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Fish, Fish Oils and Cardiovascular Disease

Years ago the scientific researcher responsible for the promotion of fish oils as an antioxidant and protector against vascular disease recommended we all eat two fleshy fish meals of cold water fish a week. He continued to endorse this dietary addition and included canned tuna fish and canned salmon in the types of fish that produced this positive effect.

Over the years I heard him lecture at a large annual medical conference held in Broward County and he fretted about the growth of the supplement industry encouraging taking fish oils rather than eating fish. He worried about the warnings against eating all fish to women of child bearing age because of the fear of heavy metal contamination and knew that the fish oils and omega 3 Fatty Acids played a developmental role in a growing fetus and child.

I then attended lectures, in particular one sponsored by the Cleveland Clinic, during which they promoted Krill oil as the chosen form of fish oil supplements because it remained liquid and viscous at body temperature of 98.6 while others solidified. I listened to this debate only to hear the father of the science speak again and this time advocate that one or two fleshy fish meals a month was adequate to obtain the protective effect of Omega 3 Fatty acids. He felt that the supplements did not actually provide a protective effect as eating real fish did. Since I love to eat fresh fish I had no problem with this message but others are not comfortable buying and preparing fish at home or eating it at a restaurant. Supplements to them were the answer.

Steve Kopecky, M.D. examined the question in an article published in JAMA Cardiology this week. He looked at 77,917 high risk individuals already diagnosed with coronary artery disease and vascular disease who were taking supplements to prevent a second event. His study concluded that taking these omega 3 supplements had no effect on the prevention of recurrent cardiovascular events. The study did not discuss primary prevention for those who have not yet had a vascular illness or event.

Once again it seems that eating fish in moderation, like most anything, is the best choice. I will continue to eat my fresh fish meals one or two times per week, not necessarily for the health benefit but because I enjoy eating fresh fish.

I advise those worried about preventing primary or secondary heart and vascular disease to find a form of fish they can enjoy if they want this benefit. If you really wish to reduce your risk of a cardiovascular event; I suggest you stop smoking, control your blood pressure and lipid profile, stay active and eat those fresh fish meals.


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.

On Loss, Death and Dying

As an internist with “added qualifications in geriatric medicine” I care for a great many elder individuals. In most cases these are individuals I met 20 or more years ago and have been privileged to share their lives with them as they aged.

The circle of life is relentless and unforgiving so there comes a time when these relationships end. In some cases it comes when they can no longer care for themselves and I suggest they move out of the area to be closer to a loved one who will provide support and care. In some cases the patient moves from their home into a senior assisted or skilled nursing facility out of the area.

There have been a few situations where an adult child from out of the area shows up on the scene and transfers their loved one’s care elsewhere. These are the most difficult situations because the children are stressed and put out by the responsibility and inconvenience of suddenly having to care for their loved one. They do not have the longstanding professional relationship with me that I have with the patient. They expect quick and simple answers and treatment plans in most cases when for the most part we are dealing with complex issues involving many professionals and treating one condition fully often exacerbates another.

Then of course there are the patients who pass away. As detached as you try to be, those of us who care invest a bit of our heart and soul in each patient who comes to us for care. I see that investment made in the vast majority of my colleagues across all the disciplines and specialties. When you lose someone, even an ancient senior citizen, it takes a piece of your being with it.

I too am no spring chicken. I talk about Medicare from experience now. Morning stiffness is a shared experience, not a term in a medical textbook. Male urinary problems, once something you treated in older guys is now a way of life. My older colleagues are retiring. When making hospital rounds I notice the prevalence of younger physicians.

My beloved pets age too. For the last 16 years my Pug (Pugsly) and my mixed-breed sweetie (Chloe) greeted me at the door, took long walks with me and provided fur therapy after a stressful day. Pugsly expired a year ago. His mate Chloe left this world in November. For a clinician well versed in Elizabeth Kubler Ross’s book “On Death and Dying” and dealing with life and death daily, the loss of a beloved pet should be easier. The pain is palpable. The sadness recurs and the heaviness on the shoulders, eyelids and heart wears you down.

I have several younger patients valiantly battling against horrible malignant diseases. Their drive and courage to overcome illness and enjoy the time they have with family and friends is inspirational. They do not know it but they are my role models for how to deal with the adversity of losing loved ones, human and pet, and sharing the diminishing independence and health that my long time patients now experience.

Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.

Water versus Diet Drinks for Dieting and Weight Loss

Water and many diet beverages quench your thirst and are listed as providing no energy or calories to your daily intake. With this in mind, researchers at the University of Nottingham in the United Kingdom set up a definitive study to assess the effect of water on weight loss after a meal versus a diet beverage’s effect on weight loss.

Ameneh Madjid, PharmD and associates looked at 81 overweight and obese women with Type II Diabetes Mellitus. Members of the group were either asked to continue drinking diet beverages five times per week after lunch or substitute water for the diet beverages. The researchers found that over a 24 week period, the water group had greater decreases in weight, body mass index, fasting plasma glucose, fasting insulin homeostasis and two hour post-meal glucose readings compared with the diet beverage group.

A similar study published in the American Journal of Clinical Nutrition looking at 89 obese women found that after six months the water group had lost an extra three pounds compared to the diet beverage group.

As a clinician, the idea of putting water into your body as opposed to diet drink chemicals makes great sense. There have been some researchers who felt that diet beverages eliminated calories in soft drinks but that users consumed more dietary food and calories when drinking diet beverages as opposed to water.

I will suggest to my patients that they try water instead of diet beverages but remind them that an occasional diet beverage probably will not hurt their long term goals.

To Floss or Not To Floss? Making Recommendations Without Data

The U.S. Department of Health has announced that there is no data that flossing your gums has any benefit.  This has led to an Associated Press review of the paucity of randomly controlled trials with evidence that flossing is beneficial. The result is a new recommendation that flossing daily is not necessary. We are living in an era where the only justification for research and observational studies seems to be to justify saving money by not teaching patients something or encouraging them not to do something. Cost containment is the key as the US Government tries to lower the percentage of dollars spent on health care as a percentage of the Gross National Product.

Experts at the Cleveland Clinic spurred on by the “Bale and Doneen” philosophy that inflammation in arterial vessels leads to acute heart attacks and strokes have pushed for greater periodontal care and health. Flossing is part of that philosophy. Cleaning in-between your teeth with hand held pics or water pics provides cleaning of the gums and spaces between teeth as well.  There are few or any studies on this subject because the benefit is so obvious that there has been no need to perform them.  Dentists assure me that proper tooth and gum care is essential to your general health and wellbeing.  This is common sense like not crossing a busy street against the light, not drinking alcohol and driving a car or truck or not jumping out of an airplane without a parachute. It’s time for our dental schools to organize and perform these studies but I suggest you keep caring for your gums and teeth while the data is being accumulated.

Pneumococcal Vaccine in Development May Fight All Strains of the Disease

Community acquired pneumonia (CAP) plus other infections attributable to the Pneumococcus bacteria account for 15 million infections per year including pneumonia, meningitis and bronchitis. The organism is the leading cause of death in children less than five years old.  Over the last 30 years pharmaceutical companies have developed Pneumovax 23 which covers 23 unique bacteria that cause CAP in adults and Prevnair 13 which covers 13 pneumococcal bacterial strains.  Twelve of the bacteria in Prevnair 13 are identical to the Pneumovax 23 with only one unique bacterial type included.

A group at the State University of New York at Buffalo led by Blaine Pfeifer, specializing in chemical and bacterial engineering; has developed a new approach to pneumococcal vaccination. Working with computer modeling and animals to this point, they have developed a successful vaccine that attacks pathogenic pneumococcal bacteria while leaving the beneficial and non-pathogenic subtypes alone. The vaccine reads proteins on the surface of the bacterial cells and destroys only those that show aggressive activity. The vaccine has been 100% effective against the 12 most virulent pneumococcal bacterial strains existing in animal studies.    The vaccine is being prepared for human testing in the near future.  The preliminary work was discussed in the medical magazine Medical Economics