Arsenic Levels Elevated in U.S. Wines

Denise Wilson, PhD, a professor at the University of Washington evaluated 65 red wines from California, New York, Washington and Oregon and found they all contained the heavy metal poison arsenic at levels of 10 parts per billion or greater. Lead was found in 58% of the wines. This would coincide with two studies published in the Journal of Environmental Health studies that showed that many U. S. Wines and beverages contained more than the limit of 10 parts per billion.

Dr. Wilson went on to say that individuals who consumed 1-2 glasses of wine per day using the same winery for their beverage should be aware of the arsenic levels of the water that supplies that winery. She counseled individuals to be aware of their total diet and its potential heavy metal content and try to limit products known to be high in arsenic and heavy metals. Dr. Wilson pointed out that the cumulative effect of these metals is very difficult to implicate as the cause of an illness but it undoubtedly has an effect. Scientists are far better at implicating heavy metals as the cause of illness in acute toxic exposure rather than a cumulative dosage.

The online periodical “Deadstate” in its March 21, 2015 issue at published a complete list of “wine brands that have allegedly been poisoning you with arsenic.” This is a list of inexpensive California wines cited in a class action suit initiated by the law firm of Kabatec Brown Kellner. They stated, “These wineries have long known about the serious health risks their products pose to customers. Instead of reducing the exposure to acceptable levels, the defendants recklessly engage in a pattern and practice of selling arsenic tainted wine to California consumers.”

There has been little research and publication in peer review journals of the presence of or health effects of heavy metals in our food and beverages. The degree of oversight of these products has been limited due to funding and lobbying of the industries. It’s probably time for a bit closer look at these allegations especially where they pertain to women of child bearing age and children. Arsenic has been detected in apple and grape juices, milk, bottled water, infant formula and cereal bars. Consumers deserve a closer look at these issues and transparency in the findings.

There is No Hope for Ending Medicare Fraud

South Florida is apparently a hotbed for criminal Medicare fraud. It is easy theft with crime rings accessing Medicare numbers of the elderly in Dade County and Broward and setting up durable medical equipment companies that bill our local Medicare subsidiary for equipment that doesn’t exist. Having said that, yesterday I received a Medicare Summary of Benefits letter for my mother at my home. She is almost 90 years old and my brother and I are her legal guardians and handle all her financial affairs while she resides in a skilled nursing facility in northern Palm Beach County, Florida. We moved her to this excellent campus in May of 2015 from a facility in Broward County and by submitting a change of address notice to the US Post Office, all her mail now comes to me. The official Medicare Benefits Summary stated that on September 11, 2015 a claim had been received for a wheelchair for my mom for $280 from a durable medical equipment company in Miami, Florida. The ordering physician was her former physician at her former Broward County skilled nursing facility. I thought it was strange that a bill would be submitted for a wheelchair four months after she was gone from that facility so I tried to reach the doctor. I was told that he was no longer at that facility. I next called my mom and asked her if she had received a new wheelchair in the last few months and she just did not remember if she had or not. I had no knowledge of it but the move from one facility to another accompanied by closing down her apartment in the assisted living section had been tumultuous and disorderly.

I then called the Medicare Fraud number listed on the piece of mail, 1-800- Medicare. The call was answered by an automated attendant who did not list “Fraud Report” as one of the choices so I pressed 5 for “other.” I was placed on hold for five minutes and a pleasant gentleman asked me why I was calling. I explained and he politely asked me to please hold on. Another five minutes elapsed before he got back on the line and apologized for the delay. He started asking me personal questions about my mother for security purposes such as her address, phone number, date of birth, Medicare number. He then asked me to hold on while he prepared a report and another seven minutes elapsed. He told me he would be transferring my call to a supervisory claims officer and I held on again.

It took five or more minutes before a woman got on the phone and repeated the same questions I had already been asked and answered. I tried to explain the purpose of the call and my relationship to my mother but she politely silenced me and told me that she had the original agent’s summary and knew the reason for the call. She asked me to hold on while she looked up the claim and another ten minutes elapsed. When she returned she told me that Medicare paid durable medical equipment claims monthly for up to twelve months and possibly this was a late claim for a 13th month. I then asked her what type of non-motorized wheelchair could possibly cost 12 X $280. I explained to her that all I was interested in was reporting a suspicious claim. She told me that without me forwarding her a copy of my Power of Attorney form she would not be able to reveal any claims history information to me. I told her I wasn’t asking for her to reveal any information but was just trying to report a suspicious Medicare claim. She responded that the claim had been denied and not paid so why was I making such a fuss in the first place. Having invested almost an hour trying to be a responsible citizen I gave up. If this is the type of system we as citizens put in place and tolerate then we deserve to be ripped off!

Two Handoffs with Different Outcomes

My 66 year old professional athletic patient had a history of a scar tissue related small bowel obstruction seven years ago related to a previous appendectomy. He now had similar symptoms with cramping, lower abdominal pain, and some nausea. Since his office was next door to his longtime friend and gastroenterologist he called over there. He was given an appointment with the junior partner since his buddy was out of town. Thirty years earlier I had referred him to that practice. The junior partner examined him, thought it was a self-limited viral illness and sent him home. The next day the two met in the Emergency Department for similar symptoms and once again the patient was sent home. The symptoms continued for 48 hours, and at the end of one of his long workdays he again saw the junior partner. This time the gastroenterologist sent him over to the hospital for a CT scan at about 6PM. Two hours later he received a phone call that the patient had a small bowel obstruction and the radiologist inquired of the GI specialist; “What should I do with him?” He was told to send him to the Emergency Department. When the physician in the ED called the GI doctor for admitting orders, he responded,” call his PCP (primary care physician) I am a consultant and I do not admit patients. “Forty five minutes later I received a call from the emergency department informing me for the first time of my patient’s problem and asking me to come in and admit the patient to the hospital. I asked him why the GI doctor was not taking ownership of the problem. I was told that the gastroenterologist said he was a specialist and did consulting not admissions. When I called the gastroenterologist directly I reached one of the covering partners who told me, “We are only gastroenterologists and we have not kept up our certification in internal medicine so we are really not qualified to admit a patient with a bowel obstruction or provide the day to day medical care.”

Another patient, 67 Hispanic and female was being treated for depression. She was under the care of a psychiatrist and in the middle of a medication adjustment. Her husband brought her to me because she was hallucinating, talking to her deceased father, acting violent and sexually inappropriate. I called her psychiatrist and then her neurologist who both answered the phone call immediately and suggested we schedule a CT scan of the brain. It showed a large brain frontal lobe tumor with much swelling around it and a hint of hemorrhage. I met with the patient and informed her of the problem and called the local university medical center to speak to the director of their brain tumor department. The university center is traditionally difficult to communicate with and receive information from. This time the young new department chair took my phone call, reviewed the clinical scans and data sent to him by fax and said, “She seems like she needs our help. If she can come down now I will have our team meet her and begin her evaluation. Later that night she clinically deteriorated. I text messaged the surgeon. He responded within minutes and said, “Send her down now; my team will meet her in the Emergency Department. “ I received daily clinical updates from this department chairman and prior to discharge he called me with a complete review, medication list, things to look for and emergency contact numbers if the patient had a problem. The professionalism, thoroughness and collegial communication was outstanding and far safer for the patient than for my local patient with a bowel obstruction. I was treated as a professional colleague asking for help with a patient rather than a generalist medical doctor expected to whatever the procedural specialist did not want to do.

I thought the gastroenterologist was both rude and dismissive of primary care physicians. I believe he abandoned his patient and created a safety issue by not calling me directly if he wanted me to assume the patient’s care. I was so upset that I brought the matter to the attention of the Chairperson of the hospital department of medicine and the associate chair of our medical executive committee. Both told me that similar things had happened to them. One told me of a nephrologist performing dialysis on a mutual patient who sent a patient unannounced to the Emergency Department because his vascular access was amiss and never called him about it but expected him to admit the patient and obtain appropriate specialty help to deal with the infection. The other doctor told of a cardiology patient who saw a cardiologist in an office that was across the street from the hospital. The patient was in dire straits with florid pulmonary edema and great distress so he sent him by ambulance to the Emergency Department. When he got there and the Emergency Department called him he said, “I don’t admit. Call his PCP for that.” He never called the patient’s PCP either to tell him he was sending this mutual patient who was critically ill to the hospital. Both medical staff officers told me that I could not hope to change a national culture which dumps on the PCPs and the patients. They told me it was not a hospital staff problem but one I needed to solve with the individual consulting groups.

Failure to communicate and take responsibility for care you have begun especially when the problem is in your area of expertise is a safety issue. It will come back to harm a patient someday. When these same gentlemen are sitting in court testifying in that medical malpractice case they will say the system is not fair rather than recognize that their inactions contributed to the problem. Hospital administrators and hospital boards using physicians they now employ and a limited number of local private physicians they can control have created a culture of poor communication between caregivers at a time when the technology exists to make communication far simpler and easy. They choose physicians for committee positions that are easy to influence. Community and public input into the policies of local hospitals and health care delivery systems has been eliminated or limited so that the driving force for policy is profits whether you are dealing with a for profit or nonprofit facility. In this setting the probability of errors occurring and patients’ being harmed because of lack of communication is greatly increased. There is institutional indifference to this problem and the safety organizations responsible for inspecting hospitals have not addressed it yet.

SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.

Fish Oils in Osteoarthritis – Low Dose vs. High Dose

Using the common sense approach that if a little bit is good then more is better in the treatment of “rheumatism” Catherine Hill, M.D., of the University of Adelaide in Australia and colleagues looked at the effect of taking low dose fish oil supplements versus high dose fish oil supplements. When one looks at the adult population of Australia, one third of them take fish oil supplements and had within a month of this study. The typical dose is one ml of fish oil per day. Experts say the dose for anti-inflammatory effect for arthritis is considerably higher at 2.7 gram or 10 ml per day. Dr Hill’s theory was that high dose fish oil for symptomatic and structural outcomes in people with knee osteoarthritis was better.

She enrolled 202 symptomatic patients in a double blind study. High dose group patients received 4.5 g EPA/HPA per day. The low dose group were given a blended of fish oil containing 0.45 g EPA /DHA per day in combination with Sunola oil. Both supplements were flavored with citrus oil.

All patients received a baseline MRI of the knee at inception of the study and at two years. The patients mean age was 61 years and body mass index was 29kg/meter squared. Both groups showed x-ray evidence of arthritis in the knee at inception and both groups were allowed to take non-steroidal anti-inflammatory medications and acetaminophen for arthritic pain during the course of the study.

At two years there was no difference in the MRI findings or cartilage volume loss between the high dose and low dose groups. Each group took similar amounts of NSAIDs and acetaminophen for pain on a regular basis. The high dose had no benefit over the low dose.

The researchers concluded that there was no benefit in their study to high dose versus low dose fish oil supplementation for arthritis. They reasoned that since patients in the study were permitted to take additional fish oils on their own during the study this may have altered the findings. The researchers additionally had little control over how much fish the participants ate.

In reviewing the data it seems to indicate that fish oil played a minor role in slowing down arthritis in the knee joint. Low dosage had as good of an effect as high dosage but the studies lack of a true control group who did not take fish oil at all made the conclusions hard to accept.

I will suggest to my patients that they continue to eat two fleshy fish meals per week to get their fish oils for arthritis and cardiovascular protection, rather than purchasing and taking low dose or high dose fish oil supplements.

Are Non-Steroidal Anti-inflammatory Drugs Safe?

In recent months patients and physicians have been challenged to find safe medications to relieve pain. Nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen and others were once the mainstay of simple pain relief. We knew that they could irritate the lining of your stomach and possibly cause gastrointestinal bleeding so we suggested that you take them with food in your stomach. We knew they could injure your kidneys so we reduced the dosage and frequency to individuals with kidney issues. When reports came out that these effective pain medications were contributing to acute heart attacks through coronary artery spasm, we grew leery of prescribing them. In recent years after a pharmaceutical industry push to use narcotics for pain relief we are confronted with addiction and all its negative connotations to deal with if we use opioids to relieve pain. What then is available to prescribe for pain?

The SCOT (Standard Care vs Celoxicab Study), championed by, Thomas M MacDonald, MD, of the University of Scotland Dundee helped provide an answer. The study was discussed at the meetings of the European Society of Cardiology this week with results that show that older patients with no heart disease history had no increased risk of heart attack or stroke while using NSAID drugs for extended treatment. They followed 7297 patients 60 years of age or older for three years who were prescribed celecoxib (Celebrex) or another nonsteroidal drug. The endpoint of the study was a heart attack, a stroke or the discovery of new cardiovascular disease. The number of new heart attacks or strokes was actually far lower than predicted proving that these drugs do not cause heart attacks or strokes in cardiovascular disease free individuals. The study did not look at these drugs effect on individuals with documented heart or cardiovascular disease.

In recent months the Food and Drug Administration has insisted that manufacturers of NSAID’s specifically inform and warn consumers of the increased risk of a heart attack within weeks of starting the drug and increasing with time. This study will now allow us to relieve the pain of the young athletic individual with musculoskeletal pain without fearing we are setting them up for a cardiovascular calamity.

Cold and Flu Season Coming

As we head into fall and winter we see an increase in the number of viral respiratory illnesses in the community. Most of these are simple self-limited infections that healthy individuals can weather after a period of a few days to a week of being uncomfortable from runny noses, sinus congestion, sore throats, coughs, aches and pains and sometimes fever. There are studies out of Scandinavia conducted in extreme cold temperature environments that show that taking an extra gram of Vitamin C per day reduces the number of these infections and the severity and duration in elite athletes and Special Forces military troops. Starting extra vitamin C once you develop symptoms does little to shorten the duration or lessen the intensity of the illness. Vigorous hand washing and avoidance of sick individuals helps as well. Flu shots prevent viral influenza and should be taken by all adults unless they have a specific contraindication to influenza. A cold is not the flu or influenza. Whooping cough or pertussis vaccination with TDap should be taken by all middle aged and senior adults as well to update their pertussis immunity. We often see pictures of individuals wearing cloth surgical masks in crowded areas to prevent being exposed to a viral illness. Those cloth surgical masks keep the wearers secretions and “germs” contained from others but do nothing to prevent infectious agents others are emitting from getting through the pores of the mask and infecting them. If you wish to wear a mask that is effective in keeping infectious agents out then you need to be using an N95 respirator mask.

Once you exhibit viral upper respiratory tract symptoms care is supportive. If you are a running a fever of 101 degrees or higher taking Tylenol or a NSAID will bring the fever down. Staying hydrated with warm fluids, soups and broths helps. Resting when tired helps. Most adults do not “catch” strep throat unless they are exposed to young children usually ages 2-7 that have strep throat. Sore throats feel better with warm fluids, throat lozenges and rest.

You need to see your doctor if you have a chronic illness such as asthma , COPD, heart failure or an immunosuppressive disease which impairs your immune system and you develop a viral illness with a fever of 100.8 or higher. If your fever is 101 or greater for more than 24 hours it is the time to contact your doctor. Breathing difficulty is a red flag for the need to contact your physician immediately.

Most of these viral illnesses will make you feel miserable but will resolve on their own with rest, common sense and plenty of fluids.


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