Light Pollution

Cities and towns are shifting their outdoor lighting to LED bulbs (Light Emitting Diodes) because they use less energy and fuel to burn and are more environmentally friendly.  They last longer and ultimately will be cheaper. The cities of New York and Seattle have replaced, or are in the process of replacing, all their street lights with white LED bulbs at a color temperature of 4000 – 5000k.  Why then did this environmentally friendly and economically sound decision result in the American Medical Association (AMA) issuing a statement condemning this practice?

It seems that the older less efficient street lamps or incandescent bulbs had a color temperature of 2400 K or less Candle light is actually a bit less than 1800 CT. At the higher color temperature the light contains more of the blue spectrum of light which has a shorter wavelength than the former incandescent bulbs which had more yellow and red. The result is that the new bulbs produce significant glare resulting in pupillary constriction and reduced vision. In addition, blue light scatters more on the retina and at sufficient levels can damage the retina in addition to making driving and night walking more difficult.

The American Medical Association believes the white LED light suppresses natural production of melatonin by the brain more than five times what the former bulbs were capable of. This has a major effect on human’s circadian rhythm and ability to fall asleep. For the animal kingdom it can adversely affect the migratory pattern of animals and can adversely affect aquatic animals such as turtles and their nesting and reproductive habits.

The AMA statement called for using the lowest level of blue wavelength light possible to reduce glare. They encourage the use of 3000k or less CT for outdoor lightings and roadway lighting to reduce glare and improve safety.  They additionally asked for dimming of these lights for off peak periods. They did not condemn or call for a ban on LED lights just for municipalities to be aware of the dangers of using the products with a high color temperature (CT) above 3000k and blue wave length predominant light.

Generics and Therapeutic Substitution – Safety and Efficacy?

Excuse me for being a “doubting Thomas,” but when I saw articles in JAMA Internal Medicine and commentaries supporting use of generics instead of brand name drugs I asked myself “Where is the proof of equivalent results and safety?”.  Generic substitution implies that the original product is no longer patented and exclusive and another firm is now producing an identical chemical version which produces the same beneficial effects on the patient.  Therapeutic substitution means your pharmaceutical insurance company or pharmacy changes the drug you are prescribed to one in the same drug class. Think of drinking Coca Cola and having the supermarket substitute a comparable brand instead.

The reason for this is simply to spend less money. Many pharmaceutical insurance companies realize if they put an obstacle in your path of obtaining your medication you likely will pay for it independently saving them money.  The authors of the JAMA articles estimate between 2010 and 2012 therapeutic substitution would have saved $73 billion. The out-of-pocket savings to the patient would have amounted to $25 billion.

I’m for saving money and spending less with certain guidelines. However; I want to know that a generic medicine is produced in a factory inspected by the Food and Drug Administration (FDA) at least as frequently as the drugs produced in North American factories. I like to know where the drug was made including country of origin, city, location and the plant’s track record for health and safety. I also want to know the generic medication produces the same drug levels and positive effects as the brand name medication and is made with no more contaminants than the original branded product.

I need reassurance that my patient isn’t receiving a counterfeit product with stolen original labeling, which has been a scam fooling pharmacists and Customs agents for years.   I would additionally like to know that the generic product, or therapeutically substituted product, works as well as the original. We know for example that Levothyroxine generics and substitutions are problematic.  We additionally know that the beta blocker carvidilol (Coreg) has certain unique properties that other beta blockers do not provide making therapeutic substitution for less expensive medications in the beta blocker class problematic.

Once this information is available it should be distributed in package inserts, online and taught in pharmaceutical, nursing and medical school courses as well as CME courses for health care professionals.

There is an abnormally perverse concern that if a pharmaceutical representative takes a health care provider out for a meal and a drink while explaining their product, we will prescribe it even if it is more expensive or doesn’t work as well.  I doubt sincerely that most physicians would do that but do believe if the cost is comparable, or less, and the efficacy is as good, they might choose the product as a viable alternative.

Zika Virus: Updates and Need for Congressional Action

As we move from spring to summer we will be facing warmer temperatures, higher humidity and more rain.  This creates a perfect environment for standing water mosquito breeding grounds, and an increase in the mosquito population especially the Aedes aegypti which carries the Zika Virus, Dengue Fever and Chikengunya Viruses.  President Obama and the Center for Disease Control have asked the United States Congress to allocate 1.9 billion dollars to fight Zika virus but conservative Republican elected officials have failed to address the issue. As a short term stop gap measure the CDC has suspended its work on Ebola and other hemorrhagic diseases and begun using those funds for Zika Virus research.  They are in the process of developing a Zika Virus Vaccine for prevention in humans but are several years away from achieving this.  Zika virus is currently widespread in South America, Central America and the Caribbean Basin.  While the infection produces an extremely mild clinical pattern in most humans, it causes severe birth defects in pregnant women including microcephaly or small skull or cranial cavity for an enlarging growing brain. Infected fetuses result in spontaneous abortion, death of the child or lifelong neurologic deficits. At this point researchers are not sure exactly at what point in a pregnancy, exposure to the Zika virus causes birth defects.  In adults the disease is mild but the body’s antibody response against the virus can result in progressive ascending paralysis with a disease known as Guillan Barre. Many of these patients eventually have their diaphragm and respiratory muscles involved and require intubation and respirators to survive. If they survive the adult illness they are often left with painful neurologic issues post paralysis.  To date most Zika infections occurred in travelers returning from areas of the world overrun with Zika. There has been documented sexual transmission of the virus between an infected and uninfected partner.  The disease symptoms are so mild in some they do not even realize they are infected.

The fear is that with the warm wet weather our local mosquito population will become infected with the Zika virus by sampling the blood of infected individuals and start a local epidemic.  NASA has created a model which predicts an epidemic in South Florida, Houston and southern Texas and parts of Louisiana. Mosquito control is one means of fighting the vector of transmission. Most local spraying programs hope to reduce the mosquito population by 50% to be considered successful but this rate of success will not prevent transmission of these three viruses.  Officials in the Florida Keys have begun releasing sterile male Aedes aegypti mosquitoes into the population in the hopes of reducing the overall mosquito population.  In a recent article in the journal Cell Symposia, researchers presented data suggesting that infecting the male Aedes aegypti mosquito with parasitic bacteria known as Wolbachia may inhibit viral replication of the virus and transmission by mosquito bites.  They have already shown that infecting mosquitoes with this parasitic bacterium reduces the spread of Dengue fever and Chikengunya.  To move forward with a project like this requires Federal funding and Congress is delaying addressing the issue as part of the politics of NO in an election year.

To protect yourself this spring and summer please make sure there is no free standing water on your property which can be used as a breeding ground by mosquitoes. Make sure your screens are intact at your home.   Wear long sleeves and use insect repellant. Consumer Reports still recommends repellant with 8 – 30% DEET, 20% Picardin or 30% Oil of Lemon Eucalyptus. They specifically suggest Sawyer Fishermans Formula Picardin or 2 Repel Lemon Eucalyptus or Deep Woods Off with 25% DEET.  Above all contact your Congresspersons and Senators and encourage them to fund the fight against Zika.

Glucosamine and Chondroitin Sulfate Preserves Knee Cartilage in Osteoarthritis

My brother in law is a well-respected researcher and biochemist. Thirty years ago he treated his post exercise aching knees with glucosamine and chondroitin sulfate and felt better. Since then he is a fan. Although he is a firm believer in the scientific method and double blind controlled research studies, we could not find any research to support his observations.   The discussion then turned to, “it helps me and it doesn’t hurt me so why not?”

In a double blind study sponsored by the National Institute of Health known as GAIT, 1500 or more patients with osteoarthritis and a painful knee were randomized to either receive glucosamine and chondroitin sulfate, each substance individually, Celebrex or placebo for six months. The results showed neither led to reduced pain.

Several other studies were as non-conclusive. In the few studies where pain was reduced the study methods and design were criticized and the results were felt to be questionable as were the conclusions of the researchers.   There was nothing positive to say about glucosamine and chondroitin sulfate until a recent study by Martel- Pellitier, Canadian researchers published in Arthritis Care and Research those individuals who took the combination for six years or greater tended to preserve their knee cartilage better than those who did not.  While the knee cartilage was maintained there was no difference in pain or complaints of symptoms between the treated and non- treated group. They believe that by preserving knee cartilage over time there may be less necessity for that joint to be replaced eventually.

I am sure over time this will be studied as well. In the meantime glucosamine and chondroitin sulfate seems to have little toxicity and ultimately my brother in law may be on to something positive.

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?

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