Thursday, December 24, 2009

Christmas Coronary

There is an interesting term I came across called "Christmas Coronary". Emergency rooms report an increased number of cardiac cases on the day after Christmas. No one is sure why but there are a few opinions.

First and most obvious is that symptoms may be present but not addressed until after Christmas. Sometimes a patient may have atypical chest pain and attribute symptoms to indigestion. Over-indulgence in rich foods,salt, alcohol, and caffeinated beverages may also account for ER visits due to heart rhythm problems and congestive heart failure. Decrease activity and prolonged sitting in the car or at the table may also contribute.

At the risk of being called Scrooge, here are my recommendations. First, don't over eat to the point where you feel uncomfortable. Eat slowly. Avoid excessive sodium intake. "Calorie saving" where you starve yourself so you can eat more on Christmas is not a good idea. Take a baby aspirin (if not contraindicated) in the morning...especially if you are traveling. Go for a walk after your meal and avoid prolonged sitting. If you have a cardiac problem it's best to avoid caffeine and alcohol.

And finally, if you develop symptoms of seek medical attention. Waiting may make things worse.

Wishing you a Merry Christmas and Happy and Healthy New Year.

Sunday, December 20, 2009

Dementia Misdiagnosis

Mary,a 92 year old woman who sustained a hip fracture, was admitted to a nursing home from a local hospital. The medical record was littered with the words dementia and alzheimers disease. I learned from staff that she was managing her affairs and caring for herself in an apartment prior to her fall. This was a red flag. The very first notation in the hospital record indicates severe dementia. But if she was so demented how could she have been taking care of herself so well. Was there a stroke or delerium that would have caused such a change?

On my initial interview I learned that she was not demented at all. She was hearing impaired. When I took the time, spoke to her clearly and gave her an opportunity to answer, I discovered she was cognitively more advanced than the staff. Once her hearing was corrected by a cerumen disimpation and a battery change in her hearing aids, we learned that she in fact she was a retired nurse and was well versed with health care.

There are lessons to be learned. First, don't rely on previous assessments. Mistakes like this tend to be repeated. Second, take a few moments to allow communication. Don't prejudge because of initial lack of response. And finally, all patients with a diagnosis with dementia should be tested for hearing loss. What you think is dementia may actually be in part or entirely due to a hearing problem.

Saturday, December 19, 2009

"If you knew where your food came from, you wouldn't eat"

In my Italian immigrant household everyone worked hard all day and somehow found the time for a multi-course sit down dinner. I now see the logic of staying home for an excellent meal but as a child I wanted to go out eat. My dad would say "If you knew where your food came from, you wouldn't eat".

I watched a documentary about the industrial food complex called Food Inc. I cannot recommend it enough. Let's be real. When someone serves up a big juicy hamburger or steak, any fleeting moment of wondering where it came from is quickly suppressed. Maybe on a subconscious level we don't want to know how our food is processed. Yet, this is the kind of movie that keeps you thinking and it may help you make better food choices.

One in three Americans born after 2000 diabetes (one in two for minorities). There is a reason for this. Children die from e coli infections and we propagate a food industrial complex that does not value the quality of food, their workers, the environment and least of all the consumer.

I'm sure we realize we are carnivores. And we know that indirectly we have to kill in order to eat. But this movie is about much more. It shows you how our meals are produced and all its political, health, environmental and moral consequences.

Food inc trailer

A movie trailer about obesity called "Killer at large" is another must see film.

Friday, December 18, 2009

Can Caffeine Be Good For You?

Coffee and tea may reduce the risk of serious liver damage in people who drink too much alcohol, are overweight or have too much iron in the blood.

The study of nearly 10,000 people showed that those who drank more than two cups of coffee or tea per day developed chronic liver disease at half the rate of those who drank less than one cup each day.

A daily dose of coffee, decaf or tea can reduce the risk of getting Type 2 diabetes by 25 to 35 percent, according to a new study published in the Archives of Internal Medicine.
Specifically, four cups of coffee or tea a day can lead to the 25 to 35 percent decrease in chances of getting diabetes -- or a 7 percent lowering of risk for every cup.

The study reviewed past research between 1966 and 2009, encompassing more than 450,000 patients, and also involved original research. It found that coffee and tea protect against metabolic syndrome.

But.... Caffeine stimulates you nervous system, increases heart rate and transiently increases BP. The Framingham study failed to show caffeine to be a risk factor for cardiac disease. Still its hard to imagine a high stress state caused by excess caffeine can be beneficial. My best advice would be moderation.

Sunday, December 6, 2009

So you or someone you love needs nursing home care

So you or someone you love needs nursing home care. You are struggling at home and it's become physically or emotionally impossible to remain at home. You are asked to pay 11,000 hard earned dollars per month for nursing home placement. But you are now desperate. The home care you expected consists of a nurse coming to check a BP once a week. Surprise! Medicare only covers a very limited service. Here are the insights of one who has worked in the industry for many years.
If you were to hire someone to care for you at home, you would choose someone who has the necessary skills and is also caring. Not so easy to find. If you find someone good don't let them go.
Going to a facility is culture shock. Institutional care is exactly the opposite of what you would look for at home. This is best demonstrated by the bathing process. Basically you are pulled out of a warm bed at the facility's convenience, not yours, and thrown into a hard plastic chair. You are stripped naked and hosed down like a car in your back yard. The water temperature depends on the mood of your aide. Maybe she thinks you need to wake up a little so the water will be colder. You are now cold, wet, and most likely combative. An alternate way is to use a bed bath system that employs lotions, massage, and moist warm towels proven to be hygienically equal or better that the traditional bath. So why doesn't the facility use this system.
Toileting is another issue. It is done on a schedule so you better be on the same timeline. If you have visitors and it's the "wrong time to go", you may have to suffer the indignity of sitting in your urine and or stool for a while. Imaging what your aide must be thinking. Probably that job at Walmart that doesn't look so bad any more.
After being involved with nursing homes as medical director for 25 years, I've come understand the problem. Facilities and their staffs are under great financial and regulatory pressure. Everyone seems to have a distorted reality. This includes administrators, staff, government, and families. The truth is nursing homes at the present configuration will not work.
When you visit the nursing home as a prospective client, don't be misled by the new carpet or the fancy conference room. The approach should be the same as if you were at home. Who is the person who will be caring for you directly. Are they well paid.? Do they have enough help? Are they well trained and how is that ensured? What is the philosophy on dignity, independence and meeting client preferences? The further you move away from the client caretaker relationship the less important it becomes.
The government underpays and over-regulates . Their oversight is well intentioned but misguided and self serving. Facility administrators spend most of their time at meetings talking about their financial hardships. Facility Boards are great people who are leaders in their own fields but easily misled by bells and whistles played by management. The dollar pyramid is inverted and ready to topple. Most money is spend at the top ; far away from the client-caretaker relationship.
There is much talk about culture change and moving toward a more homelike environment. But that's all it is- talk.... and I've heard it for many years. Facilities should de-institutionalize and spend their resources on the points of contact. When they realized that the need to reconfigure their thinking and not their physical plant, they will win the battle. Congress needs to realize that home care dollars spent will save them from extended hospital and nursing home stays. We seem to be heading in the wrong direction.

Wednesday, December 2, 2009

Who Should Receive H1N1 Vaccine

Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by “cocooning” them from the virus;
Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
All people from 6 months through 24 years of age
Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,
Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

Wednesday, November 25, 2009

Stuff the Turkey, Not Your Face

How to avoid gaining weight during the holiday gatherings! The first thing you should do is relax. Stressing about your weight is going to make you eat more. Enjoy your family and friends and be you should be on Thanksgiving Day. If you are on "Take Shape for Life", don't skip your Medifast meals in anticipation of overeating. That will just make you hungry. Plan your lean and grean around your main dinner. You should hold a tall glass of water. It may help get your mind off the potato chips and dip. If you are going to munch, raw vegies are a always a good choice. Focus on conversation not the food.

At dinner time, fill your plate with salad first. Then add some vegetables before the meat choice. And remember eat slowly. Try to be the last to finish your meal. Choose water as your beverage.

Now its time for dessert. Out comes the hot apple pie and the pumpkin pie that you have been waiting for. This is a no brainer. Have a small piece of each and don't feel guilty about it. Savor each bite. You will not spoil all your past effort. It's the repeated poor choices you make over time that will hurt you; not Thanksgiving dessert. Feel good about yourself. And enjoy the feeling of not being in a overstuffed postprandial food coma.

Most of all have a Happy Holiday

Saturday, November 21, 2009

Mammogram Screening and Breast Cancer

In 2008, approximately 184,450 new cases of breast cancer was diagnosed in the US, with approximately 41,000 individuals dying from the disease. The average American woman has a one in seven chance of developing breast cancer during her lifetime.
Studies have shown that regular screening of women with no symptoms has decreased the number of women who die from breast cancer by approximately 45 percent.

A woman's chance of being diagnosed with breast cancer is:

from age 30 through age 39 . . . . . . 0.43 percent (often expressed as "1 in 233")
from age 40 through age 49 . . . . . . 1.44 percent (often expressed as "1 in 69")
from age 50 through age 59 . . . . . . 2.63 percent (often expressed as "1 in 38")
from age 60 through age 69 . . . . . . 3.65 percent (often expressed as "1 in 27")

The following is Sloan-Ketterings recommendation that I believe we should follow:
Average Risk Women
Annual clinical breast examination (CBE) beginning at age 25
Annual mammography beginning at age 40
Women should be aware of any changes in their breasts. Monthly breast self-examination beginning at 20 years old is optional.

Women with a Family History of Breast Cancer -- i.e. One or More First-Degree Relative (Parent or Sibling)
CBE every three to six months starting no later than ten years earlier than the age at which the youngest family member was diagnosed with breast cancer
Annual mammography starting ten years prior to the age of the youngest family member with breast cancer (but not earlier than age 25 and not later than age 40)
Consider annual MRI (consult with your physician)
Women should be aware of any changes in their breasts. Monthly breast self-examination beginning at 20 years old is optional.

Friday, November 20, 2009

click on image to enlarge

Funny Medical Definitions

Artery.......................Study of paintings
Benign..................... What you be after you be eight.
Bacteria................... Back door to cafeteria
Barium..................... What doctors do when patients die.
Cesarean Section........... A neighborhood in Rome.
Catscan.................... Searching for Kitty.
Cauterize.................. Made eye contact with her.
Colic...................... A sheep dog.
Coma....................... A punctuation mark.
D&C........................ Where Washington is.
Dilate..................... To live long.
Enema...................... Not a friend.
Fester..................... Quicker than someone else.
Fibula..................... A small lie.
Genital.................... Non-Jewish person.
G.I.Series................. World Series of military baseball.
Hangnail................... What you hang your coat on.
Impotent................... Distinguished, well known.
Labor Pain................. Getting hurt at work.
Medical Staff.............. A Doctor's cane.
Morbid..................... A higher offer than I bid.
Nitrates................... Cheaper than day rates.
Node........................I knew it.
Outpatient................. A person who has fainted.
Pelvis..................... Second cousin to Elvis.
Post Operative............. A letter carrier.
Recovery Room.............. Place to do upholstery.
Secretion.................. Hiding something
Seizure.................... Roman emperor.
Tablet..................... A small table.
Terminal Illness........... Getting sick at the airport.
Tumor...................... More than one.
Varicose................... Near by/close by

Wednesday, November 18, 2009

Stop Smoking Now

Smoking Stats
Cigarette smoking is the leading cause of preventable death in the United States. Every year, more than 440,000 Americans die prematurely due to smoking and 38,000 non-smokers in the U.S. die from inhaling cigarette smoke. Yet, there are still 46 million (20.6%) adults in the United States who are current smokers and another 125 million children and adults who are exposed to secondhand smoke.

How To Stop Smoking
Some smoker just stop cold turkey. But most smokers may need to try more than once. Remember that smoking cessation may be a process rather than a single event. You may have been smoking for a long time and have linked smoking to certain situations such as driving, having a drink etc. Your body and mind may be addicted to nicotine's effect. That's why it's so hard to quit. Don't feel guilty about previous failures and don't give up. Pat yourself on the back for starting to move in the right direction. Choosing to stop smoking is the most important decision you can make in your life. So congratulations.

The first thing you should do is to think about the reasons you should stop smoking. It helps if you write them down. Set a quit date and mark it on your calendar. Enlist the support of family and friends and talk to your doctor about which method may work best for you. Nicotine replacement is effective (patch 17%, Nasal spray 30%) . Bupropion is 30% effective. Chantix is about 40% effective. The method that gets you to stop is 100% effective.

The first day you quit throw away your cigarettes and accessories. You may have cravings which will usually pass in several minutes. Keep busy. Practice breathing exercises and drink plenty of water. In the beginning don't hang out with people that smoke and avoid those areas that will likely tempt you. When you quit smoking, you may have to put up with some stuff like bad nerves and crabbiness for awhile. The "crazies" usually last for 1–2 weeks after you quit. After that, your body begins to forget about nicotine and you start feeling better.

The following are links to resources that can help:
Video about controlling cravings by auto suggestion (MC2 Method)
Real cost of smoking
Video demonstration on damaging effect of smoking
Free telephone counseling or referrals 1-800-QUIT-NOW (800-784-8669)

Tuesday, November 17, 2009

Now Open: Stages

Stages – the Center for Geriatric Cognitive Functioning is a new and vital resource for families facing the challenges of Alzheimer’s and other dementias. We provide geriatric consults, and work with your primary care physician and the family to develop a personal and long-term treatment plan that improves the patient’s daily life. We want to help you avoid crises in the future by being proactive now. Stages is directed by Rima Reitblat, MD, Board certified in Internal Medicine and Geriatrics. Please download our brochure, or for more information and to make an appointment, call us at (845) 781-8120.

Medication Errors You Can Prevent

First off you should keep a list of all your medication with you all the time. Make sure you have both the brand name and the generic name and as well as the doses. I also recommend that you keep a copy on your fridge. Paramedics will look there first.

One of the main causes of medication errors is poor communication and misunderstanding. If you are not sure of what your doctor is saying ask him to write it down for you. One assumption is that your doctor knows what medications you're taking. Don't bet on it. Your doctor may have your medication list from a visit six months ago. He does have changes that your other providers have made. So when your cardiologist makes a change in your dosage it does not magically update your primary doctors list. Computers make it easier to track things like medication but they are not always correct. Remember the adage "garbage in; garbage out" If an error was made in data entry it will translate into repeated mistakes. One mistake I've seen is patients overdosing on medication because they are taking pills from the generically labled bottle and the same pills from the brand labled bottle thinking they are different. Example: I had a patient taking one lasix and one furosemide not realizing they are the same. Pharmacies can make errors also. Check the medication on the label to make sure it is correct. I have seen Quinidine sulfate (used heart arrythmia) dispensed instead of Quinine sulfate (used for leg cramps). Handwritting is an issue but accidentially clicking the wrong drug on computer is possible also. If you receive desoxin (amphetamine) instead of digoxin (cardiac drug to slow the heart) you're in big trouble.

So here is my list of recommendations:
1) Keep an up-to-date record of your medications with you and on the fridge if you live alone.
2)Let your doctors know of medication changes at the time of the visit
3)Have you doctor write down instructions if you are not sure.
4)Ask if a new medication is an addition to your regimen or a substution.
5)Do not stockpile medications. You will end up with multiple bottles of unknown medications.
6)Do not mix tablets in bottles
7)Check you medication label when you pick it up from the pharmacy.
8)Bring all your medications with you when you go to the doctor.

Sunday, November 15, 2009

Exercise and Weight Loss

If you want to lose wt, exercise alone is not likely the answer. In fact if you are obese, you may be more susceptible to injury. Here's why. In order to lose one lb, you must burn 3500 cal. When you walk one mile you use 100 calories. So to lose one lb, you must walk 35 miles. One serious hour in a gym can burn 300 to 400 calories. So you need about 10 of those sessions to lose one lb.

Now lets look at the food side. One medium coke will add about 300 calories. In one year this could be stored as 25 lbs of fat. One coke can easily negate a heavy workout session at the gym.

My recommendation is you must diet to lose weight but a lifestyle change that includes exercise will put you on a path to achieving optimal health.

Finding medical information online

The best way to search for medical information on line is to use a  trusted site. Look for the HON or URAC logo at the bottom of the page. Avoid googling symptoms. There is just too much misdirection. My favorite patient information websites are, and 

Saturday, November 14, 2009

Killer at Large

"Killer At Large" - an amazing film about a toxin that is killing over a 100,000 people a year. And its already inside your body. see trailer