemoglobin molecules in your bloodstream. Hemoglobin is the large molecule in your red blood cells that helps to pick up and deliver oxygen to your organs.

Naturally, the normal number is not zero since you'd have to have no blood sugar or no hemoglobin!

People without diabetes have a glyco between 4.0 and 6.0, where 5.0 is an average blood sugar of 100.

If you have diabetes, this test result would be higher because your blood sugar is higher than it should be.

The glycohemoglobin test is useful because it tells us how well controlled your blood sugars have been over a 2-3 month period around the clock and not just at times you check it or the morning you go to the lab. Here is a table that shows how high your average sugar is depending on your glyco test result. A rule of thumb is add 40 points for every 1.0 above a test result of 5.0.

The American Diabetes Association recommends a glyco of under 7.0, however endocrinologists (specialists in gland disorders, including diabetes) recommend under 6.5.

I recommend this lower goal of under 6.5, too.

Under 7.0 does reduce your chances of diabetes causing damage to small blood vessels and causing blindness, nerve pain, kidney failure, erectile dysfunction (male impotence) and circulation problems to your feet.

However, getting the glyco under 6.5 accomplishes this and also prevents damage to larger blood vessels and thereby reduces your chances of having a cardiac arrest, heart attack or stroke. I think it's worthwhile going for the brass ring here, as long as efforts to do so are not causing problems with hypoglycemia or medication side-effects.

As to that computer print-out you get at the lab, do not worry about it!

• It is not a bill, and signing it does not mean MediCare or your insurance will bill you. (If you don't believe this, read the fine print carefully and think like a contract lawyer while you're doing it.)
  
• MediCare covers glyco tests every 90 days for stable well-controlled diabetes. When they say 90 days, they mean it so do know when was the last one so you can avoid this problem. Feel free to ask, too.
• If your diabetes is not well-controlled as your doctor defines it, then MediCare will pay for glyco tests more frequently than every 90 days.
• We are very careful to make sure that your lab forms reflect this, so that if we instruct you to get tests done more frequently, this will not result in a billing problem for you.
• Bear in mind that the lab simply generates a form any time they are asked to do any test for any reason where MediCare may have a time limit! THIS IS NOT THE SAME THING AS BEING TOLD YOU WILL BE BILLED. THIS IS COMPUTER-GENERATED PAPERWORK!

End of rant ; . )

Diabetic Blood Sugar Goals: where should my blood sugars be?

If you have diabetes, checking your blood sugar is a great way of being able to instantly tell how your body is responding to your diet, exercise habits and medications (whether pills, insulins, or both).

The latest generation of glucometers (finger-stick blood sugar monitors) are easier to use than older ones as they need such a small amount of blood you can test easy and less painful sites such as the forearm or sides of the fingers.

As for how low your sugars should be, the answer is basically as close to normal as possible without going so low that hypoglycemia (low blood sugar) occurs.

Fasting (first thing in the morning and pre-meal sugars should be low enough to reflect good overall blood sugars. After eating, sugars will of course be higher since your body is breaking down your food and absorbing vital nutrients into your blood for use and storage. This includes glucose, or blood sugar.

Good goals to meet are:

Fasting or pre-meal: 70-130
1 hour after eating: under 280
2 hours after eating: under 180
3 hours after eating: under 150

Notice that these goals may vary somewhat depending on the recommendations of various medical organizations (such as here, and here).

Where these recommendations all agree is that the goal is to keep your sugars as close to normal as is possible and safe, so that your are reducing as much as possible the risks of diabetes harming your body.

More coming up on what to do if your sugars are too high, and what are those every 3 month lab tests for?

Generic medicines: just as good as the brand name

When a drug company researchs, develops and then markets a new drug, the law provides a period of time in which it is illegal for anyone else to copy it and then sell it. This is intended to give drug companies an incentive to research and sell new drugs.

After a period of several years, it becomes legal for other manufactures to copy it and sell it under other brand names or generic labels.

The FDA requires that generic versions are within 5% margin of error of the brand name drug in terms of how it is released into your bloodstream over time. In other words, generics have to be the same chemical as the brand name drug with very similar action in your body.

On the other hand, it is possible for one generic to be 5% "above the curve" and for another to be 5% "below the curve" which means that the two generics might be 10% different in how they get in and out of your system.

For the most part, this difference does not seem to result in clinical differences or outcomes in a variety of medicines including blood pressure, cholesterol and hormonal medicines.

Mind you, it is possible that reactions to inert ingredients that are in one generic but not another may account for side-effects such as rashes or stomach upset.

Serevent and Foradil

Recent news coverage raises concerns on the part of the FDA (Food and Drug Administration) of these two long-acting medicines.

Both are taken twice a day, and both are bronchodilators which work by relaxing your breathing tubes and allowing them to open up.

If you are supposed to use these daily for emphysema, that's perfectly safe to do.

The safety issue on these medicines is around asthma. Asthma involves unusual sensitivity of your lungs to allergens or irritants and needs to be treated with inhaled steroids (such as Advair, Flovent, Beclovent, AzmaCort, etc.) which prevent sensitivity reactions from occurring.

The problem, then, is that if you just use the bronchodilators without the steroids (treatment without prevention), inflammation in your lungs can progressively worsen and cause potentially fatal asthma flare-ups. Using bronchodilators alone is a bit like hiding the smoke without putting out the fire.

We'll be away over the holidays!

The office will be closed on Wednesday the 24th and open as usual on Monday the 29th for the Christmas holidays. Phone calls to the office will connect you to the doctor on call.

Also, we will be out on Thursday and Friday January 1st and 2nd of the New Year to celebrate the New Year holidays. Again, phone calls will put you in touch with the doc on call. We'll be back as usual on Monday the 5th.

Plan if you have specific needs such as prescriptions or other concerns.

Have a wonderful, happy and healthy holiday season!

Keeping away the colds and flus

Colds are certainly going around, and influenza (the flu) has been cropping up in a few states such as Florida and Washington. The flu that has been seen so far is not unusual, and if you have received a flu shot this should help.

The most important and effective ways to not get colds and flus are avoidance and hygiene.

• Wash your hands frequently with soap and warm water, or waterless hand cleanser. Anti-bacterial soaps are more expensive, but are not better. It's the scrubbing action that rids your hands of bacteria and viruses. A thorough hand washing should take as long as it takes to sing the Happy Birthday To You song twice (to yourself in your head, if you prefer : .).
• Avoid rubbing your eyes, and touching your nose and mouth. This is how bacteria and viruses enter your body!
• Avoid being around people who are obviously ill. This is tricky with Christmas coming up, but if you or your children are ill it's polite to inform family and other guests in advance.
• Masks are useful in preventing the spread of colds and flus.
• Surgical masks like those worn in operating rooms are disposable and made of thin paper-like material. These are worn by the sick person to prevent coughs and sneezes from throwing cold and flu viruses into the air, where they can float for up to several hours afterwards. They do not keep you from inhaling bacteria and viruses into your mouth and lungs!
  
• N95 respirator masks are reusable and are worn by well persons to filter out bacteria and viruses when you breath. This link shows several places you can buy them. They can often be found in hardware stores (for workers around fine dusts), and in medical supply stores (for allergy sufferers).
• N95 masks are so called because they are certified by NIOSH (National Institute of Occupational Safety and Health) as filtering out 95% of workplace dusts and particles. Because of the material used, they actually filter out 99% of bacteria and viruses including TB, pneumonia, colds and avian flu ("bird flu").
• Get the kind that have a valve for breathing out because they are much more comfortable to wear.

Hopefully, these steps will help you to stay well during the cold and flu season!

Things that should concern you that you may have something more serious could include chest pain, shortness of breath or wheezing. Please feel free to call us to be seen as soon as possible to make sure that you don't have a more serious condition such as asthma or pneumonia.

Nosebleeds

'Tis the season for nosebleeds; the air is drier, indoor heating is in use and colds and flus abound.

Most nosebleeds occur because each nostril has a network of small, delicate blood vessels right at the opening of the nostril (Keiselbach's plexus, for those who like to know these things).

Problem is, this plexus in in reach of your hand meaning that sneezing, rubbing or wiping your nose (or picking your nose) can physically damage them and result in bleeding.

Most remedies for nosebleeds seem like remedies for hiccups- mainly designed for the amusement of bystanders.

Direct pressure stops bleeding in the nose just like it stops bleeding from other places such as a cut on your hand.

So, treat nosebleeds as follows:

1. Press firmly but gently along the side of your nose with your finger.
2. Do not tilt your head back (tasting your own blood is off-putting), do not pack your nose with Kleenex (you remove blood clots are renew the bleeding when you take it out).
3. DO THIS FOR 15 MINUTES WITHOUT LETTING UP THE PRESSSURE!
4. It takes 15 minutes to not only form a blood clot, but for it to be hard enough so that when you let up on the pressure it doesn't just fall apart.
5. This cannot be over-emphasized; 15 minutes is a long time in our hurry, hurry, hurry society. If you need to watch TV and wait through two entire sets of commercial breaks, do it.
6. If necessary, repeat again.
7. If this doesn't work, spray 3-4 puffs of an over-the-counter nasal decongestant spray (Afrin, Neo-Synephrine, 4-Way, etc.) into the bleeding nostril to shrink down the blood vessels and try 15 minutes of direct pressure again.
8. If this still hasn't work, you should call to be seen or go to the emergency department.

Nosebleeds are generally not a sign of high blood pressure. It takes an exceedingly high pressure to cause this to occur, such as 170-240 on your blood pressure cuff. Mind, if your blood pressure is that high you should be seen urgently about this.

Medicare Part D

You still have time to add prescription drug coverage to your Medicare!

Open enrollment ends at the end of this month.

Until then, you can go on-line or call 1-800-MEDICARE to get help adding this to your Medicare Part A and B (these cover hospital and outpatient medical care).

Basically, these are commercial insurance plans that meet or exceed standards set by the federal government. They are used for covering the costs of you medications.

There are lots of choices, and lots of differences in cost. The last time I looked, there were over 50 plans in California and the average premium was about $45/month.

DO. NOT. PANIC.

First of all, if you have very little money (make less than $14,355/year yourself, or less than $19,245/year as a couple at last count) you may be entitled to Plan D at no cost to you at all as long as you pick a plan that does not exceed the average premium cost for California.

Second, use the available resources to narrow your search:

• You live in California. Only look for plans offered in California.
• Most generic drugs are not a real issue. The ones that aren't generic are the ones that will cost you (such as Actos and Avandia for diabetes, brand name insulins like Lantus and Humalog and ARB's for blood pressure and heart failure like Diovan, Cozaar and Atacand). Generate a list of your expensive drugs, and then look for plans that cover them.
• If you already have Part D and always end up having to pay full cost on you pills before the end of the calendar year, this does not mean that your insurance no longer covers it! This means you've hit the "donut hole" for the year.
• This means Part D has covered $2,250 for the year and that you are on the hook for the next $2,850. If you go past that for the year, then Part D picks up for the rest of the year.
• If this keeps happening to you, pay a bit more for a plan with "donut hole" coverage!

This link shows all the plans available for 2009 in El Dorado county in nice neat columns showing what they are called, how much they cost, whether they are free to low income folks and whether they have gap (donut hole) coverage or not.

It also provides links to the plans so you can see all the details, and toll-free numbers for folks who prefer telephoning.

Use it or lose it!

Diabetes control: low blood sugars

Having addressed blood sugar goals, and treatment of high sugars, what about lows?

Developing low blood sugar (hypoglycemia) can be frightening, since most people find that they suddenly feel very shakey, weak "like someone just pulled the plug on me". If your blood sugar reading is under 70 (which means a lab would find that it is under 55- 60) or has dropped quickly over a short period of time to low-normal levels, then you may find your self feeling this way all of a sudden. If you do, DO. NOT. PANIC.

If it is convenient and safe to do so, go ahead and check your blood sugar. Certainly, if your were in a hospital or ER and said this was how you felt, we'd stick your finger immediately and find out if that was the trouble.

If it is indeed low, then have something to eat or drink. Orange juice is fine, but really anything with a few carbs is okay. A piece of bread, a few crackers a piece of candy, a piece of fruit will do just fine. You should feel back to normal in a few minutes. If you don't, then re-check your blood sugar.

It is generally not necessary to eat large amounts of food or drink over the few minutes until the hypoglycemic symptoms resolve. This can result in weight gain and very high blood sugars for hours afterwards.

The goal is to get low sugars back up into a normal range of less than 125 quickly and safely without feeling compelled to over-do it.

Certainly, frequent episodes of low sugars are something we should discuss to determine whether any of your medications doses are too high.

Low sugars that don't respond to eating, keep dropping back or are causing fainting or near-fainting are a serious emergency for which you should call 911 or be taken to an emergency department.

Presidential Candidate Health Care Reform Proposals

The New England Journal of Medicine in its October 16th issue provides a review of Senator McCain and Senator Obama's proposals for improving health care in our country.

This journal is one of the most widely read, well-researched and respected professional medical journals in the world and these reviews are presented for an audience of physicians and other medical professionals.

They are well worth reading as they are understandable to a broader audience which would include anyone with an interest in the opinion of one of the most prestigious medical journals in the country.

To summarize,

Early in his campaign, Obama recognized that the success of health care reform rests on the plan's ability to slow spending growth and make health care affordable for everyone. His plan would reorganize the health-insurance market — but not change the basic financial incentives in the system that drive up spending. Although the plan would significantly increase the number of Americans with health insurance, it remains to be seen whether that would come at a price Americans would be willing to pay.

The choice facing health care professionals, like all Americans, is basic: Who deserves to be trusted with the stewardship of America's health care system? The McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care. Senator McCain's plan does not demonstrate the kind of judgment needed in a potential commander in chief of our health care system.

Alli- over the counter weight loss medication

Alli (R) is the over-the-counter equivalent of prescription Xenical (R), and is approved as safe and effective in weight reduction by the Food and Drug Administration.

It is safe to take with other medicines except for Coumadin (R) or warfarin the prescription blood-thinner, and organ transplant medicines.

When taken with meals, it keeps about 20% of the fat in the meal from being absorbed into your bloodstream and then being deposited into fat cells. This 20% then is excreted in your bowel movements, which may make them oily looking.

Yes, that's right. No meal is absolutely zero fat. A fifth of the fat in your meals isn't going to your belly or thighs, but is excreted out of your body. That's the point!

Alli is capable of working as well as any other medication, assuming that you change how you eat in order to minimize this side-effect rather than not taking the pills when you plan to eat pizza or ice cream.

The oily bowel movements are not intended to be punishment; it's probably better than all the fat in meals being fully absorbed and deposited in your fat cells. However it can lead to improved eating habits, too.

This mechanism of action of this medicine is particularly of interest to folks at risk for diabetes, since the growth of abdominal fat cells is what ultimately causes diabetes in the first place!

Disclaimer: I have no financial or other interest in Alli, Xenical or its manufacturers. I am only interested in helping my patients to lose weight safely and effectively.