Hepatitis C

The Center for Disease Control and Prevention (CDC) has requested that all individuals born between 1945 and 1965 be tested for the presence of the Hepatitis C virus.   This is a clear cut change in their policy which had previously asked that only high risk patients be tested.

Hepatitis C is a viral infection usually transmitted by blood to blood transmission.  High risk patients include intravenous drug users who share needles, men and women receiving hemodialysis, patients with an impaired immune system such as HIV patients and  patients who received blood transfusions before 1992 because the system was not tested for Hepatitis C at that time. Additionally, the disease may be seen in health care workers who were exposed to blood and in life partners of infected individuals due to sexual transmission or common use of grooming items such as razors and toothbrushes. Individuals who received tattoos with non sterile equipment are additionally at risk.

During my training years we only knew of Hepatitis A and Hepatitis B.  We were aware of a third form which we named “non A, non B hepatitis.”   With improved technique and technology the “C” virus was isolated.  It is believed that there are 1.5 million baby boomers infected who have no idea that they have the illness. It is important to detect them because the virus can lead to chronic liver disease, liver failure and liver cancer – all of which can be prevented with the treatments now available.

The disease is common in baby boomers because they were the participants in the 1960’s -70’s “ free love” generation which included IV drug use and sex with multiple partners both, of which are risk factors for the disease.  Since only 1 in 10 infected individuals become acutely ill with the infection and develop fever, malaise, jaundice, darkening urine, light clay colored stool; it is highly likely that many carriers have no idea they have the infection.  We want to find those people and treat them before they become clinically ill with the stigmata of chronic liver disease.  To identify them requires a simple non fasting blood test which can be performed by a physician or the health department.

If a screening test suggests that you are infected, additional testing will be performed to determine the genetic type of the virus you have and to assess the ability of your liver to function. You will require a liver biopsy at some point.  With this data, physicians who specialize in liver diseases called hepatologists and/or infectious disease experts can tailor the treatment to your genetic type of virus.

Experts do not want baby boomers to panic over this disease.  Infected patients can interact with the public and loved ones without fear of transmission of the virus unless they are bleeding or intimate.  The Hepatitis C virus is in fact much less likely to be transmitted sexually than the Hepatitis A or B viruses are.

Low risk individuals who have donated blood recently, are not IV drug users and have not been intimate with a Hepatitis C patient have little to be concerned about. I recommend you talk about Hepatitis C screening with your physician at your next scheduled visit.

Dr. Reznick’s Interview Regarding Human Fat

Dr. Reznick was recently interviewed by Dr. Abbey Strauss on behalf of the Florida Psychiatric Society regarding Human Fat.  The interview brings common sense clarity to the role of fat in our bodies, what it was originally used for, how that role has evolved, the causes of the obesity epidemic, the medical effect of fat on our bodies and simple things anyone can do to reverse weight gain and achieve health.

Click the link to hear this important and powerful interview.

http://www.katenagroup.org/expertsspeak/STEVE_RESNICK_MD_ON_HUMAN_FAT_AUG2012.mp3

 

Hot Cocoa And Other Foods May Boost Brain Power

G. Desideri, PhD, of the University of L’Aquila in Italy performed a controlled double blind study that looked at the effects of cocoa flavonoids on cognitive function in seniors who were mildly cognitively impaired.  The data was presented in the online journal Hypertension and reviewed in the University Of Pennsylvania School Of Medicine online journal MedPage.  Existing “evidence” suggests eating flavonoids, polyphonic compounds from plant-based foods, may confer cardiovascular (heart and blood vessel) benefits.  Flavonols are a type of compound found in abundance in tea, grapes, red wine, apples and cocoa products including chocolate.

Desideri and associates looked at 90 seniors diagnosed with minimal cognitive impairment (MCI) who were randomly assigned to drink cocoa for eight weeks containing high, intermediate and low levels of flavanols per day.  They found improvement in the cognitive performance of those in the high and intermediate flavanol intake groups.   They additionally noted improvements in blood pressure and insulin resistance for these same groups. Systolic blood pressure decreased 10 mm in the high intake group and 8.2 mm in the intermediate group. A drop in diastolic blood pressure was noted as well.     There was no elevation of blood cholesterol or triglyceride levels in any of the groups and blood sugar actually decreased in the high and intermediate intake groups.

They concluded that “regular dietary inclusion of flavanols could be one element of a dietary approach to maintaining and improving not only cardiovascular health but also, specifically, brain health.”

Clearly more research is needed but initial studies like this certainly encourage clinicians to feel comfortable suggesting that a cup of hot cocoa, a glass of red wine (in moderation), red grapes and dark chocolate are healthy as well as pleasurable.

Traditional Colonoscopy vs. No Laxative CT Colon Exam

Research radiologists at the Massachusetts General Hospital in Boston evaluated the accuracy and detail of imaging the colon (a virtual colonoscopy or colonography) with no laxatives as preparation and comparing it with traditional colonoscopy.  There are clear evidence based guidelines suggesting that all low-risk men and women have a screening for colon cancer with a colonoscopy at age 50.  If that study is normal they are directed to repeat it every 10 years.  Routine screening colonoscopies are discontinued after age 80 years old.  There is no question that screening colonoscopies save lives from colon cancer.  There is no question that the laxative taken the day before to clean you out, plus the actual procedure, are reasons that individuals avoid going for colon cancer screening.

The study directors fed their patients a low fiber diet before the scan. The patients drank an oral contrast material that marked stool feces and allowed the radiologists to distinguish colon abnormalities from retained feces and stool.  This virtual colonography was excellent at detecting larger colon adenomas of 10 mm or larger picking up 91% of the existing lesions as compared to 95% with traditional preparation and colonoscopy. The difference between the 91% on virtual colonography and 95% on traditional prep and colonoscopy was not felt to be statistically significant.   The virtual colonography didn’t do as well at detecting the smaller growths.  Researchers pointed out that “the vast majority of polyps that impact cancer and survival outcomes are 10 mm or larger.”  They went on to say that the “the laxative free method would likely be worthwhile as a way to reach the many adults whose strong aversion to laxative bowel preparations stops them from getting screened.”

Clearly getting screened is always preferable to no screening.   The laxative free virtual colonoscopy was not as good as the traditional colonoscopy at finding smaller lesions.

The data in this research study were based on the skill and experience of three radiologists only. Previous studies have emphasized the need to have an experienced radiologist interpret these studies.  The researchers did not discuss the radiation exposure, which is significant, with the virtual colonoscopy.   They additionally did not mention the cost which many health insurance companies will not pay for at this time.

Despite these issues it is wonderful to have another tool in the fight against colon cancer especially to offer to those patients who have said they will “never” have a colonoscopy.

Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

The Calcium – Vitamin D Supplementation Picture Gets More Confusing

As a geriatrician who believes strongly in prevention, my perspective is that the recent high volume of research on healthy aging, chronic disease and its association with Vitamin D and Calcium supplementation has done nothing but confuse the picture for us all. I have always been an advocate of healthy eating – a balanced diet that is prepared in a manner that retains and promotes the absorption of the foods nutrients. Also, I have supported the recommendations of blue ribbon panels to supplement the diets of women of child bearing age, peri-menopausal women and post menopausal women with 1200- 1500 mg of calcium per day in addition to dietary calcium to promote healthy bones.

I have read extensively about the lower measured values of Vitamin D in men and women who are ill and have many different types of acute and chronic diseases. I have not truly accepted the idea that raising their measured serum level of Vitamin D with pill supplements did anything to improve the disease state even if we did raise the measured serum Vitamin D level. I have been amazed by experts in Europe and Asia and in the World Health Organization setting a normal lower value of measured Vitamin D level at 20 while in the USA it is 28.  I am not convinced that healthy adults with healthy kidneys cannot get adequate Vitamin D levels by 10 minutes of sun exposure a few times per week in increments which will not dramatically increase the risk of lethal skin cancers.

This was made all the more confusing by the United States Preventive Services Task Force suggesting  that Vitamin D supplements reduce the risk for older people prone to falls and this month announcing that “there is no value for postmenopausal women using supplements up to 400 IU of Vitamin D and 1000 mg of calcium daily.”  This latest ruling was based on data which showed that at 400 IU of Vitamin D and 1000 mg of Calcium daily there was no effect on the incidence of osteoporotic fractures.

Much of the data used to reach this conclusion came from the Women’s Health Initiative Studies of more than 36,000 postmenopausal women.  The USPTF noted that at this dose of Vitamin D and Calcium there was a clear increase in kidney stones which they considered a harmful effect.  At the same time as this data was being discussed, the impartial Institute of Medicine (IOM) presented suggestions and data that Vitamin D at 600 IU daily plus 1200 mg of calcium per day prevented fractures in postmenopausal women.

For my postmenopausal patients I will continue to suggest they supplement their diets with 1200 mg of calcium per day as per the IOM suggestions unless they are prone to kidney stones. They will need to stay well hydrated while I ask them to take a daily 30 minute walk exposing their arms and legs to the sun for at least 10 minutes to allow their healthy kidneys to manufacture Vitamin D.