Sodium Chloride Salt Substitution Works in a Community Trial

At a meeting of the European Society of Cardiology, J. Jaime Miranda, M.D. PhD, of the University of Peruan Cayetano Heredia in Lima, Peru reported that substituting artificial salt substitute potassium chloride for table salt lowered the blood pressure of participants, reduced the number of new cases of hypertension and ultimately reduced stroke and heart disease mortality

For this study, researchers enlisted the assistance of six semi-rural agricultural fishing villages in the Tumbes region of Peru. All adults 18 and older were approached and over 91% of the 2,605 potential enrollees agreed to participate. Patients with chronic kidney disease, known heart disease or digoxin use were excluded because of the use of potassium and potential cumulative effects of this element.

The study area and residents historically have very little high blood pressure. In Peru, 140 systolic blood pressure and 90 diastolic blood pressure are considered the upper limits of normal.

The researchers replaced the sodium chloride used in food preparation with potassium chloride salt distributing it free to all families, shops, restaurants and bakeries over a three-year period. The results revealed a very small reduction in systolic blood pressure which still reduced the risk of stroke by 10% and ischemic heart disease by 7 %. The drop in blood pressure was more definitive in the 18% having hypertension at the time they entered the study and those 60 years of age or older.

This study raised the possibility of researchers approaching food manufacturers around the world to substitute potassium chloride artificial salt for sodium chloride as a means of lowering blood pressure and its stroke, cardiac, renal and vascular complications. It reinforced the suggestions to stop adding sodium chloride salt at the table or in food preparation if you wish to keep your blood pressure under control.

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Antibiotic Use – Independent of Physician Prescribing

A recent article in the Annals of Internal Medicine looked at individuals who took antibiotics without them being prescribed by physicians at a visit.  The authors looked at 31 published studies between January 2000 and March 2019.  The medications came from family and friends, online distribution sites, drugs prescribed for their animals by their veterinary doctors and those stored after a previous indicated use.   When asked about it, and the reasons why these patients took these medications, the main factors cited were lack of health insurance or lack of healthcare access, cost of physician visits or medications, long waiting times in clinics, embarrassment for needing antibiotics, lack of transportation and/or easy availability of antibiotics  from other sources.

We are currently going through an antibiotic resistance crisis in the world.  Most of the fault lays with agricultural industry feeding livestock tons of antibiotics to fatten them up. Patterns of resistance develop on the farms and are passed species to species.

To remedy this, the US agriculture industry, especially in chicken production, has cut back drastically on this process.  At the same time, we are requesting physicians to work with infectious disease doctors in stewardship programs to reduce their use of ineffective antibiotics and to prescribe with precision when these medications are needed.  It works. Studies are beginning to show the benefits of these programs.

Despite this, the pressure from patients to be given something when they pay for, and invest in, a medical evaluation for an infection is overwhelming. In the setting of telemedicine, as well as walk-in and urgent care centers, reviews and patient satisfaction survey results are tied to whether the patient was given an antibiotic whether it was indicated or not.

As bacteria become resistant to common and inexpensive antibiotics, pharmaceutical manufacturers are not being incentivized to produce newer more efficacious medications.  At the same time, older useful antibiotics which do not generate much of a profit are not even being ordered and stored by chain pharmacies that lose money each time the older generics are prescribed.

To begin solving this problem, an improvement of our health literacy is required. Education in schools and in public health announcements, both in print and social media, need to realistically address the issue. This education will not replace the need for access to health care and health, but it is a beginning to make individuals understand how, when and why these “miraculous” medications can and should be used.

Heartburn, Indigestion & Protein Pump Inhibitors

I have seen multiple adult patients with intractable heartburn, reflux, indigestion and chest pressure all related to food and digestive enzymes kicking back up the esophagus from the stomach through a lax group of muscles known as the lower esophageal sphincter.  All these patients receive a fiber optic upper endoscopy (EGD) at some point and are observed and biopsied to eliminate the possibility of ulcers, cancer, gastric polyps, esophageal cancer, potential esophageal cancer and Helicobacter Pylori bacteria as the cause.

They are all treated with weight control suggestions, avoiding a host of foods, most of which are quite healthy from a cardiovascular standpoint plus limits on alcohol, elimination of tobacco and other indulgences of adults. We ask these patients to wear loose clothing at the waistline, avoid reclining for three hours after eating and take a host of medicines including proton pump inhibitors (PPI) such as Nexium, Protonix, Prilosec.  Drugs like Tagamet, Zantac (H2 Receptor Blockers), Tums, Rolaids are far less effective.

In recent years, numerous articles have appeared in medical journals stating that protein pump inhibitors, when taken regularly, can predispose to increased and early death, pneumonia and dementia.  A large review article from a prominent GI group in Boston, and published in the New England Journal of Medicine, tried to eloquently refute these claims but the doubt about long term safety lingers buoyed by numerous lay periodicals and online internet sites sensationalizing the down sides of these medicines.

To allay the patients fears, doctors and patients work together to try and stop the PPIs and substitute the older standbys like Tagamet and Zantac but they just don’t provide the symptom relief that the PPI’s do. Patient’s face the dilemma of taking the medicine that works best and incurring the potential risks or suffering.

In a recent edition of the journal Gastroenterology, Paul Moayyedi, MB ChB, PhD from McMaster University in Canada followed 17,000 patients for three years with half the group taking PPI’s. Those taking a PPI (Protonix) for three years had no more illness or adverse effects than those taking a placebo.  L. Cohen, MD, a reviewer at Mount Sinai School of Medicine in NY, concluded that the study provided strong evidence of the safety of PPIs for patients taking the drug for three consecutive years.

The controversy will continue. I am sure next week someone will produce data revealing some additional horrible consequences of taking these medications to relieve heartburn. It will ultimately come down to individual decisions about quality of life versus potential risks because the lifestyle changes necessary to control this problem are difficult for human beings to sustain over a long period of time.

Hurricane Dorian: Staying Focused as the Storm Moves In

As Hurricane Dorian moves through the Atlantic Ocean towards the United States and the Florida peninsula, there is no respite or escape from the constant barrage of news updates and suggestions being offered on TV, radio, print news, internet news outlets and social media.  The fierce image of the tightly curled storm is displayed everywhere.

I have been through quite a few storms starting in 1979 when the builders in our unfinished community loaned us plywood to board up our windows with concrete anchors ruining our exterior stucco finishes forever. Fourteen hours of work with a saw and hammer and screw drivers and I was too exhausted to notice the storm gracefully curled out to sea sparing us.

For Hurricane Andrew we had no shutters or knowledge, just luck. Masking tape was on the windows since no one had shutters.  A few pillows and pool floats were over the windows in the room we were closest to as we slept on the tile in a window free hall. Post-storm I volunteered to provide medical care in Dade County and was in a Ford Van that was broadsided at a Kendall intersection killing two in the other vehicle that ran what used to be a stop sign.  The impact sent our van tumbling over and over until we ended up right side up in someone’s driveway with our seat belted volunteer medical crew mercifully just frightened and sore.

Then there was the year that, as the storm passed and a curfew was in effect, we went to bed as it got dark with the power out and the windows open. The dogs started howling and there was loud knocking on the door.  I grabbed a flashlight and baseball bat and was greeted by a police officer at the door looking for “Dr. Reznick”.   ““They need you in the ER.“ he said.   “How can that be?  We have a coverage arrangement and no one is supposed to be called during the storm or immediately after?”

The poor officer told me the new administration had cancelled the plan and called into FEMA and was given a military reserve medical unit to cover the hospital.  “You are the first doc I have been able to find on my list of 20. Don’t worry about the curfew. If they stop you just show your hospital ID or driver’s license.  You’re good to go.”

I got dressed as did my wife and we threw the dogs into the car and headed for the hospital.  Every streetlight was out. Trees were down. Traffic signals were not working so each intersection was a treacherous four way stop sign situation.

As I turned onto Meadows Road my headlights lit up a big tree across the road and, off to the side, a roadblock with two military personnel in full battle gear signaling me to stop and roll down my window.  I showed my hospital ID and they told me I needed hospital ID for my passenger to proceed.  I told them it was my wife and she and the dogs would wait in the doctor’s lounge while I attended to the ER patient.

He said they were not permitted to accompany me to enter the facility area.   I told him to step aside or shoot us or get run over but I was going forward which I did. An MP met me at the entrance to the doctors’ lounge and, in language not repeatable in mixed company, I told him what he and his CO could do.  They backed off.

When I got to the ER I learned that one of my ocean front condo commando patients, who refused to heed the evacuation order, took the elevator down from the 18th floor to the lobby to view the storm. The power went out as he toured his lobby and he was trapped there.  He called 911 and was rescued by first responders and brought to the hospital because they had nowhere else to deposit him. Turns out he was constipated so they called me in to admit him.  I handled the administrative duties, told the new administrator what I thought of his decision to suspend our decade’s long program of collegially covering the hospital and each other’s patients and trudged home.

The FEMA medical team was sent packing the next morning as the medical staff chastised the administration for their poor decision making. This was one of administration’s first decisions which changed and ruined the community feeling of our small facility forever.

Staying focused prior to the storm is the hardest part.  Patients call in anxious and harried from the preparations and endless threatening updates and news flashes. Listening to the chronic complaints of your most anxious and worried patients and trying to sort out what is new, what is pertinent, what is important while your mind tries to stray to storm survival mode is a skill you are always trying to perfect.

The remaining shutters we use for the few remaining non-impact windows are ready to go. The windows have been sprayed with wasp and hornet spray so that we don’t get stung when the shutters and noise disrupt the hornet nests that pop up daily – which happened years ago. The work gloves are ready as are the work boots.  The WD40 is in great supply to make sure the Kevlar storm screen anchors easily screw in and out of their mooring holes.  We have three weeks of water and lights and batteries and nonperishable food.  The cars are full of gas. My wife is making extra ice for reasons I am not entirely certain of – but it cannot hurt to have it. The dogs have extra food ready.  Our quick escape “go bags” are packed and by the exits. Now all we can do is wait.

I head out for the office being extra careful on the wet and windy road because every driver is paying attention but distracted. The fender benders and aggressive driving due to anxiety have begun. Focus and stay safe.  That is the goal.

Alzheimer’s Disease – More Insight

The August 1, 2019 issue of the journal Neurology carried a report of a team of researchers who have developed a blood test that can detect the presence of amyloid in the brain with 94% accuracy.  Amyloid is one of the chemical constituents found to be tangling up the neuron nerve communication pathways in humans with Alzheimer’s disease.

The article emphasizes this is currently a strict research tool. It is not a laboratory test that your physician or clinic can order or use to detect this form of dementia early. The results of the blood test correlate well with imaging studies currently in use. It is one small step in the investigation of the causes of this progressive, and fatal, heartbreaking disease and hopefully will allow us to evaluate Alzheimer’s at its earliest stages.

In a journal specifically dedicated to this disease entitled Alzheimer’s and Dementia, researchers at the University of California, San Francisco discussed the increased tendency of patients with Alzheimer’s disease to nap and sleep inappropriately and ineffectively. Previously it was felt that this inappropriate sleep pattern when observed was in fact a risk factor and marker for the development of the disease.

Lea Grinberg, MD and her co-authors feel it is a symptom of the disease instead. They believe that the disease process has already destroyed or inhibited those neurons (brain nerve cells) responsible for wakefulness and alertness. In the absence of this stimulation, patients nap and sleep ineffectively and inappropriately.

Imaging of these areas is difficult to obtain because of their location in the skull and brain but, on detailed studies, more tau protein deposition in these wakefulness areas is visualized.   This concept now allows researchers to zero in on other brain chemicals associated with wakefulness, alertness and sleep as a potential form of treatment of Alzheimer’s disease in addition to those chemicals in the cholinergic system that most medications attack.

Toxic Seaweed Washing Up on Florida Beaches Poses Health Problems

Local papers have been carrying the story of large amounts of seaweed washing up on Florida beaches and the cost of keeping the beaches clean.  A recent edition of the Miami Herald shows a photo of six women in bathing suits on the beach standing in the thick seaweed that washed ashore the previous evening.

In the July 12, 2019 issue of the Journal of Travel Medicine, Dr. Andrea Bogglid of the Tropical Division of Medicine Unit at Toronto General Hospital and Dr. Mary Elizabeth Wilson of the Harvard T. H. Chan School of Public Health, discussed the fact that the seaweed causes health issues. The seaweed is the Sargassum weed probably originating in Brazil. When it decomposes it releases hydrogen sulfide toxic gas which can cause palpitations, shortness of breath, dizziness, vertigo, headache and skin rashes.  The authors note that since 2011, larger than normal amounts of the brown seaweed have been washing ashore in Florida and the Caribbean Islands.  They report almost 11,000 case of the toxicity reported from the seaweed on the islands of Guadalupe and Martinique in 2018.

Part of the problem is that local governments tend to treat the seaweed as a sanitation issue rather than a health threat. Physicians have little experience in diagnosing and treating the problems the seaweed can cause to those exposed.  In most cases when patients seek medical help the diagnosis of Sargassum Toxicity due to prolonged exposure is a diagnosis of exclusion. Treatment is simply supportive with fluids and medicines to treat the symptoms.

It is believed tourists and those contracted to clean up the mess are at risk. The researchers, along with marine biologists, are suggesting aggressive cleaning up of the beaches with workers wearing appropriate protective gear. They also suggest hotels placing physical barriers to the seaweed in designated swimming areas to prevent their guests from contact and exposure.

Collusion or Conspiracy?

A 67 year-old woman with a high stress job had a vigorous disagreement with her neighbors last week. She developed severe substernal chest pain and called 911 fearing a heart attack. She is thin, has never smoked, has normal blood pressure and normal cholesterol. She is not a diabetic and runs on a treadmill for two hours at five miles per hour with an elevation for two hours four times a week. She has few risks for developing heart disease.

The ER staff was quick and efficient. An EKG revealed changes consistent with a multivessel involved heart attack. Her cardiac isoenzymes were elevated and abnormal confirming muscle injury. The ER doctor called her PCP and the cardiologist on call. This experienced interventional heart specialists on call, has worked with and cared for many of the PCPs patients. He came right over, explained the options to the patient and, with her agreement and the PCPs blessing, took her to the heart catheterization lab to perform an angiogram to find the blockages and restore blood flow to the heart muscles.

To his surprise her arteries were perfectly normal with no blockages. The heart muscle was pumping weakly exhibiting the appearance of an octopus swimming through the sea proclaiming the unusual heartbreak stress syndrome known as Takotsubos cardiomyopathy. With rest, time and reduction of stress; she was projected to recover fully in days to weeks.

She was monitored overnight and observed until her heart enzymes were normalizing, her heart rhythm was normal, and; she could walk around the room easily. She was medicated with a low dose aspirin, a low dose of a beta blocker to blunt the stress induced surge of chemicals that caused the heart damage and mild antianxiety medicines. She was advised to cancel her work schedule for two weeks, cancel a cruise scheduled for the upcoming weekend and see a psychologist for stress reduction.

She opposed each of these suggestions and demanded that I call her relative’s cardiologist for a second opinion. The very type A characteristics that led to her stress, anxiety and illness was creating the request for a second opinion. The diagnosis and treatment were straight forward.

I called her cardiologist to explain the request never expecting the reaction I received. He is successful and experienced but when I brought it up he became anxious, angry and defensive. Why? He said he was leaving the case! I begged him not to and called the cardiologist she requested for a second opinion.

“We do not do in-hospital second opinions because we wish to maintain collegiality. Let her call my office when she is home and we will see her as an outpatient.” She called that office for an appointment and was told the next appointment is in six months. I called three other groups and received the same answer of no second opinions on inpatients to maintain collegiality.

As a primary care, physician my decisions are questioned and second guessed daily. Dr Google, Dr Cousin in NY or Boston, retired neighbor doctor offer opinions on my care regularly. It comes with the territory.

An anxious fit senior citizen suffering a frightening and unexpected heart malady should be able to obtain a second opinion without threatening the egos or collegiality of professionals. I called the medical staff office and hospital administration for help and was told to work it out with my colleagues.

As we examine our dysfunctional health system, we are quick to blame insurers, big pharmacy and government interference. Medical doctors are not without blame.