Fighting the winter blues – a lighter look

The winter blues – now is the time they can set in – shorter, dark days, colder temps and holiday stresses all contribute.  Its also been a rough couple of weeks in the news – it’s easy to feel overwhelmed when terrible things happen.  However, if you look for it, there are ways to fight those winter blues – a lighter side of the news, medical stories that can be uplifting, and studies that can make you feel better about life choices you have made.

Winter blues

Seasonal Affective Disorder is the official name for depressive symptoms that surge during a particular time of the year and resolve when the season is over.  Winter is the most common season for this – while the holiday season is supposed to be fun, for many it can be quite stressful and lonely.  It can be treated as any other depressive disorder – with therapy, exercise, medication, biofeedback or light therapy.  In fact, a recent study showed that light therapy works for non-seasonal depression as well.

Fun Studies

Some of these I’ve highlighted in the past, but some interesting and fun studies – although not necessarily the most scientific – maybe a smile will fight the winter blues.

Chocolate better than exercise for brain preservation – actually looked at high dose flavanols (talking a kilogram of cocoa daily) vs exercise.

Coffee use associated with lower mortality – perhaps my favorite article as it affirms my beverage choice!

The firefighter who was given a new face @NYULMC -what an amazing application of technology and medicine!

Sleeping in on weekends and holidays may increase your risk of heart disease and diabetes – I’ve always told patients that having a consistent wake up time makes for better sleep!

Remember moderation, activity and good sleep go a long way in getting through the holiday season without excess weight gain – and can help you fight the winter blues.

The path to wellness begins with a proper diagnosis

 

Processed meats – cancer risk or hype

Bacon is perhaps the archetypical of processed meats – whether typical US or Canadian – it is one of the most identified foods by sight or smell.  Recently, the World Health Organization (WHO) classified  processed meats as a cancer risk, equating it to smoking.  How did they come to this decision, and can we infer the same risk about all meat – processed or not?

What did the WHO say?

The WHO evaluated data from about 800 studies of meat intake and cancer.  About 14 of them were designed well enough to analyze the information.  There were another 15 studies that had strong design to help with the decision-making.  Based on these 29 studies, they found evidence that processed meat increased cancer risk – specifically colon cancer by about 17%.  The data for red meat in general was not strong enough to make an association.

How should we interpret the WHO statement?

The association of processed meats and GI tract cancer has been known for quite some time.  In cultures where these foods are consumed regularly, stomach cancer has had an increased rate, leading to screening programs.  The statement from the WHO adds strength to the association, and should encourage people who have multiple risks for colon cancer to consider their diet as a controllable  risk factor.

What does this mean for most people?

The risks for colon cancer are age, smoking, a low fiber diet, family history and now processed meats.  Just like most health decisions we make, our diets should be modified based on our risks.  Moderation, or occasional consumption of processed meats is a better choice than daily consumption.  Of course, getting a colonoscopy based on your doctor’s recommendation further minimizes the risk of developing colon cancer!

Life is full of choices – moderation and a varied diet seems to be one of the better ones.  In the words of Joe Jackson, “Everything gives you cancer”

The path to wellness begins with a proper diagnosis.

 

Back to School

It’s that time of year in NYC (I know other parts of the country already started) when buses are filled with children sporting back packs, tales of summer vacation are told and germs are spread.
In my office, it is also the time of year in which adults get re-exposed to germs they haven’t seen in years – the kids get a sniffle at best, and the adults (especially new teachers) feel like they’ve been hit by a Mack truck! Why is this?  What is it about “kid germs” that affect adults so severely?
The reason for this comes from our immune systems. The fevers we get and the aches we feel are a result of our bodies response to the infection. The more our immune systems get activated – the worse we feel!
Our immune systems develop memory. That’s why you only get certain diseases once. If you are exposed again later in life – the memory of the infection may have faded – and your body responds in full force.  When you are exposed to similar infections multiple times – or if you are vaccinated against a disease you body can respond faster and with less inflammation – and you don’t feel sick!  An MMR – measles, mumps, rubella – vaccine given in childhood and an adult booster gives enough immune memory to last a lifetime.
To help stop the spread of these infections basic hygiene is our best defense – HAND WASHING with soap and water or hand sanitizer.  Covering our mouths when we cough and sneeze; and taking our FLU SHOTS.
I wrote about flu shots last year.  Recent politics aside, there is no danger of getting the flu from the flu shot.  There can be side effects, depending on if you have an infection brewing or how strongly your immune system reacts to the shot, but there is no live virus in the vaccine to transmit disease.
The strains in this years flu shot are different from last year, and early reports show a good match between flu strains we are starting to see in the public and what is in the shot.  So get your flu shot, and feel better through the season!

Remembering

As I head to the office this morning, my first September 11 in NYC in 3 years, like most Americans I reflected on that day 14 years ago.  My wife was about 10 weeks pregnant, the Giants played Monday Night Football the prior evening and we had just put in a bid on an apartment the day before. 

I was seeing patients when my wife called to tell me the first plane had struck.  At first I thought it was a joke, and waited for the punchline. Then I saw reports on a news website. The internet became so congested, we couldn’t get updates, and the office turned a radio to an AM news station for updates. 

After a couple of hours, as the City began to organize its response, myself and 2 of my partners were driven across 23rd St in a police car to Chelsea Piers where the medical response area was being established.  At each intersection was a National Guard armed vehicle manned by soldiers with machine guns and serious expressions. We walked into an empty catering hall set up like a scene from MASH – rows of operating tables without dividers. The medical lead went through triage procedures, and we waited for the wounded to arrive.

And we continued to wait. No one came – the immediately wounded and rescued were brought directly to hospitals before we were set up.  Almost everyone else walked away – or didn’t. We couldn’t reach our families as cell phones were not working. After several hours, we were off duty and I walked home to the Upper East Side as all transportation was shut down. Later, I would find out the numbers of people who didn’t get to go home that night; the patients I lost or who lost spouses, high school classmates and family friends. 

Being out of NYC for the past 3 years I always felt guilty not being here. So today, back home again, I recall the day, the response, and the numerous stories similar to mine of those that were here.  Remembering  that everyone’s experience was so intense that they can’t be compared. And grateful to be in New York City.

Start Spreading the News…

Start Spreading the News…

I am thrilled to announce the next phase in my journey as a Physician.  After 3 years in Arizona, I am returning to NYC and will be practicing at NYU Langone Medical Center’s Internal Medicine Associates.

I have thoroughly enjoyed living in Arizona – it was a wonderful experience for my family, and I have grown as a physician.  I learned new skills, encountered diagnoses that I don’t often see on the East Coast and saw a two health care system merge and deploy a new Electronic Health Record system.  All changes that helped me see the challenges that both physicians and patients face in the coming years.

As I shared the news with my colleagues and patients in Arizona, the response was usually “sad for me, happy for you” and jokes about getting out of 119 degree summer days.  I am grateful for the support I have received!

Since I trained and had been affiliated with NYU since graduating from medical school, the news of my return has been like coming home – incredible enthusiasm from colleagues and former patients alike.  A response that again makes me feel grateful for the relationships I have built over the years – and reminds me of why I chose Internal Medicine as a career.

So I will say goodbye to excellent Southwest fare (best guacamole ever), and hello to Atlantic Ocean sushi, real bagels and pizza!  And look forward to NYC saying “AAHH”

Wishing health and happiness to all, and to more blogging now that my summer of transition is coming to a close.

The path to wellness begins with a proper diagnosis

Happy 4th of July – Keep it SAFE

As we enjoy the 4th of July, a reminder from TheDiagnosisMD to stay safe this holiday weekend.

Fireworks are beautiful to watch – the sounds, color and spirit evoke great memories for many.  Some of my favorite 4th of July memories

  • 20 years ago on call during my 4th day of Internship at Bellevue Hospital watching 2 minutes of fireworks on the East River from the cafeteria window
  • A fireworks show at Pine Hollow in Long Island, NY with friends after a BBQ dinner
  • Fireworks at my daughter’s camp while serving as the camp doctor

What each of these events had in common was that they were done by professionals, with firefighters on standby to be sure that everyone was safe.

Emergency Rooms see over 5000 firework related injuries a year, with half of them in people under age 20!  Fingers, eyes and burns are the most common injuries.  Even sparklers burn at close to 2000 degrees – so children should not use them without close supervision!

So lets enjoy the show – let those who are trained entertain you – and keep it safe!

http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/
http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/

Personalized Medicine isn’t necessarily Personal

3 months ago our family dog got sick.  Her liver was very inflamed.  The evaluation revealed copper deposits in her liver.  This was likely due to a genetic defect – very common in several breeds in dogs, but not common in hers.  Despite efforts to remove the copper with medication, the damage was too severe, and we lost her about a month ago.
This prompted some research into her family history – one “cousin” died from liver issues, but it was not known if it was copper related. There is a blood test that can see if a dog had the “copper” gene and my wife and I started discussing what we would have done differently if we had known.   
Since cloning the human genome, we have identified genes and mutations associated with cancer, drug sensitivities and the risk of other chronic conditions.  We have also identified mutations that may not have any impact on health, and others that the impact is unclear or unknown.
Using that genetic knowledge to direct diagnosis and treatment is called personalized or precision medicine. It was mentioned in the Federal Budget for 2016 and the National Institutes of Health is dedicating significant research money to it.  There have been several direct to consumer companies offering to read your DNA and tell you what diseases you are at risk for.

How is this done and what can you really learn?  

Precision Medicine assumes that by running a person’s DNA code you will get results that shows what diseases you are likely to get – heart disease, diabetes, cancer, etc.  For those diseases you already have, it can tell you which medications are most likely to be effective.  Plans can then be developed to treat illness and recommend screening programs based on one’s DNA code – offering medications with the best chance of success to those with the proper codes and not giving them to people who are not likely to respond or be at increased risk of toxicity.
There are already examples of this in use today.  We avoid medications in people with certain genetic markers because they are more susceptible to side effects (people may be more or less sensitive to certain blood thinners based on their DNA). Many cancers, from lung to breast to lymphoma and leukemia have genetic markers run to see what treatments are likely to work. Perhaps the most famous use of genetic testing determining treatment is Angelina Jolie.  She tested positive for the BRCA1 gene greatly increasing her risk of breast and ovarian cancer.  She then elected to have mastectomies and her ovaries and uterus removed before any cancer developed.
Genetic based diagnosis and treatment has the potential to change the way we evaluate risk and treatment.  However, checklist testing and treatment is not personal.  Blind application of data to a person without context (history) reduces medical care to algorithms and formula without the personalization it is supposed to offer. There is a social and ethical side to the use of genetic information that we are just beginning to understand, from privacy laws to insurance regulation to job security.  Would you hire someone you knew had an increased risk of and potentially expensive illness if you were responsible for paying for their care?  Would you marry someone knowing their illness potential?  Have children?  These are all issues that need to be sorted out as we move into this new paradigm for healthcare.
Most importantly, people need good information on what their tests mean.  Many of the kits available now report mutations that aren’t clearly associated with disease.  The FDA ordered one company to stop selling its test and services due to non-compliance with testing regulations.  They have since started selling a very specific test for a single condition, but not a general DNA analysis.  The next age of primary care will involve helping people curate and collate their genetic information.

Do I worry that the genetic classification of diagnosis and treatment will make me obsolete?  

To the contrary, I think it can make me better at what I do.  I already strive to get to know my patients, understand how health or lack thereof fits in the rest of their life.  We discuss risk for future disease, concerns about hereditary and what medicines are best for them.  That is personalized medicine.  Getting to know my patients at the genetic level can only strengthen that bond.  Using the information we get from genetic testing and putting it in the context of the person sitting across from me is how we put the Personal in Personalized Medicine.

The path to wellness begins with a proper diagnosis

Reality Check – why an Internist is important

It was a typical Monday for an Internist – lots of phone calls, catching up on results that came in over the weekend, a full office schedule.  I was about to go see my next patient when my assistant said that Dr. X was on the phone about a patient, could I take the call.  I popped into my next patient’s room and told them I’d be 2 minutes – they said no problem and I went to my office to take the call.

The call was from a sports medicine fellow working with a specialist that I’d sent Mr. Smith to (name changed).  I met Mr. Smith about 2 months ago, he had new onset high blood pressure and complained of back pain.  We’d started some blood pressure medication and he was seeing the sports medicine specialist to design an exercise program for his back.  He’d gotten an MRI as part of his evaluation, and instead of showing the expected herniated disc, it showed metastatic cancer – from where, we did not know.  We called Mr. Smith and had him come in the next day to review his scan.

I met with Mr. Smith and his wife the next day.  I took them through the scan findings, explaining what we could and couldn’t tell.  He told me his back wasn’t too painful, and the specialist was helping manage it.  We talked about a plan – blood tests and CT scans to find the source of the cancer.  I told them I’d speak to an oncologist – and arranged his appointment with him.

Two days later, I had the blood work and his CT results, and we met again.  The news was not good – there were extensive metastases in his spine and it looked like lung cancer – though we still couldn’t be sure.  I sat with the Smiths, and we discussed a plan.  They’d be seeing the oncologist in a couple of days, I’d already sent there results over.  We discussed the next steps, what the oncologist would likely do next.  We talked about how he hadn’t been sleeping well, and that I could help with that.

The Smiths left – and I was drained.  It was very emotional telling someone who felt fine they have metastatic cancer.  Yet we both left the encounter optimistic.  The Smiths understood they have an uphill battle, but together they felt informed, guided and supported.

How Mr. Smith does is mostly out of my hands – yet I know I played a huge roll in getting them ready.  I did all the things I love about medicine – bonded with a patient, made a diagnosis, educated them and got them ready for the next steps.  This is Internal Medicine, and why I do what I do.

E-cigarettes – deterrent or path to addiction

Recently, the CDC published its 2014 National Youth Tobacco Survey – which looks at smoking in middle and high school students in the US.  As a physician, but more as a parent of a newly minted teenager, the results were of great interest – and concern.  While cigarette use declined in high school students, e-cigarettes and hookah use tripled – and surpassed cigarette use for the first time.  E-cigarettes are not regulated by the FDA or subject to current tobacco marketing laws – allowing companies to market directly to teens with flavors more like candy than tobacco – something traditional tobacco companies have not been able to do since the 1970s.
The increase is not surprising – e-cigarettes are marketed as safer, they are easier to access and less expensive than cigarettes.  The real question, and one that comes up frequently in the office, is if they can help people quit smoking regular cigarettes, and are they safer?

Are e-cigarettes safer? 

There is not great data available yet.  What we do know is that the vapor produced contains particles that can irritate the lungs, and that it contains chemical byproducts such as formaldehyde – but in much lower concentrations than traditional cigarettes.  They also contain nicotine, the same addictive drug in cigarettes.  Nicotine affects brain development, may promote tumor growth and interfere with chemotherapy.  Nicotine also constricts blood vessels and increases blood pressure.  That increases stresses on any plaque buildup in a blood vessel – a precursor to heart attack and stroke.

Do e-cigarettes help you quit?

Again, the studies are still in progress.  There is some data that smokers who switch to e-cigarettes refrain from tobacco longer than those who try to quit while still using tobacco.  Neither the World Health Organization or the American Heart Association recommend e-cigarettes as a smoking cessation method.  There is no information yet as to whether those who switch to e-cigarettes quit nicotine completely, or have simply switched from one addiction to another.

How does this affect us?

So, while we await studies to more definitively address the safety question, what am I telling patients about safety?  Obviously, the best choice is not using any nicotine product.  If you are deciding between tobacco and e-cigarettes, it is reasonable (but not proven) to assume there is a lower lung cancer risk with e-cigarettes, but no data on oral or head and neck cancer.  However, since there is nicotine in both products, I advise people that there is still similar heart disease risk.  There is also no path to stopping e-cigarettes, unlike other nicotine replacement methods like the nicotine patch – which gradually reduces the dose delivered.  Studies are ongoing, so hopefully we get good information to make healthy decisions.  In the meanwhile, the FDA is seeking ability to regulate these products, and limit their marketing to children.
The path to wellness begins with a proper diagnosis