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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.

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.

Lack of Vaccination Coverage in the Medical Office

This week a patient, going on a foreign trip, was required to fill out a vaccination and immunization record to obtain a visa. To his dismay he discovered his records were not available. On further questioning he realized his vaccinations were done at retail clinics and pharmacies up and down the Eastern seaboard. Yes, he had requested a record of the vaccination be sent to the office but it never arrived.

I am a firm believer in the recommendation of the CDC, American College of Physicians and Advisory Council on Immunization Practices. Their literature is displayed in my office and available as a resource to my patients. I find it abhorrent that CMS, through its Medicare Part D program, will pay for the shingles shots (Zostavax and Shingrix) and the pneumonia series (Prevnar 13 and Pneumovax 23) at the pharmacy but not at a doctor’s office. The pharmacies use these vaccinations as loss leaders to get individuals into the store hoping that they will buy additional items while there.

As a general internist and practitioner of adult medicine, I too use these vaccinations as a “loss leader.” When patients call for a vaccination and have not been seen in a long while we encourage an appointment. We check on prevention items recommended by the ACP. the AAFP and the USPTF and make sure the patients are current on mammograms, HPV or Pap testing, colonoscopies, eye exams, hearing evaluations, skin and body checkups and other essential health items. We make little or no money on vaccinations or immunizations but like the idea that once a patient is here we can provide a gentle reminder about those health tasks we all need to follow up on with some regularity.

I like the idea of making vaccinations and immunizations more convenient for patients. I just believe the same payment should be made if the patient is in your office or in the pharmacy. In addition, the law should require the pharmacy to send a record of the vaccination to the patient’s physician so we can have immunization records readily available.

The ACP, AMA, American College of Physicians and American Academy of Family Practitioners should be using their influence to encourage the Center for Medicare Services (CMS) to pay for these vaccines in doctors’ offices as well as in pharmacies and retail clinics. If encouragement doesn’t work then legal action is appropriate.

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.

Globalization, Corporate Control and Shortages of Medication

One of my online medical information websites carried a letter from the head of the Food and Drug Administration (FDA) trying to explain why there is a shortage of standard intravenous fluids to administer at hospitals and medical clinics in the United States. The author cited an extremely busy influenza season causing patients to use Emergency Departments in record numbers plus a loss of manufacturing capabilities due to damage to a production facility in Puerto Rico during a seasonal hurricane. No more, no less.

Doctors, nurses and patients are expected to believe that there is only one production center for our intravenous fluids nationally located in Puerto Rico. If it is unable to produce and ship product then health care as we know it has to change?

If this is in fact the truth, and the only reason for the lack of available IV fluids, what exactly does it have to say about our planning and leadership at the level of the FDA and CDC? Might it in fact indict the corporate model of efficiency and productivity? Is there not a Plan B and C for supplies of intravenous fluid if one source cannot supply our needs? If this is in fact the only production source then why wasn’t it a post storm FEMA national priority similar to if the NORAD intercontinental ballistic missile system had been damaged due to Hurricane Irma or Maria and we could not monitor North Korean launches?

At the same time we have a shortage of intravenous fluids, we have a shortage of injectable narcotics for pain relief. Morphine and dilaudid are in short supply. My hospital pharmacy committee and chief medical officer are now limiting injectable pain medications to immediate post-surgical cases.

Pain elsewhere in the institution should be treated with the oral pain pills we read about causing the opioid epidemic and crisis in America. There apparently is no shortage of injectable heroin on the streets of Palm Beach County, Florida. The Mexican cartels have found a way to meet the demand of its customers unlike organized healthcare which seems unable to do so.

I do not know who is responsible for insuring that we have enough materials and medications available to care for our nation. I do know they are doing a very poor job of it and would love to know who is responsible.