Legalization of Medical Marijuana and Traffic Fatalities

The State of Florida has legalized marijuana for medical purposes. Marijuana has now been legalized for medical use in 28 states.

We know that marijuana and or alcohol impairs ones driving ability. Surprisingly, the traffic fatality rate dropped by an average of 11% in states that have legalized medical marijuana since 1996. At the moment researchers have no explanation for this finding. They believe marijuana users stay home off the road and use their medication while individuals drinking alcohol are more likely to drive to or from an establishment serving alcohol.

The state of Colorado has legalized marijuana for general recreational use. They do not yet have data on traffic fatalities and marijuana usage.

Red Meat May Not Increase The Risk For Vascular Disease But Is It Healthy?

A study published in the online version of Consultant 360 magazine looked at the relationship between eating red meat and cardiovascular risk factors. The study was performed at the Department of Nutrition Science at Purdue University. Researchers reviewed 24 studies on the topic listed on PubMed, Cocrane Library and Scopus databases. These studies examined individuals 19 years old or older who consumed at least 35 grams of red meat per day and whom listed at least 1 cardiovascular risk factor. They then examined the study participants blood total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides plus systolic and diastolic blood pressures.

They found that red meat at these quantities did not increase lipids, lipoproteins or blood pressure. This led them to conclude that the risk for cardiovascular disease did not increase in individuals consuming more than the recommended daily amount of red meat.

While this study gives hope to meat lovers, cardiovascular disease is not the only cause of illness or death. High consumption of red meat has been implicated in a greater risk of developing colon cancer, breast cancer, diabetes and an overall increased risk of death from all other causes. Some individuals seem to believe that you can counteract this negative effect of red meat by eating large quantities of fresh fruits and vegetables. Unfortunately a Swedish study published this year in the American Journal of Clinical Nutrition disproved this theory. For men, the more red meat they ate the more likely they were to develop diabetes. For both women and men, those who ate the most red meat had a 21% greater risk of all – cause mortality than those who ate the least. This higher risk did not change when the authors took into account fruit and vegetable intake. Interestingly it was processed meat that caused the rise in health risk with unprocessed meats only being associated with a slightly increased death risk even at high consumption levels.

I believe the take home advice is that consumption of unprocessed red meat in moderation with plenty of fresh fruits and vegetables doesn’t impair your risk of dying. Processed meats are to be avoided if you wish to avoid multiple illnesses and disease. Give up the bologna and salami and other processed meat products except on limited occasions.

New Common Cold, Alzheimer’s and Influenza Vaccines on the Horizon

On a regular basis I see patients miserable with symptoms from a viral upper respiratory tract infection or common cold. They run fevers, are chilled, ache all over, have painful burning throats, runny noses, sinus congestion and just feel miserable. Our therapeutic options include only rest, warm fluids, throat lozenges, cough medicines and aspirin type medications. Antibiotics do not work against viral illnesses.

Researchers at Emory University have developed a vaccine for the common cold. It contains 50- 100 of inactivated Rhinoviruses. Rhinoviruses cause 60-80% of our common colds. Rhinovirus is the most common pathogen exacerbating infections in patients with asthma and emphysema.

The initial work on this vaccine began 60 years ago but the sheer number of different Rhinoviruses, coupled with the limited technology of that time period, prevented progress. With today’s technology researchers have been able to administer 50 or more inactivated Rhinovirus variants to mice and monkeys producing neutralizing antibodies and preventing these infections. Human trials are scheduled to begin shortly with the expectation that a vaccine may be available in two years. The initial recipients will be high risk patients with COPD and asthma but all others will be able to receive the vaccine as well. They believe the immunity will last for two years and then a booster will be required.

There is a new vaccine for influenza prevention in adults 65 years or older being produced which will cover all four of the common viral influenza variants. Currently Fluzone is the senior high dose vaccine recommended to prevent the three most common A viruses. There is a B1 virus seen in the spring that is not in that product. Younger adults receive a Quadrivalent flu vaccine that includes the B1 virus. Within the last four weeks Flublok has been approved by the FDA and released as a high dose vaccine which contains the three A viruses in inactivated form plus the B virus. It will be the vaccine of choice in the 2017 fall flu season. This new vaccine was produced with new DNA technology which allows it to be egg free and received by individuals allergic to egg products. Most other vaccines are grown in egg cultures and individuals with egg sensitivity cannot receive them.

Researchers in the United States and Australia have developed a vaccine to prevent and treat early and late Alzheimer’s disease. It targets the proteins found in the brains of Alzheimer’s disease in the early and late stages. The vaccine has met with success in early animal studies and is beginning formal Phase I studies this winter. They believe this vaccine can reverse some of the symptoms seen with the disease. While the early results are encouraging, this product is a minimum of seven to eight years from being available as a commercial product.

For Arthritis of the Knee, Glucosamine and Chondroitin Sulfate is the Best Medicine to Control Long Term Symptoms of Joint Change

A paper presented at the recent American College of Rheumatology annual meeting reviewed all the research results on use of medications to control joint changes and pain in arthritic knees caused by osteoarthritis. Lucio C, Rovati, MD, of the Clinical Research Department of Rottpharm Biotech, Monza, Italy and the University of Milano Vicocca, Milano, Italy and colleagues presented the first systematic review and meta-analysis to investigate the effects of available medication used for at least a year to treat knee osteoarthritis. Their findings were published in the online journal MedPage Today. They reviewed 5992 articles discussing treatment with acetaminophen, calcitonin, celecoxib (Celebrex), chondroitin sulfate, hyaluronic acid, indomethacin, naproxen, vitamin D and zoledronic acid plus several others. The only medication that had a significant long term beneficial effect on pain and physical function was glucosamine and chondroitin sulfate. This does not mean that Tylenol, Aleve, Advil, Celebrex or other nonsteroidal anti-inflammatory drugs did not provide some immediate short term pain relief. It means that over a year they didn’t maintain the joint integrity and consistently maintain or improve function.

Need To Expand the Recommendations for Screening for Lung Cancer in Former Smokers

In 1976 when I began my internship in internal medicine almost all cigarette smokers 35 years of age or older received an annual chest x ray to screen for lung cancer. In the 1990’s as managed care and insurers’ stopped paying for these screenings, we were told by the experts that the cost of saving one life by looking at every smoker was not cost effective. Insurance companies stopped paying for these films at the same time that medical advisory boards insisted on clinicians sending their chest x-rays out to be read by radiologists, adding extra costs to each film.

The practice of routine screening virtually disappeared. With it came a large increase in the number of smoking related deaths from lung cancer. It took the “experts” almost two decades to realize the errors of their decision.

In 2014 the US Preventive Services Task Force endorsed performing low dose computed tomography (CT Scans) in patients who were a high risk for lung cancer. This group was defined as individuals aged 55 to 80 years who had smoked at least 30 pack years (computed as number of packages of cigarettes smoked per day times the years the individual smoked) in individuals who continued to smoke or had quit within the last 15 years. The data to back up this recommendation came from Ping Yang, MD, PhD and colleagues at the Mayo Clinic. Their research and the new recommendations have helped reduce lung cancer deaths by 20%.

Since these recommendations were instituted, Dr. Yang and colleagues have continued to evaluate the guidelines. They found that individuals who quit smoking 15 -30 years ago are being diagnosed with lung cancer at a rate of 12-17 % of the newly diagnosed cases. They consequently are now recommending that we screen all adults 55- 80 with a 30 pack year history even if they quit more than 15 years ago.

The US Preventive Services Task Force which produces the recommendations that insurers consider has not yet endorsed this suggestion. In our practice we will be recommending low dose CT lung scanning annually on all our smokers who meet the Mayo Clinic criteria. If you, as my patient, fall into that group and have not been getting annual low dose CT Scanning of the lung for lung cancer detection please let us know so that we may set up a surveillance program. We understand the increased cost and ionizing radiation exposure that CT Scans involve but Dr Wang’s research suggests that the benefits outweigh the costs and risks.

End of Life Decisions Are Tougher Than We Think

As an internist and geriatrician I deal with elderly patients all the time. We always end up talking about end of life issues such as “Should I be resuscitated if my heart stops and I stop breathing?”. “Do I want a feeding tube or gastrostomy tube if I stop eating and require nutrition?” “Should I be kept alive on machines and for how long if there is no reasonable hope of recovery?” “When should we refuse tests for diagnosis and subsequent treatments due to frailty, age and quality of life.” These are all immensely difficult decisions for patients and their loved ones. We have documents available such as living wills and medical directives and we appoint health care surrogates to carry out our wishes when we cannot direct care ourselves due to health reasons. Despite this, disagreement often happens between family members and loved ones when the time comes to institute the plans outlined by the incapacitated patient. There are different interpretations of “living”, “terminal condition”, “life prolonging treatment”, etc. Is having a heartbeat and a spontaneous respiration truly living if you cannot eat by mouth, walk to the bathroom, recognize your loved one?

I faced these decisions as a caregiver and co-healthcare surrogate earlier this year and, despite being a professional, felt the decision making was extraordinarily painful and difficult. I share decision making with my brother who lives out of state but will hop on a plane at a moment’s notice to help out. He is an extraordinary son to my chronically ill mom. Widowed a few years back, and suffering from severe and chronic lower extremity issues, she became wheel chair bound and incontinent in the last year. Mom has been living in a highly rated senior facility with its own on-site medical staff in a complex supported by a religious philanthropic organization. Her doctor is a “fellowship trained geriatrician” from an Ivy League institution supported by a team of nurse practitioners. For this reason I decided to interact strictly as her son, not her doctor. Since dad passed away several years ago, she became withdrawn, angry and stopped participating in facility functions. The care team brought in psychiatrists who prescribed medications that left her calmer but clearly hallucinating frequently.

With isolation came increasing cognitive dysfunction with poor decision making and extremely fuzzy thinking. Four months ago she complained to me about having foot pain. I reported it to the nurse rather than undress her and examine her. The LPN reported it to the nurse practitioner. She was seen by a podiatrist several days later and several hours after that visit a nursing aide called my brother in NYC to ask permission to apply betadine (iodine solution) to an infection on her toes. He granted it. Several weeks later while visiting her I smelled decaying flesh. I noticed that when she moved her feet under her sheets she grimaced. I walked over and lifted the sheets and gasped. I was looking at seven gangrenous toes with a blue cool foot and absent pulses in both feet. No one had told my brother or me that mom had vascular insufficiency with gangrenous feet and toes. I called in the nurse and she called the nurse practitioner. The nurse practitioner had no answer as to why no one had told my brother or me that mom had a serious vascular problem going on for months. We had participated in the monthly team telephone conference calls where we listened to social workers, dietitians and therapists discuss her eating habits, socialization and participation. No one discussed gangrene.

Mom had a living will and a State of Florida DNR form. At best she enjoyed holiday trips to my home for family dinners, reading a book and watching TV. Injuries to her hands from repeated falls had made reading a book difficult. Sensitivity about wearing adult diapers and having an accident while visiting my home or out to a restaurant had made those trips a thing of the past. No one at the facility or care team discussed gangrene, evaluation and care for it or the option of palliative care. The Nurse Practitioner said that they hoped the iodine applied to the toes would stem an infection and the bloodless toes would just fall off.

I had numerous discussions with my brother about asking Hospice to intervene and provide comfort measures only at that point. My thinking was colored by my experiences as a resident at a big city hospital where a man with a gangrenous leg chose not to amputate it for religious reasons. We treated his infection but packed his gangrenous leg in ice so the decaying tissue would not rapidly deteriorate and to reduce the horrible odor. I did not want my mother to become that gentleman dying a horrible death, packed in dry ice while caregivers avoided her room due to the horrible odor.

A kind vascular surgeon in the area with excellent credentials offered to see her and offer an opinion. He said that without a diagnostic angiogram he would recommend an amputation above the knee on one side and below the knee on the other. I could not see amputating two legs. Had mom been rational and competent she would not have wanted that. Hospice seemed like the rational decision but that decision required two health care surrogates to reach agreement. “Steve I called her on the phone yesterday and the nurse brought her the phone. We had a wonderful conversation about your nephew and your kids. She seemed with it.” Grandchildren called her and had rational conversations with her. There was resistance to calling in Hospice within the family and their concerns created seeds of doubt in me. I am not blaming my relatives at all. I never stood up to them and strongly said, “She is infirm, with a miserable quality of life and no hope of improvement and you are all crazy for wanting to intervene.” So she went for an angiogram and they opened up three arteries in the right leg and then two on the left. The vascular doctor recommended amputating the gangrenous toes while the circulation was good and creating a clean margin of tissue receiving blood. That procedure took about an hour and was done right after the angiogram. All looked well when I saw her back in her room and snuck in a forbidden corned beef sandwich and kosher pickle. One week later the pain returned to the left foot. It looked dusky and pale. Noninvasive vascular studies showed the arteries that had been opened were now closed. The vascular surgeon recommended above the knee amputation. During this period of time my brother had made multiple trips back and forth from NYC to visit Nana. Our children had flown in from out of town to rally her and support her. They saw her deterioration. They saw her go from recognizing them to confusing them for our wives and her mother and sister. The decision to call Hospice this time met with no family resistance. Hospice arrived as Hurricane Matthew bore down on this area. We went home to prepare our homes for the storm and mom died during it.

Her death clearly relieved her of suffering with a horrible quality of life. That fact is comforting. Losing a mom is an irreplaceable loss. Should I have been more forceful in demanding palliative care earlier? I am still not sure. I am very comfortable with the effort to restore blood circulation to her feet to relieve pain and suffering. I would make that decision again. Other families and clinicians might not have decided that was the best course of action for their loved ones. I will say I had no guidance or help from her medical care team. I think patients and families need guidance at times like these because the choices are not black and white. There is much grey and much pain and many life experiences and emotion coloring your decisions.

I still sit down with my patient’s families and review the end of life options. We talk more about what “living” actually means to their loved ones. The decisions are never easy.

Water versus Diet Drinks for Dieting and Weight Loss

Water and many diet beverages quench your thirst and are listed as providing no energy or calories to your daily intake. With this in mind, researchers at the University of Nottingham in the United Kingdom set up a definitive study to assess the effect of water on weight loss after a meal versus a diet beverage’s effect on weight loss.

Ameneh Madjid, PharmD and associates looked at 81 overweight and obese women with Type II Diabetes Mellitus. Members of the group were either asked to continue drinking diet beverages five times per week after lunch or substitute water for the diet beverages. The researchers found that over a 24 week period, the water group had greater decreases in weight, body mass index, fasting plasma glucose, fasting insulin homeostasis and two hour post-meal glucose readings compared with the diet beverage group.

A similar study published in the American Journal of Clinical Nutrition looking at 89 obese women found that after six months the water group had lost an extra three pounds compared to the diet beverage group.

As a clinician, the idea of putting water into your body as opposed to diet drink chemicals makes great sense. There have been some researchers who felt that diet beverages eliminated calories in soft drinks but that users consumed more dietary food and calories when drinking diet beverages as opposed to water.

I will suggest to my patients that they try water instead of diet beverages but remind them that an occasional diet beverage probably will not hurt their long term goals.