what doctors know - september 2013

7/27/2019 What Doctors Know - September 2013

1/48

Prescription

Drug Abuse

on the RiseDoes your Pancreas Overreact?

Strengthening Oversight

of Food Imports

Volume 2, Issue 8 www.whatdoctorsknow.com


2/48


3/48

WHATDOCTORSKNOW.COM 1

ON CALLwithDr. Porter

IntheUnitedStates,wearekillingmorepeoplewithprescription

padsthanguns.In2010,therewere16,451accidentalprescription

drugoverdoses.Inthatsameyear,therewere16,259homicides.

Accidentalmeanstheoverdosescouldhavebeenprevented.Americas

answertobetterhealthistoxitwithapillwithoutanythoughtsto

therepercussionsanddangersomixingprescriptionswithother

prescriptionsoroverthecountermedications,takingmedications

prescribedtosomeoneelseorsimplynotollowingthedosageinstructions.

Reachingorapillisnotalwaystheanswertobetterhealth.Ahealthyliestyleistheanswerto

betterhealth.Inmymedicalpractice,Iaskeverypatient.Whatmedicationsareyouonandwhy?

Itisdisturbingtohearthenumberomedicationsandtherationale.Frankly,Indartoomany

omypatientstakingdrugswiththepotentialorsomeseriousinteractions.Indpatientsliketoreachorapillasterthanahealthysolution.Manymedicationscanbeeliminatedroma

patientsmedicinecabinetbytakingbettercareotheirhealththroughsuchstepsasbettereating,

exercisingandquestioningmedications.Forexample,diabetesandobesitygohandinhand.Both

aredangerouslyoutocontrolinthiscountryandbothcanbecontrolledbyahealthyliestyle.

ThereareanumberomedicalissuessuchasType2diabetes,Hypertension,AcidReux,Sleep

ApneaandFattyLiverinltrationtonameaewthatcanbecorrected,eliminatedorbetter

controlledbyahealthyliestyleinsteadoanotherpill.

Iencourageeveryonetoreadmystoryontheloadedgunwecallprescriptiondrugs.Geteducated

onthedangersoprescriptiondrugsandunderstandwhythebenetocontrollingliethrough

dietaresaerandhealthierthangrabbingorapill.

StevePorter,MD

PublisherandChairman


4/48

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5/48


INEVERYISSUE

1 OnCallwithDr.Porter

11 ABCsoVitamins&Supplements:VitaminD

22 KnowYourSpecialist:Obstetrics&Gynecology

HEALTHHUBFROMCLEVELANDCLINIC

17 4FAQsAboutDiabetesInsulin, kidney disease concerns common

18 6MythsAboutPainkillersSeparate act rom ction about pain and addiction

20 MemoryLossinWomen:IsItAgeorMenopause?Decreasing levels o estrogen aect brain unction

INTHENEWS:SEPT2013

5 BrainDierencesSeeninDepressedPreschoolers

5 Three-Year-OldGraysonHearsHisFathersVoiceortheFirst

6 USCresearchIDspotentialtreatmentordeadly,HIV-relatedbloodcancer

6 NewBloodTestFindsAllergiesBeoreImplant

7 NursePractitionersCanHelpBoostQualityoCareorOlderPatientswithChronicConditions

8 CasesoWhoopingCoughReachesHighestLevelin50Years

8 BandAideSizeDiscoveryAccuratelyMonitorsPatientsBreathingDuringandAterSurgery

9 ThinkBeoreYoudrink:ErosionoToothEnamelFromSodaPopisPermanent

10 PeoplewithPre-DiabetesWhoDropSubstantialWeightMayWardOType2Diabetes

FEATUREDARTICLES

16 AmIAtRiskForOvarianCancer?The Gynecologic Cancer Foundation (GCF) has designated

September as Gynecologic Cancer Awareness Month.

The goal is to draw attention to the importance o early

detection and prevention.

27 EarlyDetection&PreventionAreKeysToGynecologicalHealth

The Gynecologic Cancer Foundation (GCF) has designated

September as Gynecologic Cancer Awareness Month. The goa

is to draw attention to the importance o early detection and

prevention.

24 DoesYourPancreasOverreact?Reactive hypoglycemia is a condition with recurring

episodes o hypoglycemia in a person who is not diabetic.

12 PrescriptionDrugAbuseOnTheRiseIt is estimated that our million Americans over the age o 12

use prescription pain relievers, sedatives, and stimulants or

nonmedical reasons every month.

36 WatchForVisionChangesAsYouAgeRecognizingCataracts

As lie goes on, we all start to notice certain changes that

are a natural part o aging. Maybe our joints arent as

exible as beore, or our hearing just isnt what it used to

be. Our vision, too, may be less sharp than it once was.

38 LateOnset,SlowerProgressionAlzheimersThe greatest risk actor or Alzheimers disease (AD) is

advancing age. By age 85, the likelihood o developing the

dreaded neurological disorder is roughly 50 percent.

28 PrescriptionDrugs...SocietysLoadedGun...ThatShotMedicalEducation

Doctors dont listen. Patients dont understand.

The Reality? Both statements are true and reversible.

Maybe thats the reason more than 100,000 people dieevery year in the United States rom prescription drug

errors, while only about 600 die rom accidental gun

shootings, and nearly 34,000 die rom trafc accidents.

Contents


6/48

Learn how you can help stop diabetes by losing weight, eating healthy and staying active.

Visit checkupamerica.org or call 1-800-DIABETES.

You have to work at losing weight. Every day. But with every step, you

lower your risk for type 2 diabetes and heart disease. Because many

of the nearly one million deaths each year from type 2 diabetes, heart

disease and stroke could be prevented with a few lifestyle changes,

including weight loss, regular physical activity and healthier food choices.Its not easy. But it is worth it.

Gaining weight was easy. Losing it's a lot harder...

but very much worth the effort.

i i


7/48

Three-Year-Old

Grayson

HEARSHis Fathers Voicefor the FirstCHAPEL HILL, N.C.

GraysonClamp,a3-year-oldromCharlotte,

NorthCarolinareceivedtherst-everauditory

brainstemimplantinachildintheU.S.duringa

surgerydonethisspringatUNCHospitals.

Ive never seen a look like that today, saidGraysons

ather,LenClamp,othedaytheimplantwasturned

onorthersttime. I mean, he looked deep into my

eyes. He was hearing my voice or the rst time. Itwas phenomenal.

Thesurgery,perormedbyCraigBuchman,MD,

ProessorOtolaryngology/HeadandNeckSurgery,

andMatthewEwend,MD,Chair,Departmento

Neurosurgery,istherstoitskindperormedinthe

UnitedStatesaspartoanFDAclinicaltrial.

Seeing him respond, that had a lot o eelings

or me,saidDr.Buchman.I elt like there was a

potential that we were eectively changing the world

in some ways.

ThedeviceGraysonreceivedwasoriginallyusedor

patientswithdeanessduetoauditorynervetumors,

whichimpacthearing.Thedeviceisnowbeing

consideredtohelprestorehearinginchildren.

Brain DifferencesSeen in DepressedPreschoolersST. LOUIS

Akeybrainstructurethatregulates

emotionsworksdierentlyin

preschoolerswithdepressioncompared

withtheirhealthypeers,accordingtonew

researchatWashingtonUniversitySchoolo

MedicineinSt.Louis.

Thedierences,measuredusingunctionalmagneticresonanceimaging(MRI),provide

theearliestevidenceyetochangesinbrainunctioninyoungchildrenwithdepression.

Theresearcherssaythendingscouldleadtowaystoidentiyandtreatdepressed

childrenearlierinthecourseotheillness,potentiallypreventingproblemslaterinlie.

The ndings really hammer home that these kids are suering rom a very real

disorder that requires treatment,saidleadauthorMichaelS.Garey,PhD. We believe

this study demonstrates that there are dierences in the brains o these very young

children and that they may mark the beginnings o a lielong problem.

Depressedpreschoolershadelevatedactivityinthebrainsamygdala,analmond-shapedsetoneuronsimportantinprocessingemotions.Earlierimagingstudiesidentied

similarchangesintheamygdalaregioninadults,adolescentsandolderchildrenwith

depression,butnonehadlookedatpreschoolerswithdepression.

The amygdala region showed elevated activity when the depressed children viewed

pictures o peoples aces,saidGarey,anassistantproessoropsychiatry. We saw

the same elevated activity, regardless o the type o aces the children were shown. So

it wasnt that they reacted only to sad aces or to happy aces, but every ace they saw

aroused activity in the amygdala.

Gareysaiditspossibledepressionaectstheamygdalamainlybyexaggeratingwhat,

inotherchildren,isanormalamygdalaresponsetobothpositiveandnegativeacial

expressionsoemotion.Butmoreresearchwillbeneededtoprovethat.Hedoesbelieve,

however,thattheamygdalasreactiontopeoplesacescanbeseeninalargercontext.

SEPT 2013

IN THE

NEWS



8/48

USC research IDspotential treatment

for deadly,HIV-relatedblood cancerLOS ANGELES

ResearchersattheUSCNorrisComprehensive

CancerCenterhavediscoveredapromising

newwaytotreatarareandaggressivebloodcancer

mostcommonlyoundinpeopleinectedwithHIV.

TheUSCteamshowsthataclassodrugscalledBET

bromodomaininhibitorseectivelytargetsprimary

eusionlymphoma(PEL),atypeocancerorwhich

thosedrugswerenotexpectedtobeeective.

Its a reversal o the paradigm,saidPreet

Chaudhary,MD,PhD,chieotheNohlDivisiono

HematologyandBloodDiseasesattheKeckSchoolo

MedicineoUSCandprincipalinvestigatorothestudy.

Our results suggest that this new class o drug may

be an eective treatment or a wider range o cancers

than previously thought.

PELiscausedbyinectionwithKaposissarcoma-

associatedherpesvirus,themostcommoncause

ocanceramongpatientswithAIDS.Theprognosis

orPELispoor,withamediansurvivalothreetosix

months.Thus,thereisacriticalneedornewtherapies

orthedisease.

Chaudharyandhiscolleaguesshowthatinhibitors

targetingtheBRD4proteinblockedgrowthoPEL

cellsinatesttubeandinamousemodel.Theresults

weresurprisingbecauseBETinhibitorswerethought

tobeonlyeectiveagainstcancerslinkedtoan

overexpressionotheMycgene.

We actually ound that cancers that overexpress Myc are not as responsive to BRD4

inhibitors. PEL is more responsive,Chaudharysaid.

CancerslikemultiplemyelomaandBurkittslymphomaoverexpresstheMycgeneandhave

beenshowntorespondtoBRD4inhibitors.InPEL,theMycgeneismoderatelyexpressed

andthereisnochromosomaltranslocationasisseeninmultiplemyelomaorBurkitts.

Moreresearchisneededtocreatecompoundsreadyortestinginpeople.Oncethosedrugs

arereadyorclinicaltrial,dataromthisstudysuggestthattheymaytreatawiderangeo

cancers.Chaudharyanticipatestestingthemaloneandincombinationwithotherdrugs.

New Blood Test FindsAllergies Before Implant

DENVER

Shortlyaterhavingahipreplacedin2011,PaulaSpurlockstartedhavingtrouble.

I had horrible itching, really bad migraines and intense pain throughout my

body,shesaid.I couldnt take it. Every single thing in me itched.

Morethanayearateritwasimplanted,testsshowedPaulawashighlyallergictothe

metalinhernewhipandtothesurgicalcementotenusedtoholdjointsinplace.

Itsaproblemthatissuretogetworseinthecomingyears.By2030,thedemandor

hipandkneereplacementsintheU.S.willskyrocket.Morethan11,000peopleaday

areexpectedtohaveimplantsurgeriesbythen,anincreaseo174percentorhipreplacementsandnearly700percentorknees.

Its huge,saidKarinPacheco,MDanallergistatNationalJewishHealthinDenver.

We are an aging society, and the number o people who need new joints is going to

increase and, or some o these people, they wont know that theyre allergic until ate

the implant is put in.

The best way to tell i someone is allergic is to do a skin patch test that takes about a

week,shesaid.Not everybody has that kind o time beore their surgery.

PachecoandherteamatNationalJewishHealthhavecomeupwithanalternative,

developingtherstbloodtestthatcandetectallergiestonickel.Nickelisnotonlyoneothemostcommonmetalsusedinjointimplants,butitsalsothemostcommoncontactallergen

intheU.S.We think about 15 percent o the population is sensitized to nickel,shesaid.

Pachecosaystherearemanyadvantagestotheconceptousingabloodtesttocheckor

allergiesbeoresurgery.First o all its much easier,shesaid.and i an allergy is detected

patients could avoid the misery o an allergic reaction by choosing a dierent implant, and

the health care system could save millions o dollars in revision procedures.

I we nd a patient is allergic ater the act, unortunately, the only option right now

is to take the joint out and replace it with something to which theyre not allergic,said

Pacheco.It would be nice to get it right the rst time.

SEPT 2013

IN THE

NEWS



9/48

Nurse Practitioners Can HelpBoost Quality of Care for Older

Patients with Chronic ConditionsLOS ANGELES

U.S.residentstodayarelivinglongerthanprevious

generations,thankstoimprovedpublichealthand

medicaltreatment.Buttheyrealsolivinglongerwithchronicgeriatric

healthconditionslikedementia,urinaryincontinence,depressionand

debilitatingalls,whichotenrequirecomplexmedicalcare.

Doctorsspendsignicanttimeandresourcestreatingindividualswith

chronicconditions,andtheaverageamilyphysiciancanbecomeseverely

overtaxedmanagingcareorsuchpatients.Thepicturebecomeseven

worsewithchronicgeriatricconditions.

Severalheathcaretreatmentmodelshavebeendesignedovertheyearsto

improvemedicalcareorchronicgeriatricailments.Onemodel,orinstance,

helpedimprovepatientcarebyteaminggeriatriciansinanacademicmedical

centersettingwithnursepractitionerstoco-managecare.Butcanthesame

modelworkincommunity-basedprimarycaresettings?

Theanswerisyes,accordingtoaUCLA-ledstudypublishedintheJuneissueotheJournalotheAmericanGeriatricsSociety.Thestudys

ndingshighlightthecrucialrolenursepractitionerscanplayintreating

chronicgeriatricconditions.

It is becoming increasingly clear that care o chronic geriatric

conditions is better when its done in teams,saidthestudys

leadauthor,Dr.DavidReuben,chieothegeriatricsdivisioninthe

departmentomedicineattheDavidGeenSchooloMedicineatUCLA.

There are some things that nurse practitioners do better than doctors

and some things that doctors do better than nurse practitioners.

Reubennotedwhiledoctorsaregenerallygoodattreatingacute

medicalconditionsandthoserequiringhighlycomplexdecision-

making,somechronicconditionstendtobeswept by the wayside

becausephysicianseitherdonthavethetimeoraresimplynotas

skilledindealingwiththem.

Thestudyauthorsoundthepercentageoqualityindicatorsthat

weresatisedorpatientswhosecaseswereco-managedbya

nursepractitionerandaphysicianwashigherthanorthoseseen

onlybyaphysician.

Foralls,80 percentoqualityindicatorsweresatisedorco-managed

cases,comparedwith34 percentorphysiciansalone;orurinary

incontinence,66 percentoindicatorsweresatised,comparedwith

19 percent;ordementia,59 percentweresatised,comparedwith

38 percent;andordepression,63 percentweresatised,compared

with60 percent.

SEPT 2013

IN THE

NEWS


10/48


Cases of Whooping

Cough ReachesHighest Levelin 50 Years

ANN ARBOR, Mich.

Casesopertussis,alsoknownaswhooping

cough,areontheriseintheU.S.,recently

reachingtheirhighestlevelin50years.

Thediseasecanbeseriousorevenataltonewborns

thathaventreceivedvaccinations.Eectivevaccines

againstpertussishavebeenavailableoryears,but

vaccineprotectioncanwearoovertime.

AnewUniversityoMichiganpollshows61percent

oadultssaytheydontknowwhentheywerelast

vaccinatedagainstpertussis,whichcouldmeanthey

mightbeunwittinglyexposingvulnerablebabiesto

thedisease.Only20percentoadultsreportedthey

receivedthepertussisvaccinelessthan10yearsago(therecommendedtimerame)and19percentsaid

theywerevaccinatedmorethan10yearsago.

Pertussis is a preventable disease,saysMatthewM.

Davis,M.D.,M.A.P.P.,directorotheC.S.MottChildrens

HospitalNationalPollonChildrensHealth. But many

adults may think their childhood vaccinations still are

protecting them against pertussis. Findings rom this

poll show ew adults have received a booster shot

within the recommended 10-year time rame and in

act, two-thirds told us they were not aware o their

vaccination status.

Pertussiseasilyspreadswithinhouseholds,daycare

acilities,schoolsandneighborhoodsandismostoten

seriousininantsandyoungchildren.Themajority

odeathsrompertussisoccurinchildrenlessthan3

monthsold.

Pertussisvaccinesarerecommendedorteensand

adults(knownastheTdapvaccine),including

pregnantwomen.Boostingimmunityagainstpertussisamongteensandadultsis

especiallyimportantorprotectingnewbornsagainstthedisease.Mostinantswhoall

sickwithpertussisgottheillnessromanolderchildoradultwithpertussis.

Welcoming a baby to the amily is a wonderul time, and no one would want to put

an inant at risk. So the results o this poll are encouraging because they indicate

some awareness that visitors need to be protected against this disease,Davissays.Teens and adults who have received the Tdap vaccine are less likely to get whooping

cough themselves, and thereore less likely to spread whooping cough to other

people including inants who have not yet been protected by the recommended

pertussis vaccinations.

Band Aide Size Discovery

Accurately Monitors PatientsBreathing Duringand After SurgeryHOUSTON

Oneothemostimportantindicatorsoapatientsmedicalstatusisquite

simplythewayheorshebreathes.Duringandatersurgery,physicians

closelymonitortheratebywhichairpassesinandoutothelungs.Goodbreath

owisagoodsign.Irregularornoisybreathingcanraiseaseriousredagandan

increasingrespiratoryratecanbeanearlywarningsignoamajoradverseevent.A

decreasingrespiratoryratemayindicateopioidsinducedrespiratorydepression.

Researchersmayhaveidentiedadevicetoexpandmonitoringopatientsinrecovery.

Thedevicethemeresizeoasmallbandagecouldsoonaddtothesaetyopatients

inrecovery.

Dr.MichaelRamsay,presidentoBaylorResearchInstitute(BRI)andhisteamreviewed

theeectivenessoanacousticrespiratoryratemonitor,atoolthatmeasuresapatients

breathingthroughsound.Thesmalldevice,placedonthepatientsneck,isequipped

withacoustictechnologythattranslatesrespiratorysoundsintoanelectronicsignal.Itis

basicallyadigitalstethoscopethatcantransmitbreathsoundstoaremotemonitor.

Existing technology measuring exhaled carbon dioxide (capnometer) is placed in a

very sensitive area under the nose. These devices are requently dislodged and not

wireless,Dr.Ramsaysaid.Thenewdevice,hesaid,measuresrespiratoryratean

importantcomponentoventilationanddisplaysthequalityothebreathsound.Itis

unobtrusivetothepatientandwireless.

Amongtheirndings,theteamsawthattheacousticdeviceaccuratelyrecordedbreath

ratebothautomaticallyandcontinually.

SEPT 2013

IN THE

NEWS



11/48

Thats the key,Dr.Ramsaysaid.Having continuous

respiratory records is vital, because with enhanced

breath monitors, physicians could potentially be

alerted when a patients condition worsens.

Plus,sincethedeviceispositionedontheneck,

whereitcanserveasasteadymonitor(ratherthan

insertedintoapatientsnasaltubes,whereitcouldbe

dislodged)themonitorenhancespatientcomort.

All patients who receive intravenous opioids

ater surgery are at risk or respiratory depression.

Some patients have a very high risk because o

comorbid conditions such as sleep apnea. This

type o unobtrusive technology will allow continual

monitoring.Dr.Ramsaysaid.

Think BeforeYou drink:Erosion of Tooth Enamel FromSoda Pop is Permanent

OMAHA, Neb.

Youmaybesavingcaloriesbydrinkingdietsoda,butwhenitcomesto

enamelerosionoyourteeth,itsnobetterthanregularsoda.

Inthelast25years,KimMcFarland,D.D.S.,associateproessorintheUniversityo

NebraskaMedicalCenterCollegeoDentistryinLincoln,hasseenanincreaseinthe

numberodentalpatientswitherosionothetoothenameltheprotectivelayerothe

tooth.Onceerosionoccurs,itcantbereversedandaectspeopletheirwholelie.

Id see erosion once in awhile 25 years ago but I see much more prevalence

nowadays,Dr.McFarlandsaid.A lot o young people drink massive quantities o soda

Its no surprise were seeing more sensitivity.

Triggerslikehotandcolddrinksandevencoldairreachthetoothsnerveandcause

pain.Dependingontherequencyandamountosodaconsumed,theerosionprocess

canbeextreme.

ShesaidtheNationalSotDrinkAssociationestimatestheaverageAmericandrinks44gallonsosodaayear.Phosphoricandcitricacid,whicharecommoningredientsinmany

popularsodasanddietsodas,altersthepHbalanceinthemouthandcancausetooth

erosionovertime.

It can be more harmul than cavities because the damage causes tooth sensitivity,

Dr.McFarlandsaid.I a tooth is decayed, a dentist can x it by placing a lling, but i a

tooth is sensitive there is really nothing a dentist can do.

Dr.McFarlandsaidasignicantnumberoscienticstudieshaveshownarelationship

betweentheconsumptionosodaandenamelerosionandcavities.

Shesaiditsbestnottodrinksodaatall,butsheoerstipsorthosewhocontinuetodrinkit:

Limitconsumptionosodatomealtime

Dontdrinksodathroughouttheday

Brushyourteethaterwardstoothpastere-mineralizesorstrengthensareas

whereacidweakenedtheteeth

Itoothbrushingisnotpossible,atleastrinseoutyourmouthwithwater

Chewsugarreegumorbetteryet,gumcontainingXylitol

WHATDOCTORSKNOW.COM 9WHATDOCTORSKNOW.COM 9

SEPT 2013

IN THE

NEWS


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SEPT 2013

IN THE

NEWS

People with Pre-DiabetesWho Drop SubstantialWeight May Ward OffType 2 DiabetesBALTIMORE

P

eoplewithpre-diabeteswholoseroughly10percentotheirbodyweight

withinsixmonthsodiagnosisdramaticallyreducetheirriskodevelopingtype2diabetesoverthenextthreeyears,accordingtoresultsoresearchledby

JohnsHopkinsscientists.

Thendings,investigatorssay,oerpatientsandphysiciansaguidetohowshort-

termbehaviorchangemayaectlong-termhealth.

We have known or some time that the greater the weight loss, the lower your risk

o diabetes,saysstudyleaderNisaMaruthur,M.D.,M.H.S.,anassistantproessorin

theDivisionoGeneralInternalMedicineattheJohnsHopkinsUniversitySchoolo

Medicine.Now we understand that we can see much o the benet o losing that

weight in those rst six months when people are adjusting to a new way to eating

and exercising. Substantial weight loss in the short term clearly should go a long

way toward preventing diabetes.

Preventingpre-diabetesrombecomingull-blowndiabetesiscritical,Maruthur

says.Uncontrolleddiabetesmarkedbyexcesssugarinthebloodcanleadto

eye,kidneyandnervedamage,aswellascardiovasculardisease.Thenewresearch

suggeststhatipeoplewithpre-diabetesdontloseenoughweightinthoserst

months,physiciansmaywanttoconsidermoreaggressivetreatment,suchasadding

amedicationtopushbloodsugarlevelslower.

Patientswithpre-diabeteshavebloodsugarlevelshigherthannormalbutnot

yethighenoughtobeclassiedastype2diabetes.Althoughnotallpeoplewith

pre-diabetesdevelopull-blowntype2diabetes,withoutinterventiontherisko

gettingitwithin10yearsissubstantiallyincreasedanddamagetohealthmay

alreadyhavebegun.

Thegoodnews,Maruthursays,isthatstudieslikehersshowthattheprogression

romprediabetestotype2diabetesisnotinevitableandliestylechangescanbring

bloodsugarlevelsbacktonormal.



13/48

WHATDOCTORSKNOW.COM 1 1

VitaminDisaat-solublevitaminthat

youcanobtainromoods,sunlight

exposure,andsupplements.Onceinyour

body,vitaminDisprocessedthroughyour

liverandthenyourkidneysintoitsactive

orm,calcitriol.

OneovitaminDsmajorrolesisitseect

onbonehealth,byassistingwithcalcium

absorptionandmaintainingsuicientcalcium

andphosphatelevels.Withoutenough

vitaminDtohelpmaintainstrongbones,

childrenmaydeveloprickets,andadults

maydeveloposteomalaciaandbeathigher

riskordevelopingosteoporosis.Vitamin

Dalsohasotherimportantrolesinyour

body,suchasitsinvolvementincellgrowth,

neuromuscularunction,andimmunity.VitaminDsimpactonvarioushealth

conditionscontinuestobestudied.Whileits

importantroleinbonehealthisrecognized,

itsbeneitsandriskswithotherconditions,

suchascancer,needurtherresearch.

VitaminDisoundnaturallyinsomeoods,such

asattyshlikesalmon,tuna,andmackerel.

Otheroods,suchasbeeliver,cheese,egg

yolks,andcertainmushroomsalsocontain

smallamountsovitaminD.Themajorityo

dietaryintakeovitaminDisromvariousoods

thathavebeenortied,whichmayinclude

milk,breakastcerealsandorangejuice.Inant

ormulasarealsoortiedwithvitaminD.

The Food and Nutrition Board (FNB)

established the following recommended

dietary allowances (RDAs) for vitamin D

based on age:

Birthto12monthsoage:400IU(10mcg)

Childrenandadults1to70yearsoage,

includingpregnantandnursingemales:

600IU(15mcg)

Adults71yearsoageandolder:

800IU(20mcg)

(IU=InternationalUnits)

Exposuretosunlight,specicallyultraviolet(UV)

Bradiation,helpsyourbodymakeadditional

vitaminD.UVBradiationdoesnotpassthrough

glass,thusindoorexposuretosunlightdoes

nothelpyougetvitaminD.However,exercise

cautionwhenoutinthesunduetotheharmul

eectsthatstemromUVradiation.

DietarysupplementscontainingvitaminDare

anothersourceandmayberecommendediyou

arenotobtainingenoughvitaminDthroughyour

dietandexposuretothesun.VitaminDisavailable

asD2(ergocalcierol)orD3(cholecalcierol)in

thesesupplementsandortiedoods.

HavingtoomuchvitaminDcanbeharmul.

VitaminDtoxicityusuallyoccursromexcessive

dosesodietarysupplementscontaining

vitaminD.Symptomsmayincludevomiting,

weakness,andweightloss.Resultingelevations

incalciummaycausedamagetobloodvessels

andorgans,includingthekidneys.

The FNB also established the following tolerable

upper intake levels (ULs) for vitamin D:

Birthto6monthsoage:

1,000IU(25mcg)

Inants7to12monthsoage:

1,500IU(37.5mcg)

Children1to3yearsoage:

2,500IU(62.5mcg)

Children4to8yearsoage:

3,000IU(75mcg)

Childrenandadults9yearsoageandolder,

includingpregnantandnursingemales:

4,000IU(100mcg)

BloodtestscanmeasureyourvitaminDlevels.Discussingtheseresultswithyourhealthcare

providerwillhelpassessyourvitaminDstatus.

Iyouaretakinganymedicationsthatcan

aectvitaminD,youshouldalsodiscussthis

withyourhealthcareprovider.Suchmedications

includecorticosteroids,orlistat,cholestyramine,

phenobarbitalandphenytoin.

Likeothervitaminsandminerals,itsimportant

toknowhowmuchoagoodthingisgood

oryou.Talktoyourphysicianaboutyour

vitaminDintakeandbesureyougettherightamountinyourdiettomaintainhealthybones

throughoutyourlie.

ThisinormationcontributedbyMargaretY.

Pio,PharmD,BCPS,CDE,ClinicalPharmacy

Specialist,FamilyMedicineClinic,Parkland

MemorialHospital

The Bare Bones:What You Need to Know About

VITAMIN DOF VITAMINS & SUPPLEMENTS


14/48

MOTHERS LITTLE HELPER

What a drag it is getting old

Kids are dierent today

I hear evry mother say

Mother needs something today to calm her down

And though shes not really ill

Theres a little yellow pill

She goes running or the shelter o a mothers little helper

And it helps her on her way, gets her through her busy day

Things are dierent today


Cooking resh ood or a husbands just a drag

So she buys an instant cake and she burns her rozen steak

And goes running or the shelter o a mothers little helper

And two helps her on her way, get her through her busy day

Doctor please some more o these

Outside the door, she took our more


Men just arent the same today


They just dont appreciate that you get tired

Theyre so hard to satisy. You can tranquilize your mind

So go running or the shelter o a mothers little helper

And our help you through the night, help to minimize your plight

Doctor please some more o these

Outside the door, she took our more


Lies just much too hard today


The pursuit o happiness just seems a bore

And i you take more o those, you will get an overdose

No more running to the shelter o a mothers little helper

They just helped you on your way through your busy dying day

~ Mick Jagger / Keith Richards

1 2 WHATDOCTORSKNOW.COM

Whenmostpeoplethinkoaddiction,they

thinkosomederelictonastreetcorneror

inabackalleyhomelessandwastingawayroma

nastyandillegaldrughabit.Butdidyouconsideranaddictcouldbetheteennextdoor,yourneighbor,

thepersoninthepewnexttoyouinchurch,the

soccermom,aco-worker,anathleterecoveringrom

aninjury,orevenyourdoctor.Thisgrowingsegment

otheaddictioncommunityisanepidemicthatis

killingthousandsoAmericanseveryyear.Itscalled

prescriptiondrugabuse.

ItisestimatedthatourmillionAmericansoverthe

ageo12useprescriptionpainrelievers,sedatives,and

stimulantsornonmedicalreasonseverymonth.

Prescriptiondrugabuseisreachingepidemic

proportionsintheUnitedStatesandbecauseitaects

peopleromeverydaywalksolie,oursocietyhas

changedthenomenclature.Addictionissuchanugly

word.Livinginasocietythatisincreasinglystrivingor

politicalcorrectnesswenowcallprescriptiondrug

addictionadependence.Inreality,thisdependence

isallpartodierentphasesanddeinitionsowhatis

commonlycalledDrugAbuse.

Forexample,drugabuseismerelytheinappropriate

useoacontrolledsubstance.Chronicdrugabuse

isasustaineduseoveralongperiodwhentheuser

cantlivewithoutthemedication.Bingeusageisan

occasionalorrecreationaluseoadrug.Dependency

isaphysiologicalphenomenonandallhumansare

susceptible.Whenthebodybecomesaccustomedto

thepresenceoasubstance,thebodyitselcanbecome

addicted.Finally,addictionisamentaldependency

(withorwithoutphysiologicaldependence).Usually

thereisanunderlyingmentalhealthissue.

PrescriptionDrug Abuse

On the RiseAddiction:

a persistent, compulsive

dependence on a

behavior or substance.

It is estimated that

four million Americans

over the age of 12 use

prescription pain relievers,

sedatives, and stimulants

for nonmedical reasons

every month.


15/48


Whateverwecallit,prescriptiondrugabuseisontheriseanditkills.

Opioidusealonehasgoneuprom76millionprescriptionsin1991

to219millionin2011.Opioiddeathshaveincreasedmorethan400

percentrom1999to2010.Oddlyenough,traicrelateddeathshave

beenonthesteadydecreasesince1980.

Insteadochanginghowwelabeladdiction,perhapsabetter

approachwouldbetotakeacloselookatwhoisaddictedor

dependentonprescriptiondrugs.Prescriptiondrugabuseisnt

particularaboutitsvictims.

WHYTHEINCREASEINPRESCRIPTIONDRUGABUSE?

Thereareanumberoreasons.Themostcommonistheassumption

thatbecauseaphysicianprescribesthedrugs,theymustbesae

underallcircumstances.Littlethoughtisputintotherealization

thatdrugsprescribedbyadoctoraretheresultoanexamination,

thepatientsillness,potentialreactionsandinteractionswithother

medications.

Anotherproblemisaccessibility.Opioidprescriptionshaveincreased

nearly300percentrom1991to2010.Impropercontrolinthe

householdandthecuriosityoteensisbecomingaormulaor

disaster.Arecentsurveyo12thgradersindicatedthat70percent

otherespondersobtainedtheirprescriptionnarcoticsroma

riendorrelative.Threemillionteenagerswillbecomeprescription

drugabusersthisyearandteenagegirlsbeingmorelikelytoabuse

aprescriptiondrugthanaboy.Overall,48millionpeople(nearly

20percentotheentireUSpopulationovertheage12),willusea

prescriptiondrugornon-medicalreasons.

Whilemostothesemedicationsarebeingprescribedorpain,they

arebeingabusedtogethigh,tocounteranxiety,orsleepproblems

andinsomecases,simplyabusingtheprescriptionandbecoming

addictedtothemedication.

Onebigreasonorprescriptiondrugabuseisthatitcreepsup

onyou.Generallydoctorsprescribingpainmedicationsmakethe

necessaryeorttowarnpatientsaboutthepotentialoaddictioni

themedicationisntusedproperly.Still,itseasytogetusedtothe

euphoriathesedrugssometimesgive.Theearopaindetersothers

romgettingoandthentherearethosewhohaveanaddictive

personality.

THEQUESTIONSOMANYASKABOUTANYADDICTIONBATTLEIS:

WHATISTHEGOVERNMENTDOING?

Governmentisnttheanswer,notesUtahSenatorMarkB.

Madsen.Bearinmindthesearelegaldrugsbeingmisused,sothe

governmentsrolecanonlybeoneoinormingthepublicabout

thepossibilitiesoaddictionandothersideeects.Medicineversus

governmentisnottheanswer.

Prescription drug abuse isnt new. Its just getting worse. The Rolling Stones made

reerence to prescription drug abuse in a recording nearly fty years ago.


16/48


Madsensaysphysiciansareputinthemiddlewhenitcomesto

addictionprevention.Thephysiciansgoalistohealpatientsbased

onthemoralguidelinesotheHippocraticOath.Bettereducation,

moreeectivetreatmentprogramsandacilitiesarestepsintheright

directionindealingwiththeprescriptiondrugproblem.

We are being unair to doctors when we put them on the ront lines o

the drug abuse war. Doctors arent the ront line or the DEA,Madsen

added.Doctors arent supposed to administer government programs.

WHATARESOMETREATMENTOPTIONSFORPEOPLEWITHOPIOID

PRESCRIPTIONPAINKILLERADDICTION(OPIOIDDEPENDENCE)?

Thereareavarietyotreatmentoptionsorpeopleaddictedtoor

dependentonopioidprescriptionpainkillers.Treatmentinterventions

includeabstinence-based12-stepprograms,cognitive-behavioural

therapy,individualorgroupcounselling,acupuncture,medication-

assistedtreatment,andmore.Treatmentcanbeaccessedinmany

dierentsettings,includingresidentialorinpatientacilitiesor

outpatientprogramslikeamethadoneclinic.Certainmedications,

includingSUBOXONE(buprenorphineandnaloxone)Sublingual

Film(C-III),canbeprescribedbycertiieddoctorsinoice-based

treatmentsettings.

Thismedicationallowspatientstobediscreetlytreatedwithinthe

privacyoadoctorsoice.Becausethemedicationisavailableor

prescriptionuse,patientscancontinuetheirdailyactivitieswhile

underadoctorscareinmuchthesamewayotherchronicdiseases

suchasdiabetesandasthmaaremanaged.Themedicationshouldbe

usedaspartoacompletetreatmentplanthatincludescounselling

andpsychosocialsupport.

TheactiveingredientsinSUBOXONEFilm

arebuprenorphineandnaloxone.

Takenoncedailybydissolvinga

thinilmunderthetongue,the

buprenorphinehelpsreduce

opioiduseandincreases

retentionintreatment

byhelpingtomanage

withdrawalsymptoms

anddecreasecravings.Thenaloxone,an

opioidantagonist,

worksbyminimizing

thepotentialothe

prescriptionmedication

ordeliberatemisuseand

abuse.Whenthismedication

istakenasprescribed,the

naloxonehasnoeect.

WHATARETHESIGNSOFOPIOIDPRESCRIPTION

PAINKILLERADDICTION?

Opioidprescriptionpainkilleraddictionisachronicdiseasecaused

inpartbychangesinthechemistryothebrainthatcanresultrom

regularopioiddruguse.Long-termuseosuchmedicationscan

physicallytransormthebrainandleadtocompulsive,drug-seekingbehavioranddependency.Severalsignsandsymptomsinclude:

Drowsinessandlackoenergy

Inabilitytoconcentrateandlackomotivation

Socialbehavioralchanges

Changesinappearance

Increasedsecrecy

Uncontrolledcravingsoropioids

Continueduseoopioidsdespitenegativeconsequences

WHATAREOPIOIDS?

Opioidsaresubstancesderivedromopiateplantmaterialor

synthesizedtoproducetheeectsoopiates.Theyworkinthebody

likeopium,blockingthebodysabilitytoeelpain.Somearemade

directlyromopium(orexample,morphineandcodeine),while

othersareman-madebutsimilarchemicallytoopium(orexample,

thepainkillersoxycodone,hydrocodone,andentanyl.Heroinisalso

anopioid.Overtime,opioidprescriptionpainkillerscanalterthe

brainschemistrybyresettingthebrainsoonebeginstoeelthey

needthedrugjusttogetthroughyourday.

CANYOUBREAKOPIOIDPRESCRIPTIONPAINKILLERADDICTION

COLDTURKEY?

Somepeopledosucceedinstoppingcoldturkeythatis,quiton

theirownwithouttreatmentorhelp.Butopioidaddictionisachronic,

relapsingillness,andtheinabilitytoquitwithouttreatmentorhelp

shouldnotbeconsideredasignoweaknessormoralailing.An

attitudeSenatorMadsenpointsout,underpins much o governments

and law enorcements attitude regarding controlled substance abuse.

ISTHEREASPECIFICKINDOFDOCTORTOSEEFOROPIOIDPRESCRIPTIONPAINKILLERADDICTION?

Whilemanypeoplebelievetraditionalinpatientrehabilitationor

substanceabuseacilitiesandmethadoneclinicsaretheonlyavailable

comprehensivetreatmentoptionsorpeoplelivingwithopioid

addiction,thediseasecanbemanagedeectivelyintheprivacyoa

doctorsoice,providinglessdisruptiontopatientsdailyliveswhile

helpingthemworktoovercometheiraddiction,similartotreatment

orotherchronicdiseases.


17/48


AsaresultotheDrugAbuseTreatmentAct(DATA)2000,certiied

doctorscanprescribecertainbuprenorphineproducts,whichsuppress

withdrawalsymptomsandcravingssothatpatientscanocustheir

eortsandenergyonaddressingotheractorscontributingtotheir

addiction.Havingtheoptionoreceivingtreatmentprivatelywhile

goingaboutotherdailyactivitiesenablesindividualswhomay

nothavesoughthelppreviouslytoaccesstreatmentintheirown

communityotenromtheirowndoctor.

Peoplewithopioidprescriptionpainkilleraddictioncanvisit

www.SUBOXONE.comtoindacertiieddoctorintheirareawho

understandsandtreatsthedisease.

ISTHEREEFFECTIVETREATMENTFOROPIOIDPRESCRIPTION

PAINKILLERADDICTION?

Qualitycarerequiresaplantailoredtoindividualpatientneeds;

howeverstudies,showcombiningoice-basedtreatmentwith

counselingincreasesthelikelihoodosuccessandmayimprovethe

psychosocialhealthopatientsightingopioidaddiction,helping

themmakebetterdecisionsandpreventingthemromdamaging

closerelationships,doingregretulorimpulsivethings,hurtingamily,

havingmoneyproblems,takingoolishrisksandbeingunhappy,

amongotherthings.Counselingalsocanhelppatientslearnhowto

copewitheventsorsituationsassociatedwithpastdruguseand

adoptskillsthatcanhelpthemrecognizetriggersandpreventrelapse.

HOWLONGDOESITTAKETOBREAKTHEHABITWHENYOUARE

ONAMEDICATIONSUCHASSUBOXONE?

Thereisnosilverbulletoropioidaddictiontreatmentandoutcomes

varyrompatienttopatient.SUBOXONEFilmcombinesbuprenorphine

withnaloxone.Buprenorphinehelpsreduceillicitopioiduseand

increasesretentionintreatmentbymanagingwithdrawalsymptoms

andreducingcravings,whilenaloxoneisadeterrenttomisuse.A

studypublishedintheArchivesoGeneralPsychiatrydemonstrated

theeectivenessoofce-basedtreatmentwiththebuprenorphine-

naloxonecombination.Inaddition,areporttoCongressdeveloped

bytheSubstanceAbuseandMentalHealthServicesAdministration;

medication-assistedtreatmentwithSUBOXONEwas85percent

eectiveinreducingillicitopioiduseinpatients.SUBOXONEFilm

shouldbeusedaspartoacompletetreatmentplanthatincludes

counselingandpsychosocialsupport.Thereisnoone-size-ts-all

approachtodiscontinuingthismedication.Thedecisiontostopshould

bemadeaspartoacomprehensiveindividualizedtreatmentplan

betweenadoctor,patientandotenacounselor.

ONCEYOUBREAKTHEPRESCRIPTIONDRUGHABITISTHEREA

DANGEROFBECOMINGADDICTEDAGAIN?

Similartopatientswithotherchronicconditions,patientslivingwith

opioidaddictionmayneedlong-termmedicalcare.Thechronicnature

othediseasemeansrelapsingisnotonlypossible,butalsolikely.

AccordingtotheNationalInstituteonDrugAbuse,nearlyallopioid-

dependentpeoplebelieveatrsttheycanstopusingopioidsontheir

own,yettheyaceadiseasethatcancauserelapseinratesthatparallel

thoseinpopulationsopatientswithtype1diabetes,hypertensionand

asthma.Formonthsorevenyearsateranindividualsactiveopioid

misusehasstopped,thedamagedonetohisorherbraincantrigger

cravingsthatleadtomisuse.Forthisreason,addictedpatientsaremost

likelytobenetromlong-termtreatmentthatallowsthemtocontinue

tomanagetheirsymptomswhileavoidingrelapse.

AFTERBREAKINGTHEHABIT,WHATHAPPENSIFYOUNEEDA

POTENTIALLYPROBLEMATICPRESCRIPTIONFORANAILMENT?

ARETHEREPRECAUTIONSYOUNEEDTOTAKE?

Patientsshouldspeakwiththeirdoctorsandotenacounselorabouthow

thistsintotheircomprehensivetreatmentplan.Inaddition,theSubstanc

AbuseandMentalHealthServicesAdministrationsupportsamentoring

systemontheuseoSUBOXONE(buprenorphineandnaloxone)Filmand

otheropioidmedicationsorthetreatmentoopioiddependence.The

website,www.pcssb.org,providesresponsestorequentlyaskedquestions

includingthequestionposedhere.Inaddition,thewebsiteprovides

guidancedocumentsorofce-basedphysicians,webinarsoncurrent

clinicaltopics,andpeersupportormentoringopportunities.


18/48


Thereisreallynowaytoknoworsureiyoure

goingtogetovariancancer.Still,certainactors

canmakeyoumorelikelytogetitthananotherwoman.

Thesearecalledriskactors.However,justbecauseyouhaveoneormoreriskactorsdoesntnecessarilymean

youwillgetovariancancer.Inact,youcanhaveallthe

riskactorsandstillnotgetovariancancer,oryoucan

havenoknownriskactorsandgetit.

Iyouagreewithanyotheollowingbolded

statements,youmaybeatanincreasedrisko

developingovariancancer.Someriskactorsareouto

yourcontrol,suchasyourageoramilyhistory.Others-

-likeyourweightortakinghormones--areactorsyou

cancontrol.

MYMOTHERORSISTERHADOVARIAN,BREAST,OR

COLONCANCER.

Amotherorsisterisconsideredairst-degreerelative.

Iyouhavetwoormoreirst-degreerelativeswhohave

hadovariancancer,thissuggeststhathereditymaybe

acause.Iyouhaveaamilyhistoryobreastorcolon

cancer,youramilymayhavecertaingeneticmutations

thatalsoincreasetheriskorovariancancer.These

typesoovariancanceraccountorabout10percento

ovariancancercases.

IHAVEHADBREASTORCOLONCANCER.

Apersonalhistoryobreast,uterine,rectum,orcolon

cancerputsyouatincreasedriskorovariancancer.

IAMAWOMANOLDERTHANAGE60.

Theolderyouare,thegreateryourriskorgetting

ovariancancer.Awomansriskorovariancancerrises

withageandpeaksduringher70s.

IVENEVERHADCHILDREN.

Womenwhohaveneverbornechildrenareatslightly

increasedriskorovariancancer.

IAMOBESE.

Beingobesemeanshavingabodymassindexgreater

than30.(VisittheNationalHeart,Lung,andBlood

Instituteorhowtocalculateyourbodymassindex.)

Obesityincreasesriskorovariancancer.Themore

excessweightyouhave,themoreyourriskisincreased

IUSEDTALCUMPOWDER.

Somestudiesshowarelationshipbetweenovarian

canceranduseotalcumpowderonthegenitalarea.

Thismaybebecausethispowderoncecontained

asbestos.Formorethan20years,thelawhasrequired

thatthesepowdersbereeoasbestos.

IHAVETAKENESTROGENREPLACEMENTTHERAPY

FORMANYYEARS.

Iyouveusedmenopausalestrogenreplacement

therapy(takingestrogenalone,withoutprogesterone)

ormorethan10years,youmayhaveaslightly

increasedriskoovariancancer.

IHAVEUSEDFERTILITYDRUGS.

Iyouveusedertilitydrugs,youmaybeatincreased

riskorovariancancer.Researchstudieshaveproduced

conlictingresults.

This inormation provided courtesy o the University o

Missouri Health System

Am I at risk for

Ovarian Cancer?A woman may be at

greater risk if her mother,

sister or daughter has

been diagnosed withovarian cancer.


19/48


H E A LT H H U

1WhyshouldIcareaboutbloodsugar

iImgoingtoendupondialysisanyway?

Youcanpreventordelaytheprogressionokidneydiseaseanddialysis

bycontrollingyourbloodsugarandbloodpressure.Studiesshowthat

eveniyourelatestartingtocontrolyourdiabetes,itdoesntnecessarily

meanyouretoolatetopreventprogressionokidneyproblemsand

dialysis.Andeveniyoureverylate,youcanstilldelaytheonseto

dialysis.Signicantlyewerpatientsneeddialysiseachyear,andthisis

decliningby3to4percentannually.

2OnceIstarttakinginsulin,

doesthatmeanIllbeonitorever?

Itdependsonthepersonandthesituation.Startinginsulincanbejusta

temporarymeasuretoxashort-termproblem,oritcanbelong-term.

Thegoodnewsisthattwo-thirdsopatientswhoarenewlydiagnosed

withdiabetesandhavebeenstartedoninsulincanreverttoother

medicationsaslongastheyollowaprogramodietandexercise.

Here are 4 of the most common questionsI hear from my diabetes patients:

4 FAQsABOUT DIABETESI N S U L I N , K I D N E Y D I S E A S E C O N C E R N S C O M M O N

from


20/48


H E A LT H H U B

However,therearepeoplewhohavehaddiabetesormanyyears,have

ollowedagooddietandareusingthreeormoremedicationstocontrol

bloodsugaryetstillhavehighbloodsugar.Theywillprobablyalways

needinsulin.

Gastricbypasssurgeryisnowanoptionoroverweightpeoplewithtype

2diabetes.Thisproceduremayreducetheneedorinsulin.Dietand

exercisebothbeoreandatergastricbypasssurgeryimproveyourodds

ostayingomedications,oratleasttokeepthenumberdown.Both

greatlyimprovetheexpectedbenetsosurgery.

3WhydoIneedtoollowadietiImoninsulin

ortakingdiabetesmedication?

Thebenetsodiabetesmedicationandinsulinadjustmentscouldbe

short-lived,andotenwontbeachieved,withoutdietandexercise.

Agooddietandexercisemayreducetheamountomedicationsyou

needandalleviateinsulinssideeects,whichincludelowbloodsugars

andweightgain.Lessmedicationmeansewersideeects,notto

mentionlesscost.

4Bloodsugarcontrolisthemostimportantactor

orpeoplewithdiabetes,right?

Bloodsugarcontrolisveryimportant,butyouneedtoalsoconsider

bloodpressureandcholesterolcontrol.

Breakingitdownalittlemore:

Controllingbloodsugarhelpspreventkidneydiseaseandeye

complications,particularlydiabeticretinopathyaseriousdisease

thatcanleadtoblindness.

Bloodpressurecontrol,ideallystayingunder130/80inadults,may

slowkidneydiseaseandpreventheartattackandstroke.

Keepingcholesterollow,alongwithgoodbloodpressurecontrol,

protectsbloodvesselsloweringriskoheartattack,strokeand

circulationproblemsinthelegsandeet.

Beyondmakingsureyoucontrolyourdiabetes,dontneglectyouroverall

healthtoo,withannualphysicalsandscreenings.Yourgoodhealth

improvesyourqualityolie.Andthatsthemainpurposeoanytreatment.

MarwanHamaty,MD

6 Myths

AboutPainkillersSeparate fact from

fiction about pain and

addiction

from


21/48


H E A LT H H U

When it comes to prescription pain medications, theres a lot o

misinormation out there. Whether youre searching or inormation

about how they can help you relieve pain or reading the latest tabloid

story about a celebrity addict, separating act rom fction can be tough.

Richard Rosenquist, MD, Chairman o Pain Management at Cleveland

Clinic, debunks six common myths about prescription painkillers such

as oxycodone and hydrocodone.

Myth1Themoreyoutake,thebettertheywork

Moredoesnotequalbetter.Itstruethatintheshorttermaterasevere

injury,orexampletwopillsmaybemoreeectivethanoneatrelievingpain.

Butovertime,takingtoomuchbackres.Researchsuggeststhatpain

medicationsmaydosomethingtodesensitizethewayyourbrainand

spinalcordinterpretpainsignals,Dr.Rosenquistsays.

You develop a tolerance to the medication over time, he says.

Sometimes i you take chronic pain medications or a long time, your

pain may actually get worse.

Myth2Iyoutakethemoravalidreason,youcantgetaddicted

Itcanthappentome.Imagoodcitizen.Imanormalperson.Icouldnt

possiblygetaddicted.Thinkingthiswayisdangerous.Eveniyoustart

takingaprescriptionpainmedicationoralegitimatereason,yourunthe

riskoaddiction.Ithasnothingtodowithmoralcharacterandeverything

todowiththehighlyaddictivenatureothesedrugs.

Myth3Everyonewhotakesthemgetsaddicted

Ontheipside,justbecauseyoutakeaprescriptionpainkillerdoesnot

meanyouwillbecomeaddicted.

Itdependslargelyonyourownpersonalriskoaddiction.ThatswhyDr.

Rosenquistandothersinpainmanagementscreenorriskactors:aamily

historyoaddiction,apersonalhistoryoalcoholanddrugabuse,orcertain

psychiatricdisorders.

I Im considering prescribing opioids, Im going to do drug screening

and make sure youre not taking recreational drugs,Dr.Rosenquistnotes

I somebody uses recreational drugs, the likelihood theyre going to use

pain medications inappropriately is really high.

Noteveryonegetsaddicted,buteveryonewhotakespainkillersoran

extendedtimeperiodwillexperiencesymptomsowithdrawalwhenthey

stop.Itsanaturalreaction.

Myth4Therearenolong-termconsequences

Addictionisnottheonlyriskthatcomeswithprescriptionpain

medications.Whentakenorextendedperiodsotime,theyalsocanharm

yourbodysendocrinesystemandthrowyourhormonesoutowhack,

aectingeverythingromyourlibidotoyourriskoosteoporosis.

There are a lot o bad things that can happen, but people dont always

hear you when you describe them,Dr.Rosenquistsays.

Myth5Youshouldavoidpainkillersaltogether

Asyoucantell,thereisplentyoscaryinormationaboutpainkillers.

However,therearecertainlylegitimateuses.

Inadditiontotreatingthepainromacuteinjuries,averysmallractiono

chronicpainpatientsseeimprovementsinbothpainlevelsandunction

romtakingpainmedicationsespeciallywhenotherpainmanagement

techniquesailorthem.

Forthemajorityopeople,though,prescriptionpainmedicationsshould

beashort-termtreatmentatmost.

Myth6Painmedicationcanxyourpain

Thismaybethebiggestmythoall.Painmedicationssimplymaskyour

symptoms;theydonttreattherootcauseoyourpain.ThatswhyDr.

Rosenquistocusesonhowyouunctionratherthanjusthowyoueel.

Areyoumovingbetter?Areyouabletogetbacktowork?Theseare

importantquestionsaboutunction.Soisthequestionowhetheryouve

beenmakingeortstogetbetter.Forexample,haveyoubeenollowing

doctorsordersanddoingphysicaltherapytorecoverromaninjury?Have

youbeenlosingweightiyouresueringromweight-relatedbackpain?

I youre not doing the other things you need to do, Im not going to

keep prescribing those drugs,Dr.Rosenquistsays.Ontheirown,theyre

nottherapeutic.ChronicConditionsTeam

from


22/48


H E A LT H H U B

Memory Loss in Women:Is It Age or Menopause?

Decreasing levels of estrogen affect brain function

Memorydifcultyisatypicalsymptomomenopause,butsomemight

earthatitsanearlysignoAlzheimers.Manydescribeasudden

inabilitytorecallsimpleactsasbrainog.

Ithissoundsamiliar,dontworry.Yourenotlikelylosingitordeveloping

dementia.Dippinglevelsoestrogenwhetherrommenopauseor

havingababyaectbrainunction.

Factstoeaseyourmindaboutmemoryblips

PeoplewithAlzheimersarentawareenoughotheirconditionto

recognizeitandtelltheirdoctor.

TherstsignoAlzheimersotenisorgettinghowtoperormactivities,

suchasdrivinghomeromthestore,notumblingorwords.Generally,thosewithAlzheimersaremucholderthanwomen

experiencingmenopauseusuallyintheir40sand50s.

Midliebrainogistreatable!Hormonetherapyhasbeenshownto

sharpenamenopausalmindandmayhelpprotectyouromurther

memoryloss.

Exercisingyourbrainisanotherwaytostaymentallyt.Iyourjobis

let-brained,relaxbydoingright-brainedactivitiesandviceversa.For

example,iyouworkasanaccountant,dosomethingphysicallyactiveor

creativeinyoursparetime.

Theimportantthingistoengageandchallengebothsidesoyourbrain.Midliedoesnthavetobethebeginningotheend.Itcan

bethestartoyourbestyearsyet.

HollyL.Thacker

To nd more great health tips and inormation,

visit HealthHub from Cleveland Clinic at

www.health.clevelandclinic.org

AFEWBRAIN-BOOSTINGID

EAS

4 Docrosswordpuzzles

4 Playgameslikechessormon

opoly

4 Goforavigorouswalk

4 Readanovel

4 Takeupballroomdancing

4 Journalpositiveexperiences

4 Learnaforeignlanguage

from


23/48


24/48


( OB-GYN )


25/48


Obstetrics& GynecologyObstetrics and gynecology (ob-gyn) are the two surgicalmedical

specialties dealing with the female reproductive organs in their

pregnant and non-pregnant state, respectively. The specialties are

often combined to form a single medical specialty and postgraduate

training program.

Thecombinedtrainingpreparesthepracticingob-gyntobeadept

atthesurgicalmanagementotheentirescopeoclinicalpathology

involvingemalereproductiveorgans,andtoprovidecareorboth

pregnantandnon-pregnantpatients.

TrainingThetrainingrequiredtopracticemedicineasanob-gynisextensive.

Allob-gynsaregraduatesocollegeandanaccreditedmedical

school.Eachmustalsocompleteanadditionalour-yearcourseo

specialtrainingcalledaresidencyinobstetricsandgynecology.

Thistrainingequipstheob-gynphysiciantoprovidegeneralcareto

women,inadditiontospecializedcarerelatedtopregnancyandthe

reproductiveorgans.

BoardCertied

Followingresidencyplusatleasttwoadditionalyearsopractice,a

doctormayapplyorboardcerticationbytheAmericanBoardo

ObstetricsandGynecology.Heorshemustpasstwoteststobecome

boardcertied.Therstisawrittentestcoveringbothmedicaland

surgicalcare.Passingthistestdemonstratesthatthecandidatehasthe

necessaryknowledgeandskillstotreatwomen.Thesecondisanoral

exambeoreapanelonationalexperts.Thisexamreviewstheskills,

knowledgeandabilitytotreatdierentconditions,andincludesa

reviewocasesthecandidatehastreatedduringtheprecedingyear.

Subspecialties

Someob-gynsurgeonselecttodourthersubspecialtytrainingin

programsknownasellowshipsatercompletingtheirresidency

training,althoughthemajoritychoosetoenterprivateoracademic

practiceasgeneralob-gyns.Fellowshiptrainingcanrangeromoneto

ouryearsinduration,andusuallyhavearesearchcomponentinvolved

withtheclinicalandoperativetraining.

Examplesosubspecialtytrainingavailable

tophysiciansintheUSare:

Maternal-fetal medicine an obstetrical subspecialty, sometimes reerred to as

perinatology, that ocuses on the medical and surgical management o high-risk

pregnancies and surgery on the etus with the goal o reducing morbidity and mortality.

Reproductive endocrinology and infertility a subspecialty that ocuses on the

biological causes and interventional treatment o inertility

Gynecological oncology a gynecologic subspecialty ocusing on the medical and

surgical treatment o women with cancers o the reproductive organs

Female pelvic medicine and reconstructive surgery a gynecologic subspecialty

ocusing on the diagnosis and surgical treatment o women with urinary incontinence and

prolapse o the pelvic organs. Sometimes reerred to by laypersons as Female urology

Advanced laparoscopic surgery

Family planning a gynecologic subspecialty ofering training in contraception and

pregnancy termination (abortion)

Pediatric and adolescent gynecology

Menopausal and geriatric gynecology

ob-gyn [oh-bee-jee-wahy-en]

: a physician who specializes in

obstetrics and gynecology

O

OU


26/48

Reactivehypoglycemiaisaconditionwith

recurringepisodesohypoglycemiainaperson

whoisnotdiabetic.Truereactivehypoglycemia

symptomsarecausedbylowbloodglucoseranges,usuallylessthan70mg/dL,andoccuratereatinga

meal.Forthemajorityopeoplewithpostprandial

symptoms,theactualcauseothesymptomsis

notclear,butmayrelatetowhatoodwaseatenor

variationsinthetimingotheoodmovingthroughthe

stomachandintestinaltract.Reactivehypoglycemia

istheresultoexcessiveinsulinreleasetriggeredby

theintakeocarbohydrates,buttheinsulinrelease

continuespastthedigestionphase,andpastdisposalo

glucoseromthatpastmeal.

People who have had intestinal surgery (gastricbypass or surgery or the management o ulcer

disease) or tumors in the pancreas may have an

increased production o insulin that puts them

at a higher risk o having reactive hypoglycemia

because o the rapid passage o ood into

the small intestine. Rare enzyme deciencies

diagnosed early in lie, such as hereditary ructose

intolerance, also may cause reactive hypoglycemia.

OTHERCAUSESOFREACTIVE

HYPOGLYCEMIAINCLUDE:

Certainmedicines

Drinkingalcohol,especiallydrinkingalot

overaewdays

Certainillnessesthataecttheliverorkidneys

AnorexianervosaThisisaneatingdisorderthat

makespeoplelosemoreweightthanishealthy.

Growthsorproblemsinthepancreas

DIAGNOSIS

The doctor may ask about signs and symptoms to

diagnosis reactive hypoglycemia:

Test blood glucose while the patient is having

symptoms by taking a blood sample rom the arm

and sending it to a laboratory or analysis

Check to see whether the symptoms ease ater

the patients blood glucose returns to 70 mg/dL or

above ater eating or drinking

A blood glucose level below 70 mg/dL at the time

o symptoms and relie ater eating will conrm

the diagnosis. The oral glucose tolerance test is no

longer used to diagnose reactive hypoglycemia

because experts now know the test can actuallytrigger hypoglycemic symptoms.

Symptoms may vary according to the individuals

hydration level and sensitivity to the rate o decline

o their blood glucose ranges.

SIGNSANDSYMPTOMSMAYINCLUDE:

Doublevisionorblurryvision

Unclearthinking,conusion

Sleepingproblems

Heartpalpitationorbrillation

Fatigue,depression

Dizziness,lightheadedness,conusion

Sweating

Headaches,tremors,fushing

Nervousness,irritability,panicattack

Increasedappetite,cravingsweets

Numbness/coldnessintheextremities

Two types of

hypoglycemia can

occur in people who

do not have diabetes:

Reactive hypoglycemia,

also called postprandial

hypoglycemia, occurs

within 4 hours after meals.

Fasting hypoglycemia,

also called post absorptive

hypoglycemia, is often

related to an underlying

disease.


Does your

PancreasOverreact?


27/48

INCREASEDAPPETITE

In severe untreated cases, coma can be a result o reactive

hypoglycemia.

HOWISREACTIVEHYPOGLYCEMIATREATED?

Dietary recommendations or reactive hypoglycemia can help

to relieve symptoms o postprandial syndrome. Eating ood will

help to stabilize your blood glucose range. The quickest wayto eel better is to eat ood that will help your blood glucose

range go up quickly; sugars and carbohydrates seem to work

ast. Foods high in protein and at will also help to maintain

your blood glucose ranges and prevent another reactive

hypoglycemic episode.

The ollowing are general guidelines that can help you control

reactive hypoglycemic episodes. Your doctor can also reer you

to a registered dietitian or personalized meal planning advice.

Eatseveralsmallmealsandsnacksthroughouttheday,

aboutevery2hours.

Eatmealsandsnacksontime.

Recommendedchoicesinclude:yogurtorcottagecheese;nuts

withruit,ornutbutterwithwholegrainbreadorcrackers;slices

ochicken,turkey,beeortunaonwholewheatbread;dairy

productsandbeans,cheese,andeggaddedtosalads.

Youdonthavetolimitcarbohydrateintake;thisisnotamealplan

ordiabetes.

Avoidorlimitsugaryoods,especiallyonanemptystomach.

Besuretoeatoodiyoureconsumingalcoholandavoidusing

sugarysotdrinksasmixers.

Eliminatecaeineorhaveverysmallamountsromdrinksandood.Increaseyourberandfuidintake.Fiberhelpstostabilize

glucoseranges.

Planandcarrysnackswithyou.

Exerciseregularly,activityhelpsglucoseuptakewhich

decreasessymptoms.



28/48

MEALPLANNINGTIPS

For many adults, eating 3 to 5 carbohydrate choices at each

meal and 1 or 2 carbohydrate choices or each snack works well.

A meal plan tells you how many carbohydrate servings to

eat at your meals and snacks. In a healthul meal plan, most

carbohydrates choices will come rom:

5servingsoruitsandvegetables

3servingsowholegrains

2to4servingsomilkormilkproducts.

Planmealswithoodthatishighinberandlowinsodium.

Chooseleanprotein(bee,pork,poultry,sh,cheese,eggs).

Servingsizeormostwomenwouldbe3ouncesatameal;ormen,

4to5ouncesatameal.Have1to2ouncesoleanproteinora

snackwithcarbohydratechoice.

Usehealthyats,suchasoliveoil,canolaoil,avocado,andnuts.

Eatverylittlesaturatedats.Theseunhealthyatsareoundin

butter,cream,wholemilk,cheese,andattymeats,suchasbacon,

processedmeats,andsausage.Removepoultryskinbeorecooking.

Bake,boil,roastorstirryyouroodtodecreaseatcalories.

Avoidoodwithtransats;lookorpartiallyhydrogenatedoil

listedasaningredient.

Eat meals on time, eat every 4 to 5 hours, and have planned

snacks mid-morning, mid-aternoon and evening.

LABELREADINGTIPS

Start with the serving size; look at the total grams ocarbohydrate. 15 grams = 1 carbohydrate choice

SAMPLEMENUPROVIDES4CARBOHYDRATE

CHOICESFOREACHMEAL.

BREAKFAST

1 carbohydrate . . . . . . . . . . . . . . . . . . . . . . . 1 slice whole wheat toast2 carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . 1 cup o grits, cookedProtein, 2 meats . . . . . . . . . . . . . . . . . . . . . . 2 ounces turkey sausage1 carbohydrate choice. . . . . . . . . . . . . . . . . . . .4 ounces orange juice

LUNCH

1 carbohydrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1/2 cup corn2 carbohydrates . . . . . . . . . . . . . . . . . . . .2 slices whole wheat breadProtein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ounces turkey breast1 carbohydrate . . . . . . . . . . . . . . . . . . . . . . 1 cup o sliced strawberries2 vegetable servings . . . . . . . . . . . . . . . . . . . . .2 cups o green salad,

tomatoes, cucumber slices2 at servings . . . . . . . . . . . . . . . . . . . . 2 Tbsp. low at salad dressing

DINNER

2 carbohydrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 cup wild rice1 ruit serving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 cup honey melon2 vegetable servings . . . . . . . . . . . 1/2 cup o steamed carrots and

1/2 cup o broccoliProtein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ounces grilled sh1 at serving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 tsp. sot margarine1 carbohydrate . . . . . . . . . . . . . . . . . . . . . . . . 1 whole wheat dinner roll

Snacks include: 1 to 2 carbohydrate choice(s) with a protein.

Sandwich with whole wheat bread turkey breast, Grilled cheese, Wheat crackers

and peanut butter, Sliced apple with string cheese, Cottage cheese with pineapple

Sharon Cox, Registered Dietician, Parkland Health & Hospital

System Nutrition Services



29/48


TheGynecologicCancerFoundation(GCF)has

designatedSeptemberasGynecologicCancer

AwarenessMonth.Thegoalistodrawattentiontothe

importanceoearlydetectionandprevention.

Gynecologiccancersincludeallcancersotheemale

reproductivetract.Thismeansovarian,cervical,uterine,

vaginal,vulvar,ortubalcancer.Thesecancersdonothave

tobeatal.Earlydetectionandeducationtools,suchas

Paptestsandriskassessmenttests,notonlycandetect

them,butalsocanhelppreventthem.

4WAYSTOTAKECONTROLOFYOUR

GYNECOLOGICHEALTH

Theprogramsgoalistoshowyouoursimpleways

totakecontroloyourgynecologichealth.Bydoing

this,youcanprotectyourhealthandyourlie.Heres

awaytorememberthegoalsoGynecologicCancer

AwarenessMonth.

GGETTOKNOWYOURFAMILYHISTORY.

Learnaboutyouramilyhistoryobreast,ovarian,uterine,

andcoloncancers.Thegeneticriskorovariancancer

canbepassedontoyouthrougheitheryourmotheror

ather.Thismakesbothamilyhistoriesequallyimportant.

Familialriskisthemostsignicantriskactororovarian

cancer.Alertyourgynecologistaboutyouramilyhistory

ocancersoyoucantakepreventivesteps.

CCONDUCTANONLINERISKASSESSMENT.

Take15minutesoutoyourdaytodetermineyourrisk

odevelopingoneothesecancers.VisittheWomens

CancerNetwork(WCN)website(www.wcn.org).Takethe

ree,personalizedassessmentoyourriskodeveloping

cervical,ovarian,uterine,andbreastcancer.TheWCN

websitealsohasinormationonthesecancers,resources

orwomenwhohavebeendiagnosedwithcancer,and

inormationoncancerexperts.

AASKQUESTIONS;EDUCATEYOURSELFABOUTGYNECOLOGICCANCER.

Educateyoursel.Learnthewarningsignsothese

cancers.Knowyourbody.Thisknowledgeisanimportant

steptoprotectingyourhealthandwell-being.

MMAKEANAPPOINTMENTFORYOURANNUALGYNECOLOGICEXAM&CANCERSCREENINGTESTS .

Getanannualgynecologicexam,nomatterwhatyour

age.Someothesecancershavenosymptoms.Theycan

beoundonlythroughregularvisitstoyourgynecologist.

Thisregularhealthcareroutineiscriticaltomaintaining

yourhealth.

TheSocietyoGynecologicOncologists(SGO)is

anonprot,internationalorganizationmadeupo

obstetriciansandgynecologistswhospecializeinthese

cancers.Itspurposeistoimprovethecareowomenwith

gynecologiccancer,toraisethestandardsopractice,and

toencourageresearch.

TheSGOestablishedtheGCFin1992asanonprot

charitableorganization,andasanextensionoSGOs

commitmenttothehealthandwell-beingowomen.

Itsgoalistoraiseundsorphilanthropicprograms

thatbenetwomenwhohave,orwhoareatrisko

developing,thesecancers.

This inormation provided courtesy o the University o

Missouri Health System

Early detection &

prevention are keys to

Gynecological HealthIts important to know

about your familys

history of breast, ovarian,

uterine, and colon cancer.These can be genetically

transmitted through

either your mother

or father.


30/48


Prescription Drugs...

Societys Loaded Gun...

That Shot MedicalEducation


31/48


Doctorsdontlisten.Patientsdontunderstand.

TheReality?Bothstatementsaretrueand

reversible.Maybethatsthereasonmorethan100,000

peopledieeveryyearintheUnitedStatesrom

prescriptiondrugerrors,whileonlyabout600dierom

accidentalgunshootings,andnearly34,000dierom

trafcaccidents.

WHYTHECONCERN?

Weareseeingthereintroductionoaclassodrugsused

totreatParkinsonsdiseaseanddepression.Thesedrugs

arecalledMonoamineOxidaseInhibitors(MAOIs).

Onthesurace,thesedrugsposelittleornoproblem.But

30yearsago,anMAOIwasatthecenteroalegalcasethat

changedthecourseomedicaleducation.Beorediscussing

thecaseanditsaectonthemedicalworld,itsimportantto

givealittlebackgroundonhowthisclassodrugsworks.

Monoaminesarechemicalsderivedromtheessential

aminoacidtryptophan,whichisconvertedbyenzyme

intoserotoninordopamine.Monoamineoxidases

areenzymesinthenervoussystemunctioningto

breakdowndopamineandserotonin.Asthename

implies,MAOIsinhibitthebreakdownenzyme,thereby

increasingnervoussystemlevelsodopamine,

(anessentialpartoParkinsonstreatment)and

serotonin(usedinthetreatmentodepression).At

normalbloodlevels,theyaregoodmedicines.Ithe

bloodlevelsgettoohigh,theycancauseserotonin

syndromeandspiralintopotentiallyatalNMS

(neurolepticmalignantsyndrome).

Thesearesoundandsaemedications,butwhenthey

interactwithothermedications--including160othetop

200prescribedmedicationsinthecountry--theresult

canbeNMS,anddeath.Thegoalthen,istoavoidthese

druginteractions--ahetygoalconsideringthereare160

drugstoavoid.

MAOIsareeliminatedmainlybytheliver.Itturnsout160

othetop200drugscanblockordelaythereaction.

Majorprecipitatingclassesodrugsincludetheproton

pumpinhibitors(reuxmeds),thetricyclics(depression,

chronicpain,IBS),stimulants,andrecreationaldrugs

suchascocaine.

MAOIsbecameinamous29yearsagoandwerethe

epicenteroaverycontroversialmedicalmalpracticecase

thatstartedin1983andendedin1995.

Thesad,butnotisolated,caseoLibbyZion

In1983,an18year-oldemalepatientwastakinga

medicationcalledphenelzine,whichisaMAOI.The

patientwasadmittedtothehospitalandgivenDemerol,

in pursuit of perfection

man often ruins that

which if left alone

would sufce

Chinese Proverb


32/48



33/48

whichincombinationwithphenelzinecanresultinNMS.Inthecase

oLibbyZion,itprovedatal.NobodyknewatthetimethatLibby

wasusingcocainealongwiththephenelzineandthecombination

playedamajorroleinherate.Moreimportantly,thepatientandher

amilyailedtotellthephysiciansaboutthecocaineortheMAOI.Her

drugusewasnevermentionedinthe12-yearplusmediatrial.The

casewaspopulardiscussionatthetime,evenwithoutallotheacts.

Unortunately,itwentontoimpactmedicaltrainingbeginningwell

beorethetrialstartedandbeorealltheactssuraced.Thebasiso

thelegalcasewasthattheinternintheZioncasewasoverworkedand

overtired,directlyleadingtothedeathothepatient.

Themediatrialmademuchotheoverworkedinternandcauseda

completerestructuringothemedicaltrainingsystemintheUnitedStates.

Thecaseservedtoindicttheentirestructureomedicalresidency

trainingbasedontheailureoaresidentsabilitytopickupadrug

reactionthat85percentowide-awakedoctorswouldntcatch.Picking

uponadversedrugreactionsrequiresknowledgeothemedication

beingstarted(inthiscaseDemerol)andknowledgeoanydrugsin

thepatientssystem.Theamilydidntwinthelawsuitbecauseotheir

ailuretoinormtheattendingphysiciansaboutthecocaine.

CocainecancauseNMSthroughitsownactioninthenervoussystem,

butitalsocanincreasetheeectoMAOIs.LibbyZionsdeathwas

probablytheresultoNMS.However,withoutmoreinormation,

malignanthyperthermiacantberuledout,giventhemixtureo

medicationsandherseizure-likesymptomsincludingaevero107.

Ineithercase,themedicalteamwaswrongtotreatwithDemerol.

DemeroliscontraindicatedinNMS,butisrecommendedormalignant

hyperthermia.EvenwithouttheDemerol,thisyoungladymighthave

diedromwhatwasinhersystem.Recommendedtreatmentorher

symptomswouldbeabenzodiazepinelikeValium,whichwouldbe

indicatedinthetreatmentoNMS.A1999study(ouryearsater

thetrial)showedthat85percentophysicianswereunawareothis

possibledruginteraction.

THEPAST

ThereisaChineseexpression: in pursuit o perection man oten

ruins that which i let alone would suce .

DoctorstrainedatoraroundthesametimeasI,wentthroughmedical

schoolabout30yearsago,startedresidencyabout25yearsago

andtheirpracticesbetween20and22yearsago.Wewereactually

intrainingduringthetransitionothiscase.WhatImeanbythe

transitionisthis.WhenIbeganmyinternshipinInternalMedicine,the

internshipyearwasextremelydifcult.Oncallwaseveryothernight

oreverythirdnightdependingupontherotation,startingat8:00in

themorningandgoingto8:00thenextmorning.Wedidntgohome

at8:00inthemorningtosleepbecausewewereexpectedtostay

untilabout5or6:00intheevening.Wewouldsignouttotheon

callresidenttheollowingeveningbeoregoinghometosleepor12

hours,beoredoinganother36-hourstretch.Thejokeatthetimewas:

Whats wrong with being on call every other nighttheanswerwas

you miss hal o the interesting cases.

Thedownsidewasweinternsweretiredmuchothetime.Theupsidewaswewerentreallymakinglie-and-deathdecisions.Everynight,

oncall,therewasajuniorresident,aseniorresidentandanattending

physician.Theywerenotinthesamesleepdeprivedrotationasus.We

wereintimatelyinvolvedinthecareprocessandwerelearningmassive

amountsthroughexperience.Thejuniorandseniorresidentswere

betterrested,overseeingallothedecisionmakingprocesswithnal

oversightromtheattendingphysician.

Theendotheinternshipyearwashistoricallyacelebratorytime,

becauseitmeantthatliewouldbeconsiderablyeasierorthenext

twoyears.Thosenexttwoyearswereatimetooverseethenew

internsandtoconsolidateknowledgebase,interactingwiththecare

team--particularlytheproessorsromdierentspecialtiesonthe

variousrotations.

Thisallstartedtocomeunraveledattheendomyinternshipyear

becauseotheLibbyZioncasepublicity.

Mysecondyearasajunioradmittingresidentwentrombeinga

celebrationosomeslightimprovementinqualityolietoasurreal

sentencing.Sincetherewasnomoneyandnomechanismtoadd

residents,theanswertotheproblemotheinternshipoverworkwas

tomakeliehellorsecondyearresidentsbytakingupmuchothe

workloadortheinternssotheywouldbesufcientlyrested.Theircall

wasslasheddramaticallyandplacedonourshoulders,andwedidit

airlyquietly.Theunairnessbecamequicklyapparentneartheendo

oursecondyear,whenitwasdecideditreallywasntairorthirdyear

residentstonotsharetheload,leavingalltheworkorthepoorsecond

yearresidents.Thisresultedinanotherrealignmentotheworkload

justintimeorourthirdyear,sowewereabletoassumemuchothe

workloadorthesecondyearresidents.Ratherthanbeappreciative,

andconsistentwithhumannature,thenewrstandsecondyear

residentswerejubilantandmockingabouttherollingtsunamio

misortunemypoorgroupsuered.

IwasexcitedtostartmyFellowshipinGastroenterologybecausemy

qualityoliewasnallygoingtochange.Unortunately,theotherrst

yearFellowcamedownwithanautoimmuneillness,whichmeantI

hadtobeoncalleverydayor365continuousdays.Ididntseemy

rstdaughteruntilaewdaysaterherbirth.Ihavereadthebook

The House o Godandmyonlyresponseisthathehadnothingto

complainabout.



34/48


Thoseousridingthewaveomisortuneprobablysettheworld

recordorbeingoncallduringmedicaltraining.Ultimately,wereceived

bettertrainingbecauseothetimewespentinthehospitaltakingcare

opatients.Myquestionis,whoistheloserinthiscascadeoevents?

Nottheheavilyburdenedresidentsomytime.Iwouldsaytheloseris

everyinternthathadaneasierpaththroughtrainingandthepatients

intheircare.

OUTCOMESMEDICINE

Anotherinterestingphenomenondevelopinginthesameplaceat

thesametimewasamedicalpracticecalledOutcomesMedicine.In

myopinion,OutcomesMedicinehasdamagedmedicaleducation.

Mytraininginstitutionwaspioneeringtheeldwhiletheseother

changeswerehappeninganditbecameabizarreactbeingcarried

outinrontous.Thiswastheresultothewell-intendedeorto

tryingtoeliminateanecdotalmedicaltrainingandreplaceitwith

statisticalanalysisooutcomes,culminatingintheannouncemento

anoutcomeservice.Theservicewouldbetakingcallandwouldbe

availabletohelpuswithdifcultdecisionmaking.Weresidentsound

thiscomical,especiallywhenputintopractice.Wewouldpurposely

callthe outcomes expertinthemiddleothenightwithdifcult

medicalmanagementquestions.Wewouldspend20-30minuteson

thephonegivingallotheactstotheexpert,usuallyonaconerence

callwiththeotherresidentslisteningandbitingtheirtongueswhilewe

weretoldtheywouldhaveananswerorusin48-72hours.Wewould

hangupthephoneandlookateachotherindisbelie.Everybody

knewdifcultdecision-makingoccurs on-the-fy,inlie-and-death

situationswiththeapparentexceptionotheheadothemedicine

departmentandhisnewminion(knowntousaectionatelyasying

monkeys).Nobodydoubtedthatoutcomesassessmentwouldplay

avaluableroleasapartothearmamentinmedicalpractice.The

problemwehad,andstillhave,istheattempttomakeittheessenceo

medicalpracticeratherthanasmalltool.Theresultisadependencyon

cookbook medicine.

Outcomesdidtakeholdandbegantoreplacein-depthknowledgeo

genetics,embryology,cellularbiologyandbiochemistryalongwith

physiology,anatomyandpharmacology.Whenwewereintraining

therewasanexhaustiveconsolidationoeverythingwehadlearned.

Thebasicsciencesandmedicinewerebeingappliedinasettingo

livinghumanpatients,explainedbyacademicspecialistswhospent

mostotheirtimeeducatingresidents.Thisconictedatthesame

timewithanothergrowingsocialphenomenonstartedin1990with

theelectionoBillClintontothepresidencyandconcernthathiswie

wasgoingtosocializemedicine,leadingtotheadventoor-prot

medicinewhichurtherdisruptedmedicaleducation.Asmedical

centersbecamebusinessmodels,simplyeducatingwasnolonger

consideredaviablebusinessposition.Theseeruditeproessorswith

theiraccumulatedknowledgewereexpectedtobeginseeingpatients

andbeginperormingproceduresatamuchhigherratetopaytheir

ownsalariesandgenerateincomeinthisneworprotbusinessmodel.

THEPRESENT

Wehavenowarrivedatapointinwhichweseeyoungdoctorsin

trainingbeingtreatedlikeinternsinanyotherbusinessdoingbasically

shitwork.Meaningitheyareoncallatnight,theyresleepingthe

nextday.Theyrestilldoingthesamenumberoyearsintraining,but

presentinthehospitalonlyaboutonethirdothetimeexpectedin

thepast.Medicaleducationisnowleaningheavilytowardsoutcomes

assessment,insteadoanintertwineddeeperknowledgeodisease

processes.Doctorscurrentlytrainingarenotexpectedtounderstand

thebiochemistryorphysiologyasmuchastorememberthelist

owhatdiagnosisgoeswithwhatsymptoms.Anyonecanseethe

downsideinthatittakesawaytheabilitytoreasonthroughaproblem

ratherthanrelyingontheregurgitationoinormation.Couplethese

withthedisappearanceotheacademicinstructorsromthehospital

oor,puttingthemintotheclinicorprocedureroomandreplacing

themwithayounghospitalisthiredtocarryouttheteachingrole

withoutspecialtyinsight.InanassessmentothepresentsituationI

wouldalsopointoutthatIspendmuchomytimewithpatientsgoingthroughtheirlistomedicationsandmakingchangesbecauseo

contraindicationsthatalthoughperhapsnotasimmediatelylethalasin

theZioncase,theycertainlycanhavemajorcomplicationsandIdonot

seeanimprovedknowledgebaseinmostphysicianspracticingtoday.

Itismyopinion,andtheopinionoolderphysicians,andranklythe

opinionomostnursesandmostpatients,thecurrentsituationisnotan

improvementoverthepast.Wehavetwopossiblechoices.Therstisto

ignoretheactsandproceedorwardwiththecurrentlearningmodel,


35/48

ortotakeastepbackward.Thereissimplynowaytoteachthesame

amountinone-thirdothetime.Becauseothistimeproblem,shortcuts

havedevelopedandweneedtore-explorethequestionohowdowestep

backtoamoredifcultlearningmodel.Inotherwords,oncetremendous

libertieshavebeengranteditisverydifculttotakethemback.

Mysuggestionwouldbetosimplyacknowledgebadthingshappen.Not

everyoneintheworldtakingcareopatientsshouldbedoingso.Inthe

handsomostdoctors,andwithouttheknowledgeothecocaineuse,

LibbyZionwouldhavediedinagreatmanydierentmedicalcenters

aroundthecountryoraroundtheworld.Mostimportantly,wouldshebe

morelikelytodieinthehospitaltodaybecauseothechanges,ormore

than20yearsagobeorethe

changes?Patientsdierommedicationerrors,mostothemhowever,

donothaveaatherwhoisanattorneyandwritesortheNewYork

Times.Idontmeantodiminishthegrieotheamily,butIhavetoaski

redirectionomedicaltrainingprovokedbythecombinationotheZion

casealongwiththeadventooutcomesmedicineandtheneedoror-

protmedicinehasnotbroughtusinthesearchorimprovementtoan

actualdegradationomedicaleducation.Iweailtoaskthesedifcult

questionsbecauseopoliticalsensitivitieswearedoomedtoorever

throw the baby out with the bathwater.

Iotenopenanarticlewithsomelamejoke,butbecauseothe

seriousnessothesubject,Iwillclosewithajokeinstead.

Ayounggastroenterologisthasjustnishedhistrainingandiscomingto

joinhisatherspractice.Aterallthearrangementshavebeenmade,the

youngdoctorsaystohisather:

Dad we really havent talked about the call situation.

Theatherresponds,I have given this considerable thought and I think

that the only air way to do it is to split the call 50-50.

Thesonreplies,Im so glad to hear that you have such a reasonable

attitude about it.

Theathersmilesandsays, The way I see it, I have been on call or the

last 25 years, why dont you take the next 25?

ThatjokewasntgreatsoIwilladdonemore;weCajunswouldcallitlagniappe(alittlesomethingextra).Whatswrongwithneverbeingon

call?Ocoursethereisnopunchline.Ithasntbeenwrittenyet.

StevePorter,MD



36/48

Strengthening Oversight

of Food Imports

Consumer Health Inormation www.da.gov/consumer


37/48

Consumer Health Inormation www.da.gov/consumer


38/48



39/48


Asliegoeson,weallstarttonoticecertain

changesthatareanaturalpartoaging.Maybe

ourjointsarentasexibleasbeore,orourhearing

justisntwhatitusedtobe.Ourvision,too,maybelesssharpthanitoncewas.

Onecauseoimpairedeyesightlaterinlieiscataracts.

Acataractisacloudingothelensintheeye.People

withcataractsmaynoticecloudyvisionorhalosaround

lightswhendrivingatnight.Iletuntreated,cataracts

cangreatlylimitvision.Inact,somepeoplewithsevere

cataractsmayonlybeabletotellthedierencebetween

lightanddark.

Cataractsarecommoninolderadults.Abouthaloall

Americanswilleitherhavecataractsorhavehadcataract

surgerybythetimetheyreachage80.

I dont usually think o cataract as an eye disease. In

most cases, its simply a normal aging change o the

eye,saysDr.RachelBishop,anophthalmologist(eye

doctor)atNIH.Typically, cataracts dont cause damage

to the eye the way most eye diseases do.

Earlysymptomsocataractcanbeimprovedwith

eyeglasses,brighterlighting,anti-glaresunglassesor

magniyinglenses.Ithesestepsdonthelp,surgery

istheonlyeectiveoptionortreatment.Surgery

involvesremovingthecloudylensandreplacingit

withaplasticlens.

Cataractproceduresareamongthemostcommon

surgeriesperormedintheUnitedStates.Mostpatients

recoverinjustaewweeks,andmanyhaveimproved

eyesightateraewdays.Recentadvanceshaveallowed

doctorstotailornewlensestopatientsandhelpreduce

theneedoreyeglassesatersurgery.

Thedecisiontohavecataractsurgeryisapersonalone

thatshouldbemadebetweenyouandyourdoctor.Some

expertsadvisethatcataractsberemovedonlywhen

visionlossinterereswithyoureverydayactivities,suchasdriving,readingorwatchingTV.

Thebestwaytopreventordelaycataractsistoprotect

youreyesromharmulultravioletraysromthesun.Try

wearingsunglassesorahatwithabrim.Researchers

alsobelievethatgoodnutritioncanhelpreducetherisk

oage-relatedcataract.Theyrecommendeatingplenty

ogreenleayvegetables,ruits,nutsandotherhealthy

oods.Also,dontsmoke,becausesmokingmayspeed

what doctors know - september 2013

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