• Boca Raton Concierge Doc

  • Advertisements

Cleaning Is Hazardous to Your Lungs and Overall Health

In an article published in the American Journal of Respiratory and Critical Care Medicine it was shown that women who regularly clean homes show a marked decline in pulmonary function. The study looked at 6,230 persons participating in the European Community Respiratory Health Survey over a period of 20 years.

Normally lung function declines as we age but women who were professional home cleaners, and who used cleaning sprays, declined at a far faster rate than women who did not clean at home or professionally. For unclear reasons in this study cleaning did not appear to effect the measurements on men. The study authors were quick to point out that there were very few men in the study making their conclusions on men less meaningful.

The authors looked at two main parameters, Forced Vital Capacity (the maximum amount of air exhaled after a maximum inspiration) and Forced Expiratory Volume in one second. They noted that decrease in Forced Vital Capacity is associated with decreased long term survival in patients without known pulmonary disease. They additionally noted a slight increase in the development of asthma in the home cleaners.

The authors postulated that cleaning products were “low grade irritants” and chronic exposure could lead to remodeling of the airways and resultant decline in pulmonary function. While reading this article I thought about how infrequently we read labels on the products we use to clean our homes, cars and elsewhere before using them. How often do we actually follow the health advice listed on the bottle? Should we be wearing N95 respirator type masks when using cleaning sprays and working in sparsely ventilated areas? What about children and their exposure? Should we be using these products around them and or our pets? Is it the actual spraying that exposes cleaners or does the products effects linger well after use?

These are all questions that few, if anyone, looks into or answers but certainly need to be addressed now that these findings have been published.


Do Epidural Injections for Spinal Stenosis Produce Systemic Effects?

In adult medicine we see a great many senior citizens in chronic pain limiting their ability to walk and function due to severe spinal stenosis usually at the lumbar and or sacral spinal level. The bony vertebrae designed to protect the nerve bundles of the spinal cord impinge on the spinal cord as we stand upright and try to walk causing severe pain in the anterior thighs limiting activity and walking.

One of the treatments of choice prior to surgical intervention is injection of the area with an anesthetic pain killer such as lidocaine and corticosteroids. The injections are given by back and pain specialists usually in a series of three shots over time. Usually they provide some pain relief for a period of time. Since the pain is severe and life activity restricting we do not think much about the consequences of these injections beyond the usual risks of bleeding, introducing infection and or getting too close to a nerve or the spinal cord itself.

In a recent study published and then summarized in the online journal “Primary Care “, 400 hundred patients were randomized to receive lidocaine (a pain reliever anesthetic) or lidocaine plus a corticosteroid. The study determined that at three weeks there was a greater than 50% reduction in the measured level of cortisone in over 20% of the participants receiving the steroid injections. The average base line reduction in cortisol level over 3 weeks was over 40% in those receiving methylprednisolone and triamcinolone.

This information is important because it indicates these steroids are being systemically absorbed and suppressing the patient’s own production of cortisol through the adrenal glands especially in those receiving longer acting preparations. The patients are primarily elderly with multiple medical issues requiring us to look closely at whether they need a steroid stress level boost in medication during that time period if they develop an infection or exacerbation of any of their non-back related medical chronic conditions.

It will be important for patients to let their doctors know if they have received epidural steroid injections recently and to be aware of the name of the steroid used so you can be protected from not being able to respond to a stress with a cortisol burst.

More on Shingrix, the Shingles Vaccine

Recently, the FDA approved a new shingles vaccine called Shingrix. It is a two shot series with the suggestion made that the second shot should be taken 2 – 6 months after the first one. Shingrix will replace the original shingles vaccine Zostavax. Shingrix is recommended in all patients over 50 years old.

For those of you who have had the original shot, Zostavax, the new vaccine is still recommended. It is covered by Medicare Part D which means you must take it in a pharmacy or walk in center not in your doctor’s office. While this makes NO sense, it is the rule. If you have had shingles it is still recommended you take the new vaccine (Shingrix).

Shingles is a skin rash and painful skin condition caused by the chicken pox virus Varicella. When you have chicken pox and complete the infection course you are immune but the virus remains alive forever, living in sensory nerve endings along the spinal cord. One third of adults will have an outbreak of this varicella virus which will appear along the path of a sensory nerve or dermatome on one side of your body. It will go through the full cycle of rash, pustule and then scab that the chicken pox did. A significant number of patients will continue to have pain over the involved skin for prolonged time periods in what we call post herpetic neuralgia. The pain is described as severe as an eye scrape, passing a kidney stone or going through labor and delivery.

The original shingles vaccine, Zostavax, protected against the rash 51% of the time and against post herpetic neuralgia 67% of the time. This efficacy dropped to about 30% after four years. The new vaccine, Shingrix protects against the rash over 90% of the time and against the pain syndrome 85-90% of the time while lasting for more than four years.

Only five percent (5%) of patients receiving Shingrix develop side effects. The most common are fever, myalgia and chills. In view of this, I am suggesting to my patients we allow the vaccine to be on the U.S. market for a year to see the adverse event profile and, if safe, we then start the series of shots.

The Blood Pressure Guidelines Dilemma

The American College of Cardiology and American Heart Association recently published blood pressure control guidelines that suggest we should be treating blood pressure in 25 year olds the same way we treat it in 79 year olds and older patients. If you have any cardiovascular disease, or a 10% cardiovascular risk assessment over the next few years, they want your systolic blood pressure to be less than 130. They present excellent data explaining that as the blood pressure elevates above 130, the risk of a heart attack, stroke, vascular disease or kidney disease and, ultimately, death increase. No one is arguing these facts.

The American College of Physicians (ACP) along with the American Academy of Family Physicians (AAFP) recognizes this one size fits all in blood pressure control creates many problems. As we age, our arteries become less compliant or elastic. Stiffer arteries are more difficult to assess for blood pressure value. After we have exhausted the lifestyle changes of smoking cessation, weight loss, salt restriction and increased activity to control blood pressure; we are forced to use medications. We try to use low doses of medicines to avoid the adverse effects of the pills that the higher dosages can bring.

These medicines are costly. The more we prescribe the more patients don’t take them due to the cost. The more we prescribe, the more patients forget to take multiple pills on multiple schedules of administration. If we get the patients to take the medication we run into the problem of blood pressure precipitously dropping when patients change positions from supine to sitting to standing. If we are lucky, and the patient is well hydrated, then we may only be dealing with a brief dizzy spell. In other cases, we are left treating the consequences of a fall and injury from the fall. The more we strive to control your blood pressure to the new levels with medications the more we must consider drug interactions with prescription medicines being prescribed for other health problems seen in older Americans.

At this point, experts from the ACP Policy Board and noted hypertensive experts at the University of Chicago have suggested we follow the more liberal guidelines of the ACP individualizing our care based on the patient’s health issues. Personalizing care with individual goals makes sense to me, especially in my chronically ill patients battling blood pressure, weight control, age related orthopedic issues, and age related visual and urological issues plus other problems. We strive to do that in our practice allowing the time for discussion, questions and evaluation at each visit.

Emergencies and the Rational For Our Treatment Algorithm

We are a primary care medical office that tries to deliver personalized attentive care. We define emergencies as chest pain, significant breathing difficulty and loss of consciousness, uncontrolled bleeding or pain, sudden change in mental status and behavior or major trauma. In these situations, my office staff receiving a phone call interrupts me so I can speak with you and determine whether or not to advise you to call 911. We do this because we know with life threatening situations time is of the essence.

Emergency Medical Services at 911 can arrive within 5 minutes. They are all Advanced Cardiac Life Support (ACLS) trained and carry the equipment and medications to provide life sustaining care while you are transported to a hospital Emergency Department that has the staff, medications and equipment to keep you alive while we diagnose the problem and create a plan to rectify it.

The office staff is trained in Basic Cardiac Life Support. We do not have a defibrillator. We do not maintain and store medications to correct low blood pressure – cardiac arrhythmias. We do not have endotracheal tubes to intubate you and breathe for you. In the past, when we tried to maintain these supplies, they became outdated due to infrequent use and were expensive to replace. Since we do very few resuscitations day to day we are not as experienced or efficient as EMS and emergency department personnel are.

I realize the wait for care and institutional care settings are not pleasant. We sacrifice that for the best chance to keep you healthy. Trust me, it is no fun cancelling a scheduled patients to run to the ER and then return already behind. We do it for your comfort and security and safety.

In the recent past patients with chest pain resembling heart disease, trouble breathing and excessive bleeding have refused to call 911 and were upset when we did not bring them into the office. We do this for your health and safety not our convenience. If you would like to discuss this feel free to contact the office.

Extreme Exercise Tied to Gut Damage

I was out doing my morning two mile trot on an unseasonably cool late spring morning in South Florida. The crispness of the day, coupled with unexplained lack of my normal warm up aches and pains made me particularly frisky. I had walked the dog for a few miles slowly, then engaged in my normal pre-run stretching routine and felt unusually energetic and fluid. I was enjoying the outdoors and weather, while listening to music on my play list and struggling to stay within the parameters of speed, pace, and target heart rate appropriate for a 67 year old man. The inner competitor within me was screaming, “You feel great, go for it.” Moderation and common sense are always the great traits to keep exercising and not injured. The inner stupid competitor in me said pick up the pace. I did pick up the pace. I completed my course far quicker than usual. I performed my cool down and stretching routine and was feeling pretty cocky about doing more than I should when I heard that rumble in my gut and saw the distention begin. The distention was followed by cramps, gas and profuse uncomfortable loose stools for several hours. My gut was sore and my appetite was gone.

I mention this after reading an article review in MedPage Today about a publication in the journal Alimentary Pharmacology and Therapeutics published by Ricardo J.S. Costa, M.D., of Monash University in Victoria, Australia. He and his colleagues showed that exercise intensity was a main regulator of gastric emptying rate. Higher intensity meant causing more disturbances in gastric motility. High intensity exercise at a rate you are not used to for a period of time longer than you usually exercise leads to gut problems including all the issues I experienced. Low to moderate physical activity was found to be beneficial especially to patients, like myself, suffering over the years from irritable bowel syndrome.

The researchers found that ultra- endurance athletes competing in hot ambient temperatures running in multi stage continuous 24 hour marathons were far more likely to develop exercise associated GI symptoms than individuals running a less intense half marathon. The results are fairly clear for us non ultra-endurance athletes. There is great wisdom in regular moderate exercise to keep your effort within the parameters your physician and trainer recommend based on your age and physical training. Even if it’s a cool crisp day and you feel that extra surge of adrenaline and competitiveness, moderation is best for your health and your gut. I hope the competitor in me remembers that the next time the urge to push the limit pops up.

Treatment of Gastroesophageal Reflux with Magnet Device

Gastroesophageal reflux disease causes heartburn and regurgitation of food and digestive enzymes. Treatment includes weight loss, wearing loose clothing not binding at the waste, dietary restriction and medications. The main class of medications used have been the protein pump inhibitors (PPI’s) such as Nexium, Protonix, Aciphex and Pepcid. Most recently this class of medications has come under major criticism from researchers believing they may be responsible for increased risk of community acquired pneumonia, malabsorption of nutrients resulting in bone disease and even dementia and cognitive decline. Physicians have been trying to limit the use of these medications but recurrent and persistent symptoms have made that very difficult.

Last month at Digestive Disease Week, a meeting sponsored by the American Association for the Study of Liver Diseases, The American Gastroenterological Association, The American Society of Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract; a paper was presented demonstrating the success of a magnetic band placed with laparoscopic surgery around the lower esophageal sphincter (the juncture of the esophagus and stomach).

Reginald Bell, MD of the SurgOne Foregut Institute in Denver, Colorado along with MedPage reported that at six months post procedure, 92.6% of the patients with the magnetic device LINX, had relief of regurgitant symptoms compared with 8.6 % taking a double dose of PPI’s. Only one surgical complication had occurred and it was corrected. The research was done at 22 different locations enrolling 150 patients with moderate to severe regurgitation despite once-daily use of a PPI treatment.

The improvement numbers are dramatic and if this stands over time will change the way we treat this disease. The publication did not reveal the cost of LINX and we certainly want to observe these patients for more than six months before endorsing a new and promising treatment.