Happy 2016

Wishing everyone a Happy and Healthy 2016!

To wrap up the year, some New Year’s Health Tips:

  • Moderation – in both food and drink will make 2016 easier to start
  • Make a commitment to exercise on January 1 – even a walk will give a sense of accomplishment
  • Dress warm if you will be at an outdoor event – layers and hats
  • If improving your health is part of your plan for 2016, do a set of body measurements – weight and waist circumference – you can’t know how much you improve unless you know where you start
  • Put your exercise commitments into your calendar
  • Don’t do another set of measurements for at least a month – you can see bigger change if you don’t micromanage things
  • Get a physical – baseline your health as well as your size

I’m not making any resolutions this year – but I am setting some goals

  • Exercise more during the work week
  • Unplug from electronics occasionally
  • Write 2 posts a month

What are your goals for 2016?

The path to wellness begins with a proper diagnosis

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

Stop Counting Cholesterol? New Dietary Guidelines say so

At the end of 2014, The Dietary Guidelines for Americans Council issued its 2015 guidelines and analysis of what we should eat, what we do eat, and what the consequences of what we eat are.  Many of the recommendations and observations are what we expected – we eat too much sodium and sugar, not enough fruits, and are overweight.  What was surprising is that they do not recommend watching cholesterol intake any longer – saturated fat yes, but cholesterol, no.

What did the report say?

The main thrust of the report emphasizes a diet with lots of fruits and vegetables, whole grains, low in saturated fat.  Limiting processed meats, refined grains (white bread) and drinks with added sugar is also recommeded.  Good food such as seafoods, nuts and legumes, as well as low-fat dairy are emphasized.
Notably, the report for the first time removed the recommendation to limit cholesterol intake.  Prior recommendations were to limit cholesterol intake to under 300mg daily.  Instead, it is recommended to limit saturated fat and empty calories such as processed sugars.  It is these foods that are contributing to obesity and its consequences much more that dietary cholesterol.  Added sugars and saturated fat should be < 10% of total calories in a day.
Saturated fat has 9 calories per gram.  So in a 2000 calorie diet, saturated fat should be limitied to 22 grams daily.  Sugar has 4 calories per gram.  In the same diet, sugar should be limited to 50 grams daily.
For a real world example, a Snickers bar has 250 calories.  That is over 10% of a 2000 calories diet.  It has 4.5 grams of saturated fat, which is 20% of daily recommendation, and 27 grams of sugar, which is 54% of the daily recommendation!  By contrast, 2 scrambled eggs has about 200 calories and the same amount of saturated fat, but only 2.1 grams of sugar, or about 4% of the daily recommendation.

So what does this mean?

The report brings dietary guidelines more in line with current research.  We have seen several studies showing the benefits of a Mediterranean style diet – high in fish, nuts, vegetables and good fats such as olive oil.  The guidelines now support those findings.  It means a heart healthy diet can include some fats, and should limit the empty starches – those made with refined flour that add little nutrition but many calories.  It means that moderate intake of eggs and lean meats is healthier than meals based on breads, rice and pasta.
Perhaps the best news in the report (at least for me) is that up to 5 cups of coffee a day does not seem to be harmful!!!

The path to wellness begins with a proper diagnosis 

Challenge Completed

So many people start the New Year stating what they wish to accomplish, without reflecting on the past year. So for my first post of 2015 I’d like to reflect back on the first year of TheDiagnosisMD.com – and a challenge I undertook.

In the first year of my blog, I posted 34 times – with over 3400 views from 76 countries! Reflecting on what I posted, and the responses I got will help me shape 2015.

My goal for 2015 with TheDiagnosisMD is to make it educational, useful and fun!

In January of 2014, I ran the PF Chang’s Rock n Roll Half Marathon, with my running partner, Dr. Craig Primack. After the race, he suggested we try to run one half marathon a month for 2014. I accepted the fitness challenge. Two weeks later, on a cold morning in Sedona, we ran our 2nd half marathon of the year. It was a fun race, but we had not trained for the hills in Sedona!

After another organized race in March, schedules and races became difficult to match up, so we mapped out several 13.1 mile courses near our homes, and, on December 20, 2014 we completed our 12th Half Marathon in 2014.

Training for this, I ran over 545 miles and 83.5 hours. I went through 4 pairs of running shoes, several minor injuries and 4 toenails. The injuries have healed, and 3 out of 4 toenails are normal again.

So what did I learn?

Consistent long distance running is great for cardiovascular endurance. I have no doubt that at any time I could go run 13 or so miles without worry. However, from an overall fitness perspective I’m the same as I was in January of 2014. Same weight and non-running strength!

When I knew I was running long distances on the weekend – I found it mentally difficult to go for a 3 or 4 mile run during the week – it didn’t seem worth it if I couldn’t run 6 miles – so I ended up stacking the runs and concentrating things on the weekends. So there was less balance to my overall activities.

I’ve always told my patients that moderation was the key to success for health. So it’s time for this physician to heal himself. My goal for 2015 is to be more balanced in my fitness and in life. Challenge accepted.

I look forward to writing more about the topics you are interested in – so let me know what you’d like to learn about!

Wishing you health and happiness in 2015.

The path to wellness begins with a proper diagnosis.

Got Milk? Too much of a good thing?

The USDA recommends 3 cups of milk or dairy a day.  This is mostly to promote bone health.  However, it has also been linked to increased cancer risk in some studies, others have supported health benefits.  A recent study tried to sort out these conflicting results by separating milk from other dairy products and looking at death rates, heart disease, cancer rates and fractures.
What they found was surprising – adults who drank 3 or more glasses of milk a day died sooner, had more fractures as well as heart disease and cancer.  Those with similar dairy intake, but from fermented dairy like yogurt, cheese, sour milk, etc. had a lower incidence of death and disease.  The difference?  Lactose content.

What is lactose?

Lactose is a sugar found in milk.  When digested, it is broken down into glucose and galactose.  Galactose has been linked to oxidation and inflammation – triggers for disease.  The study authors hypothesized that the difference in lactose, therefore galactose intake with milk versus other dairy products is the cause of the difference if death and disease

What did they do?

The researches used 2 health registries of residents in Sweden where records are centralized, totaling over 61,000 women and 45,000 men and sent them questionnaires that looked at milk and dairy intake.  They then followed their records from the early 1990’s until now, looking at death and disease rates.  What they found was that women who drank 3 or more glasses of milk daily were:
  • 1.9x more likely to die
  • 1.4x more likely to get cancer
  • 1.6x more likely to fracture a hip
In men, the effects were less pronounced:
  • 1.1x more likely to die, mostly from cardiovascular disease
  • no increase in fractures
They also messed marks of inflammation and oxidation in the blood of participants and found higher levels of both in those with higher milk intake.

So what does this mean?

There are some interesting associations based on this study.
  • ingestion of milk, with it’s higher lactose content, may be linked to increase risk of disease
  • ingestion of low lactose dairy products (yogurt, cheese) is associated with a decrease of disease
  • moderate intake of milk is not associated with increased disease risk

There are some limits to this study

  • the data is based on 1 or 2 food surveys, and subject to people’s memory and answers
  • the population studied was very uniform – 2 or 3 counties in Sweden – which may limit generalizing to the population at large
  • All subjects were over 39 years old so no conclusions can be made about children and young adults
  • Lactose free milk was not evaluated

What can we take away from this?

  • High amounts of lactose may contribute to disease based on its breakdown into oxidation and inflammation promoting compounds
  • Dairy foods with low lactose contents are associated with lower death rates and illness
  • Moderation again seem to be the word of the day – it is possible to have too much of a good thing!

The path to wellness begins with a proper diagnosis

Breast Cancer Screening – In October We Wear Pink

It’s October and that means post-season baseball, (sorry Yankees), football season is in full swing and it is Breast Cancer Awareness month. Many athletes, celebrities and people affected by breast cancer in some way are sporting pink clothes or accessories and advocating for breast cancer screening. Why has breast cancer gotten such universal recognition in the US?

Breast Cancer Statistics

  • 1 in 8 women will get breast cancer in the US
  • About 300,000 women will be diagnosed this year
  • About 2300 men will be diagnosed as well
  • 40,000 women will die from their cancer this year – a death rate that is decreasing due to early diagnosis and treatment advances
  • Breast cancer is the 2nd most common cancer in women – the first is skin cancer
  • Breast cancer is the 2nd leading cause of cancer death in women – the first is lung cancer
  • 2.8 million women in the US are either living with breast cancer or post treatment
  • having a 1st degree relative with breast cancer doubles breast cancer risk
  • 85% of women diagnosed have no family history
  • 8-10% of breast cancers are linked to a genetic risk such as the BRCA gene
    • BRCA-1 carries a 55-65% risk
    • BRCA-2 carries a 45% risk as well as an increase in ovarian cancer risk

Breast Cancer Screening Guidelines

Given the number of women affected by breast cancer, as well as the high death rates and the fact that early detection and treatment have improved survival, one would think there would be little debate about the value of breast cancer screening. However, there are conflicting guidelines regarding screening – what age to start, when to stop, and how often to test.

The American Cancer Society (ACS) recommends yearly mammograms beginning at age 40 and continuing as long as a woman’s health and activity level make it feasible to continue.

In 2009 the US Preventive Services Task Force (USPSTF), a key driver of guidelines in the US, changed its recommendation from the ACS guideline to mammograms starting at age 50 and repeating them every other year, stopping after age 74, and eliminating self breast exams.

This change caused a lot of confusion and backlash, and later the USPSTF “softened” its recommendation to include a section stating that all women should discuss the risks and benefits of breast cancer screening with their doctors and make a decision based on their individual concerns.

So there are somewhat conflicting guidelines, but a decision about breast cancer screening should be based on your preference, your doctor’s assessment of your risks and likely your insurance company’s willingness to pay.  As of now, there have not been any major changes to the reimbursement of mammograms.

So how do we screen for breast cancer?

The main screening tool we use is a history!

  • What age did you start menstruating
  • Do you have a family history of breast cancer
  • Have you had breast surgery
  • Have you ever been pregnant

The answer to these questions add context to the next part of screening – a mammogram. A mammogram is an x-ray of the breast taken from 2 angles with the breast pressed against the machine to give a standard view. That image is evaluated for irregularities that suggest cancer.

There are many variables that go into a mammogram – size of the breast, age, and density are several. Density describes the ambient of breast tissue and fat in a breast. Denser breast make it harder to detect abnormalities on a mammogram. Denser breasts tend to be found in younger women, those who never had children, and athletic women. When this occurs, adding an ultrasound of the breasts can improve the reliability of the results.

MRI has been looked at recently as a screening tool – attractive because it does not use radiation, and can create very detailed images. Therefore, it can detect much smaller abnormalities. Currently this is only recommended for very high risk women.

Another technology recently developed is called Digital Tomosynthesis. Similar to a mammogram, the breast is pressed into position but 11 x-rays are taken instead of two. The images are fed into a computer and a 3-D image of the breast is created and evaluated for abnormalities.

MRI and tomosynthesis are not currently recommended for routine screening.

What do I tell my patients?

  • Every patient is unique, and needs their risk factors evaluated
  • Based on the risk assessment, a mammogram and possibly an ultrasound will be ordered
  • I reserve MRI and tomosynthesis to those women with very high risk
  • Breast implants do not change the need for a mammogram – the implants can be maneuvered out of the image so the breast can be assessed

After the study is done, we will decide when to repeat it – usually yearly based on the ACS guidelines.

One important aspect of breast cancer screening that is overlooked is communication – any test, especially one looking for cancer will provoke anxiety, and I try to get results to my patients as soon as possible. In fact, reducing test anxiety was one of the reasons the USPSTF recommended less testing!

Often there will be an area that was not well seen on the mammogram. In this situation, close up views of the area need to be done – called spot compression views. This does not mean you have cancer – it means a closer look is needed.

Regardless of which screening guideline one follows, one thing must be stressed – if you feel something that does not seem normal to you – bring it to your doctor’s attention! Breast tissue does change and often develops cysts (tender lumps) throughout the menstrual cycle, and where you are in your cycle as well as caffeine intake can influence cysts.  These changes tend to go away at the end of a period. When there is a lump – especially if it persists through a complete menstrual cycle – it is not considered screening and all guidelines stress the need to further diagnose a lump – regardless of age. When discussing self breast exams with my patients I tell them to learn what is normal for them – all breast tissue has some irregularities. If something is different from your normal, see your doctor. It may be nothing but all evidence shows early detection improves outcomes – and ignoring a lump will delay things – either peace of mind that everything is ok or the opportunity to find a cancer early.

The path to wellness begins with a proper diagnosis

Ebola in the US – what’s next!?

Last month, the first Ebola patient was brought to the US – a physician infected in Africa and brought back to the US for treatment.  I reviewed Ebola and that case in a earlier post on 8/2/14. That was a controlled transfer, just as the 2 other known cases transported to the US for treatment were. On September 30th, the first case of newly diagnosed Ebola in the US occurred, in a person who had recently traveled from West Africa to Dallas, Texas.

Once in the US, he went to an Emergency Room for fever.  He was sent home with antibiotics. He returned 2 days later when his symptoms had progressed and his travel history was noted. He was quarantined, tested and diagnosed with Ebola.  Why he was discharged after the first visit has been blamed on a computer error and then on poor communication between the intake nurse and the doctor. Since I wasn’t there I can only hypothesize that the truth is somewhere between.

Since being admitted to the hospital, his immediate contacts have been isolated and a HazMat team is cleaning the apartment where they stayed.  The CDC is monitoring about 50 more people he may have had contact with and so far, no one has developed fever – the first sign of Ebola.

What does this mean for the US now?

Ebola is a virus, causing fever, body aches, headache and sore throat. Unlike most viruses, it can also cause internal bleeding. You need to have symptoms to be contagious, and the incubation period – the time from exposure to symptoms is 2 to 21 days. Treatment is mostly supportive – meaning fluids and oxygen, although experimental treatments are in use as well.  It is likely that the death rate, nearly 50% in West Africa, would be much lower in the US due to better facilities, quarantine and access to care.

Ebola is spread by fluid contact – meaning you need to directly come into contact with secretions from an infected person – similar to HIV or Hepatitis.  It is not an airborne virus – meaning a cough or sneeze won’t spread it.  It also does not live long on surfaces. Therefore, if none of this person’s contacts develops symptoms, then the current US outbreak will be over.

That said, it is likely that another traveler will bring the virus to the US. Modern air travel makes this more likely, even with screening at both the departing and arriving airports.  Vigilance in the doctor’s office and Emergency Department will be needed to quickly identify potential cases – and most importantly, a travel history!

For updates from the CDC

The path to wellness begins with a proper diagnosis