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.

Back in the Saddle

Yes, I'm back from vacation which was absolutely great (except for the jet lag)!

Many thanks to Drs. Boston, Camisa, Ramos and Young and to Marshall's hospitalists who took care of everyone in my absence.

What about the side effects?

Yes, medicines can have effects on you that are not intended but that you may find obnoxious or may even be dangerous. These would be side-effects, and this is different from the actual desired effects of the medicine such as reducing pain, lowering blood pressure and so forth.

This can occur with prescription medicines, and also over-the-counter ones (OTC's) and also with vitamins, herbs and supplements.

In the case of prescription and OTC medicines (not herbs and supplements, though), the effectiveness and also the safety of the medicines is regulated by the federal government's Food and Drug Administration (FDA).

Believe it or don't, the FDA frowns on medicines that have side-effects that are dangerous. However, if a medicine causes a side-effect that is pretty rare (say, one in 10,000 people who take it), a lot of people are going to have to take it before a pattern of harm from the medication becomes apparent. Drug companies have to do incredible amounts of testing and trials before the FDA will even approve the drug for sale, but it's not realistic to expect them to test 100,000 people before FDA approval to uncover rare side-effects that affect 1 in 10,000 people.

This is not to say that once a drug goes on the open market that that's the end of the story. There is actually ongoing surveillance afterwards to be able to detect rare side-effects as people start to be prescribed the medication in offices by their doctors.

Even so, that's why being prescribed a medicine should involve discussion of what the benefits of taking it are balanced against the risks involved. In this less than perfect world, perfect benefit with absolutely zero side-effect is often not possible. However, as long as the probable good to you far outweighs the potential for serious harm taking a medicine is probably an overall good idea.

Sometimes, this is obvious and sometimes it's not.

For example, it's usually clear that taking an antibiotic for pneumonia is worth risking the antibiotic causing a rash or stomach upset versus letting the pneumonia kill you.

On the extreme opposite end of the spectrum, taking medicines for osteoporosis (low bone density) very clearly reduces your risk of falling and breaking a hip which in itself is known to have a 50% risk of being dead or in a nursing home within the following six months. However, with the TV coverage of jaw necrosis, you would scarcely know that the risk of having jaw necrosis happen to you is literally one in one million. Since the risk of dying in a fall is one in 281, taking the medicine is probably a safe bet. Just goes to show that TV finds bad/scary news sells ad time, but good/calming news doesn't: "if it bleeds, it leads" journalism at work.

So, bottom line:

• Medicines can have side effects, but dangerous ones are rare.
• Make sure that you understand and are comfortable with why you are being asked to take a medicine, what's in it for you, and what is the potential for any down side.
  

Away from the office

Just to let you all know, I'll be out of the office on vacation from the 14th through the 27th of this month.

Amy or Abbie will be in during usual office hours, and will be able to take care of any routine matters.

Otherwise, my colleagues in the community and at the hospital will be available should anything arise that cannot wait for my return!

Can I keep from becoming diabetic?

Short answer; yes.

This doesn't seem to get as much media airplay as it should, but then no one stands to profit much by extolling the virtues of moderate diet and exercise habits.

Becoming diabetic should concern you if you are overweight, and especially if diabetes runs in your family, you have high blood pressure or abnormal cholesterol tests. In fact, it's not so much what the scale says as your waist circumference (at the belly button, not at the hips). Over 40 inches in men and over 35 inches in women predicts folks who are likely to develop diabetes.

The good news?

Losing weight can reduce your odds of becoming diabetic by about 80% or more, and it doesn't take as much as you probably think. Losing 5-7% of your weight will do it. If you weigh 200 pounds, that means losing 10-14 pounds, not the usual 30-50 pounds that people often say if I ask them.

This can be done by limiting your calories to 1,800/day, avoiding any food over 30% calories as fat (check the Nutritional Fact labels) and getting a fast walk in for 30 minutes, 5 days a week. Just enough to break a little sweat will do. Sorry, "being on my feet all day" doesn't help. Yes, just eating smaller portions does help. The problem here is that many people eat up to 3,000 calories a day!

Most folks can lose about 4-6 pounds a month this way. 10 pounds off lowers your blood pressure by 8-10%, which is as good as starting doses of medicines for this. 7% weight loss, and you really cut down your odds of ever seeing me every 3 months for diabetes.

You get a taste for it and want to keep losing weight because you feel better and like what you see in the mirror, well the rest is gravy!

So, what about CalPERS Blue Shield EPO?

Well, that's a good question!

Between the newspapers, phone calls, and conversations with patients I think Blue Shield made real efforts to revise their way of running the EPO here to reduce costs. This was at CalPERS's request back around January. They were so far into this that they were mailing contract offers to doctors, and outlining the specific changes: mainly requiring authorization for CAT scans and more expensive tests, and requiring you to see me first before going to a specialist. The first requirement would have been a minor nuisance, the second not a problem. Heck, that's what we're for is to see you if you don't feel well!

However, I don't believe CalPERS had any intention of accepting any offer Blue Shield could reasonably make. I suspect they have a big wave of retirement coming in, and a lot of financial incentive to funnel people into cost-effective (read: cheap) HMO's. They would arouse too much complaint by simply doing away with everything but Kaiser, so they simply keep eliminating every other choice one at a time and jacking up the price on everything else.

Remember two years ago, when you could have brain or spine surgery and cancer treatment at Sutter? How about just before then when you could also choose HealthNet or PacifiCare?

So, now what?

You've got two choices; stay local, or go down the hill.

The two HMO's are Kaiser and Western Health Advantage. Kaiser is Kaiser, 'nuf said. WHA is an HMO based around UC Davis, which is a good place if you have acute leukemia or need a transplant, but otherwise is Big County in my book. I think there may still be one or two docs up here who take WHA, but maybe not.

In any event, WHA means down the hill for any X-Ray, surgery, or specialist. If you go to Marshall ER, a lot of effort will be taken to transfer you down the hill once you are medically stable because Marshall doesn't have a contract with WHA. WHA will therefore pressure them to send you to a hospital where they do have a contract.

HMO'S are cheaper, but you get what you pay for.

BTW, docs get paid by HMO's on what's called capitation. Meaning, the doc gets a dollar figure per patient per month (PMPM) whether any of them are seen or not. Problem is, that's what your insurance company is supposed to deal with; it's called managing risk. In an HMO, then the doc has to manage risk and decide whether you are too ill (expensive) to keep or take as a new patient, and whether to see you (expensive) or treat you by phone. You have to take on a lot of patients to make this risk a safe bet, which is where the stereotypic HMO experience of packed phone lines, impacted schedules, and "I'm Dr. Smith's patient, but I've never seen Dr. Smith" comes from. Do docs learn to game this system? Only if they want to live.

The remaining alternative would be with Blue Cross as a PPO: PERSChoice or PERSCare. Same as with any other cafeteria plan. The PPO means you can go just about anywhere you want (not many docs or hospitals that don't take Blue Cross), but it's more expensive. How much more? If you are a single employee not covering dependents, PERS Choice (less cost, higher deductibles than PERSCare) would cost you $1.80/day more than WHA. Naturally, it's more if you are covering dependents.

So, what to do?

If your employer is local (like City of Placerville, EID) then raise a stink! Being a local employer with local employees and sending them all down the hill every time they become ill, or need to take a sick child to the doctor is crazy and costly in terms of missed work to boot!

If you're retired, do the same! If you live over 30 miles from Sac, how can you be expected to go there for every medical need or problem?

Otherwise, it's all going to boil down to money- yours. You're going to have to look at the cost of a Blue Cross PPO compared to a cheaper down-hill HMO. I know my medical care is better than theirs, I hope you agree and find the additional cost worth the value.

Up and Running

Good Morning!

I plan to use this site to make information about the practice available on line, and to provide information that affects us. This might be changes in insurances, alerts about illness in our community or frequently asked questions.

The Link List is a list of websites I often mention to patients interested in general medical information, or on specific things like identifying their generic pills, or finding out whether their insurance covers them, or whether their supplements or herbs contain the labelled amount in each pill.

I don't intend, for now, to post absolutely every day (like, in my spare time). Still, come on by regularly and check it out!