Dr Melgar

Are You Really Allergic to Penicillin? The Truth Might Surprise You

Michael Melgar — Sun, 19 Jan 2025 19:46:59 +0000

Why You Should Get Tested for a Penicillin Allergy
You or someone you know has likely lived most of your life with the belief that you are allergic to penicillin, afraid that a prescription for this drug could result in dangerous side effects or even death. Current estimates suggest that nearly 10% of the U.S. population have been labeled as penicillin allergic. But here’s a surprising fact: The vast majority of those people are not allergic to penicillin after all and unfortunately if you are one of those people a penicillin allergy incorrectly included in your medical record can actually put you at risk.

In this blog post, I am going to explain why it’s important to get tested for a penicillin allergy. It could make a big difference in your healthcare and even help you avoid unnecessary treatments that might be less effective or be more likely to cause significant side effects.

What is a Penicillin Allergy?
Penicillin isn't just one antibiotic. Penicillins and the closely related Cephalosporins are a whole family of antibiotics, used to fight bacterial infections. The Penicillin family of antibiotics represent over a half century of antibiotic development and are some of the most commonly prescribed, safest, and most effective antibiotics we have. People who have a true penicillin allergy may have to avoid all of these medications.

Many people believe they’re allergic to penicillin because they experienced a bad reaction to it in the past or because a parent or even a health care provider told them they were allergic, but studies have shown that at least 90% (and maybe 99%) of people who believe they are allergic to penicillins are not allergic to them at all.

Often times people believe they are allergic because they had a reaction when they were very young. The reaction may have been a rash they developed soon after they were given an antibiotic for an infection. But its very common for viruses to cause rashes especially in young children. In most cases the rash was caused by the virus and not the antibiotic.

Other people were told they were allergic because they developed nausea, vomiting, lightheadedness or some other symptom after taking an antibiotic but most of these symptom may have also been caused by the infection itself. Even if they were caused by the antibiotic these are intolerance symptoms, not allergic symptoms. The difference is important because an allergy can be more severe the second time around and in rare cases can become a life threatening anaphylactic reaction but intolerance never leads to anaphylaxis

Other people were told to report a penicillin allergy because a family member was allergic to penicillin but even if that family member had a true allergy, these allergies are not hereditary.

Why Test for Penicillin Allergy?

Penicillin is often the best choice for treating infections.
Penicillin and other related antibiotics are highly effective at treating many common infections, including strep throat, ear infections, pneumonia and many very serious infections. If you’re allergic to penicillin, doctors will have to choose a different antibiotic, and some of those alternatives might not work as well or could cause side effects like nausea or diarrhea.
Penicillin allergies are often misdiagnosed.
As states above studies have shown more than 90% of people who believe they’re allergic to penicillin are not truly allergic. That means if you haven’t been tested, you could be unnecessarily avoiding a medication that’s safest and most effective for you.
Testing is easy and reliable.
The good news is that getting tested for a penicillin allergy is a straightforward process. There are two main ways to test for an allergy: a skin test and a blood test. The skin test involves placing a tiny amount of penicillin on your skin to see if it causes a reaction. If you’re allergic, your skin will break out in a rash. If you’re not allergic, there won’t be any reaction. This test is quick, and the results are usually available in just 15 minutes.
If the skin test is negative, your doctor may also perform a blood test to check for specific antibodies that your body would produce if it were allergic to penicillin. This testing is accurate, simple, and can give you peace of mind about your allergy status.
You could avoid unnecessary treatments and could save your life.
If you are not allergic to penicillin, knowing that could help your doctor prescribe it when appropriate. If you continue to tell your doctor you’re allergic, they will have to give you a different antibiotic that could have more side effects or be less effective. Studies have shown that patients admitted to the hospital with a penicillin allergy in their record have a higher mortality rate and are more likely to develop wound infections
It’s never too late to get tested.
Even if you’ve had penicillin before and had a bad reaction, it’s still worth getting tested to confirm whether you’re truly allergic. Sometimes, reactions that seem like allergies can be the result of other factors, like a viral illness or taking another medication at the same time. If you’ve been avoiding penicillin for years based on an old diagnosis, now might be a good time to get tested and reassess your options.

How to Get Tested
If you think you might be allergic to penicillin, the first step is to talk to your doctor. They will ask you about your past reactions and might recommend testing. The tests are typically done by an allergist or a specialist in immunology.

During your appointment, the doctor will walk you through the process and explain what to expect. If the results show that you are not allergic to penicillin, you’ll have more treatment options available to you the next time you need antibiotics.

The Bottom Line: It’s Worth It
Penicillin and related antibiotics are among the safest and most effective antibiotics we have. If you’re avoiding it because you think you’re allergic, you could be missing out on your best treatment option and could be putting your health at risk at some point in the future. Getting tested for a penicillin allergy is simple and highly accurate.

It's important to understand that no one should assume their penicillin allergy is incorrect, but if you’ve ever been told you’re allergic to penicillin no matter how certain that person was, consider getting tested. It could be a small step that makes a big difference in your health. Remember, it’s always a good idea to talk to your doctor about any concerns you have. They can help guide you through the process of getting tested and understanding your options.

By learning whether you're truly allergic to penicillin, you’re making an informed choice about your health. Don’t let misconceptions or outdated information hold you back from receiving the most effective treatments available!

Citations

Understanding Homeopathy: A Critical Look

Michael Melgar — Fri, 25 Oct 2024 21:25:20 +0000

The Theory of Homeopathy

Homeopathic medications are often confused with herbal remedies or supplement but they are two entirely different things. Herbal remedies and supplements have actual ingredients which may or may not have some benefit for patients. That can't be said for homeopathic remedies.

Homeopathy was developed in the late 18th century by Samuel Hahnemann, a German physician. The central idea behind homeopathy is based on two key beliefs: "like cures like" and the "law of infinitesimals." The phrase "like cures like" suggests that a substance causing symptoms in a healthy person can be used to treat similar symptoms in someone who is ill. For example, if a person experiences symptoms similar to those caused by onion (such as watery eyes and runny nose), a homeopathic remedy made from onion might be prescribed to alleviate those symptoms.

The second principle, the "law of infinitesimals," suggests that diluting a substance in water or alcohol enhances its healing properties. Homeopaths believe that even after extreme dilutions, the remedy can retain a "memory" of the original substance. This idea suggests that water can somehow remember the substances it has come into contact with, even after those substances have been diluted to the point where none of the original molecules remain.

The Process of Serial Dilution

To create homeopathic remedies, practitioners use a process called serial dilution. This involves repeatedly diluting a substance in water or alcohol, often to the point where the final product contains little to no molecules of the original substance. For instance, a common dilution method is known as 30C, which means the original substance has been diluted 1 part to 99 parts of diluent 30 times. After such a process, there would be one molecule of the original substance for every 100³⁰ (or 10⁶⁰) water molecules, thats a 1 with 60 zeros after it.

To put this in perspective, it is estimated that the final solution may contain only one molecule of the original substance in a volume of water that could fill a sphere so large that if you put the Earth in its center, the outer edge of the watery sphere would extend 50 times further away than the moon is from the earth. Think about that. One single molecule of something smaller than anything you can see even in a common microscope diluted in a volume of fluid so large it extends beyond the moon. That amount of water is equal to 22 trillion times the water in all the earths oceans. If you have ever been on a ship in the ocean or flew over it and looked down you have some idea how incredibly huge that is. Even crazier, a popular homeopathic remedy called Oscillococcinum is often diluted to 200C. That means we would have to have a sphere of water far bigger than the entire known universe to contain even a single molecule of the original substance. Oddly according to homeopathy, the more dilute a preparation is, the stronger it is.

The extreme dilutions used in homeopathy lead to the conclusion that most homeopathic products are essentially just water or alcohol, which is sometimes is added to inert binders to make tablets but with no active ingredients at all. Despite this, homeopaths claim that the water retains a "memory" of the original substance, supposedly allowing it to influence the body in a healing way. The chemistry and physics of water is well understood and there is no conceivable method by which pure water can maintain a memory of substances it was previously in contact with. Even homeopathic practitioners have not proposed any realistic hypothesis or mechanism for this process.

The Scientific Perspective

Despite its appeal to some individuals, homeopathy has been criticized by the scientific community. Numerous studies and systematic reviews have shown that homeopathic treatments are no more effective than a placebo. A placebo is a substance or treatment with no therapeutic effect that is given to a patient, often in the context of a clinical trial.

The claims made by homeopathy about water retaining memory and the healing properties of diluted substances have not been substantiated by scientific research. The laws of chemistry and physics suggest that once a substance is diluted beyond a point where the active ingredient is present then the substance will no longer retain any of its properties. Furthermore, rigorous testing has consistently shown that homeopathic remedies do not outperform placebos in clinical trials.

Conclusion: Homeopathy is Pseudoscience

While homeopathy may be appealing to some due to the idea that it may seem "natural" and focus on holistic healing, it fundamentally lacks scientific validity. The principles of homeopathy—like cures like and the law of infinitesimals—do not align with what 100's of years of scientific research have taught us about how the world works. The process of serial dilution results in remedies that usually contain not a single molecule of the original ingredient, and the concept of water memory has no basis in fact.

For patients seeking effective treatments, it is crucial to rely on therapies backed by rigorous scientific evidence. Evidence-based medicine has been shown to improve health outcomes, while homeopathy has not demonstrated its efficacy in any meaningful way. As you consider your healthcare options, always consult with qualified healthcare professionals and prioritize treatments supported by science. Understanding the limitations of homeopathy can help you make informed choices about your health and well-being.

Citations:

The Lancet (2005): A meta-analysis by Shang et al. reviewed over 200 homeopathic trials and concluded that homeopathic treatments are not more effective than placebo. This comprehensive analysis indicated that the clinical effects of homeopathy could not be distinguished from placebo effects.
British Journal of Clinical Pharmacology (2002): The article discusses a study that investigated multiple other studies looking at whether homeopathic treatments are more effective than placebo for various health conditions. The findings suggest that homeopathy does not show significant benefits beyond what you would expect from a placebo.
Database of Abstracts of Reviews of Effects (DARE) (2000) :Evidence of clinical efficacy of homeopathy: a meta-analysis of clinical trials. The article reviews research on the effectiveness of homeopathy, concluding that high-quality studies generally find no significant benefits compared to placebo. It suggests that while some lower-quality studies reported positive effects, these results may not be reliable. Overall, the evidence does not support the use of homeopathy as a valid treatment option for health conditions.
National Health and Medical Research Council (NHMRC) of Australia (2021): This comprehensive review concluded that there is no reliable evidence that homeopathy is effective for any health condition.

HPV Vaccines - Fact and Fiction

Michael Melgar — Fri, 05 Jul 2024 15:24:38 +0000

Understanding the HPV Vaccine: What You Need to Know

Human Papillomavirus (HPV) is a common virus that can affect both men and women. In fact, it's so common that nearly everyone who is sexually active will get infected at some point in their lives. This is because the virus is highly contagious through sexual contact and even if you have had only one sexual contact that person may have had others. While most HPV infections resolve on their own without causing any symptoms or problems, some can lead to genital warts and several different kinds of cancer.

Among the various strains of HPV, some are more concerning than others because they are linked to cancers such as cervical, vaginal, vulvar, penile, anal, and throat cancers. In fact, almost all cases of cervical cancer are caused by HPV infections.

The Importance of the HPV Vaccine
The good news is that there's a vaccine available that can help protect against the most dangerous types of HPV. The HPV vaccine works by teaching the body's immune system to recognize and fight the virus before it can cause problems like cancer. It's recommended for both boys and girls before they become sexually active, typically around the age of 11 or 12, but can be given as early as 9 years old and for those who were never vaccinated in their younger years, it can be given up to age 45.

Debunking Myths About the HPV Vaccine
There are several myths and misconceptions about the HPV vaccine that are important to clarify:

Myth 1: The HPV vaccine reduces fertility.
Fact: There is no scientific evidence to support this claim. The HPV vaccine does not affect fertility in men or women. Despite millions of doses administered and continuous monitoring for nearly two decades no signal has arisen to suggest that the HPV vaccines affect fertility in a negative way.

Myth 2: The HPV vaccine promotes promiscuity.
Fact: The HPV vaccine is given at an age before most individuals become sexually active. Its purpose is to prevent HPV-related cancers, not to influence behavior. There are many other sexual transmitted diseases of concern including HIV, Syphilis, Gonorrhea, Chlamydia and others. There is little reason to believe that protection against this one STD will cause young people to be less concerned about STD's and therefor more sexually promiscuous and there is no evidence to support that concern.

Myth 3: Only women need to be vaccinated against HPV.
Fact: Both boys and girls should receive the HPV vaccine. It protects against cancers that can affect both sexes.

Myth 4: The vaccine has caused young women to pass out
Fact: Patients who receive the HPV vaccine pass out at the same rate as anyone who is given any other vaccine or has had their blood drawn. Any time a needle is used some patients pass out momentarily during the needle stick. It has nothing to do with the vaccine itself.

Who Should Get the HPV Vaccine?
The HPV vaccine is recommended for adolescents and young adults because it is most effective when given before exposure to the virus through sexual activity. Even if you think your children will only have one sexual partner in their lifetime, their one partner may have had others, and if thats the case then that person most likely will have had HPV. The HPV Vaccine is specifically recommended for the following individuals:

Girls and boys starting at ages 11 to 12: The vaccine is most effective when given at this age because it ensures protection before potential exposure to HPV.

Men and Women up to age 45: If not vaccinated earlier, it's still beneficial to get vaccinated within these age ranges as the vaccine can still offer protection.

How is The Vaccine Given?

Children ages 9-14 - Intramuscular injection. Two doses. The first dose followed by a second dose 6-12 months later. No additional boosters are ever needed
Individuals Age 15-45 - Intramuscular injection. Three doses. The first dose is followed by second dose 1-2 months later and. third dose 6 months after the first. No booster doses are recommended

The Bottom Line

The HPV vaccine is a safe and effective way to protect against several types of cancer caused by HPV infection. It is recommended for both boys and girls to be vaccinated around age 11 or 12, but it can be given as early as age 9 and as late as 45 but the earlier the better. Dispelling myths about the vaccine, such as its impact on fertility or behavior, is crucial to understanding its true benefits. By getting vaccinated, you not only protect yourself, but also future partners, and you contribute to reducing the overall burden of HPV-related diseases in our communities. Talk to your healthcare provider to learn more about the HPV vaccine and how it can benefit you and your loved ones.

Gardasil Vaccine Information Statement (VIS)

CITATIONS

HPV Vaccination and the Risk of Invasive Cervical Cancer: Published September 30, 2020N Engl J Med 2020;383:1340-1348DOI: 10.1056/NEJMoa1917338 VOL. 383 NO. 14
Real-World Effectiveness of Human Papillomavirus Vaccination Against Cervical Cancer: Journal of the National Cancer Institute, Volume 113, Issue 10, October 2021, Pages 1329–1335, https://doi.org/10.1093/jnci/djab080
Monitoring HPV vaccine impact on cervical disease: Status and future directions for the era of cervical cancer elimination: Preventive Medicine
Volume 144, March 2021, 106363
No association between HPV vaccination and infertility in U.S. females 18–33 years old: https://www.sciencedirect.com/science/article/abs/pii/S0264410X2030414X
The Effect of Vaccination Against Human Papillomavirus on Fecundability: Paediatric and Perinatal Epidemiology. 07 September 2017 https://doi.org/10.1111/ppe.12408

Ear Pressure Problems: Navigating Eustachian Tube Dysfunction

Michael Melgar — Mon, 24 Jun 2024 07:00:00 +0000

Many people have had the experienced of being on a plane as it descends for a landing and feeling a sharp pain in the inner ear. Even if you have been lucky enough to avoid that sensation most people know what it like to have ear pressure when changing altitude. This happens when the eustachian tube is not functioning properly

The Eustachian tube is a small passageway that connects your middle ear to the back of your throat. Its main job is to equalize the air pressure in your middle ear with the air pressure outside your body. It also helps drain any fluid that might collect in the middle ear. When this tube doesn’t work properly, it’s called Eustachian tube dysfunction (ETD). This condition can lead to discomfort, hearing problems, and even severe pain, especially during changes in weather and altitude.

Anatomy and Physiology of the Eustachian Tube
The Eustachian tube is about 35 mm long and is lined with mucous membrane, similar to the inside of your nose. It is usually closed and opens only when you swallow, yawn, or chew. The opening and closing of the tube help to equalize air pressure on both sides of the eardrum and allow fluid to drain from the middle ear to the throat, where it can be swallowed.

Why Eustachian Tube Dysfunction (ETD) Happens
Eustachian tube dysfunction occurs when the Eustachian tube becomes blocked or doesn't open properly. Usually this happens when the mucous membranes lining the eustachian tube swell reducing the ability of the tube to open. If the tube can't open and the air pressure changes we can not equalize the pressure on both sides of the ear drum. When there is a big difference in pressure the ear drum get pushed out or pulled in. This pressure on the ear drum reduces its ability to vibrate and transmit sound. When that happens hearing becomes muffled. If the pressure is greater we experience pain which can be quite severe and if the pressure is even greater we can even perforate the ear drum.

Several factors can cause this, including:

Inflammation and Swelling: Allergies, colds, and sinus infections can cause inflammation and swelling in the nasal passages and throat, which can block the Eustachian tube.
Anatomical Problems: Some people have Eustachian tubes that are naturally narrower or more prone to blockage.
Age: Children are more susceptible to ETD because their Eustachian tubes are shorter, narrower, and more horizontal compared to adults.
Obstructions: Enlarged adenoids or tumors can obstruct the Eustachian tube.

Triggers and Exacerbations
Certain conditions can exacerbate ETD, causing severe discomfort and pain. These include:

Changes in Altitude: Rapid changes in altitude, such as during flying or driving up a mountain, can cause a sudden change in air pressure. If the Eustachian tube is blocked or doesn’t open properly, the pressure difference can’t be equalized, leading to ear pain and even damage to the eardrum. Pain usually is worse when coming down from high altitude such as when a plane descends to land.
Weather Changes: Weather changes, especially sudden drops in atmospheric pressure, can also affect the pressure balance in your ears, causing similar issues.

Symptoms of Eustachian Tube Dysfunction
Symptoms of ETD can vary from mild to severe and include:

A feeling of fullness or pressure in the ears
Muffled hearing
Popping or clicking sounds
Pain in one or both ears
Tinnitus (ringing in the ears)
Balance problems or dizziness

Managing and Improving Symptoms
Managing ETD involves a combination of home remedies, medications, and sometimes medical procedures. Here are some strategies:

Swallowing, Yawning, and Chewing Gum: These actions can help open the Eustachian tube, equalizing pressure in your ears.
Nasal Decongestants: Over-the-counter decongestant sprays or pills can reduce swelling in the nasal passages, helping to clear the Eustachian tube.
Antihistamines: If allergies are causing your symptoms, antihistamines can reduce the allergic reaction and associated swelling.
Steroid Nasal Sprays: These can reduce inflammation in the nasal passages and Eustachian tubes.
Valsalva Maneuver: Pinch your nose shut, close your mouth, and gently blow as if you were blowing your nose. This can help to force air through the Eustachian tube.
Oral Corticosteroids: In severe cases, or in situations where a person needs to fly after having recent ETD symptoms, your doctor may advise a short course of oral corticosteroids

Avoiding Acute Exacerbation During Flights
Flying can be particularly challenging for people with ETD. Here are some tips to prevent severe symptoms:

Use a Decongestant: Take a decongestant pill or nasal spray about 30 minutes before takeoff and landing to reduce swelling and help keep your Eustachian tubes open.
Stay Hydrated: Drink plenty of water. This helps keep your mucous membranes moist and reduces congestion.
Chew Gum or Suck on Candy: This stimulates swallowing and can help keep the Eustachian tube open.
Practice the Valsalva Maneuver: Do this periodically during the flight, especially during ascent and descent.
Earplugs: Special earplugs, called filtered earplugs, can help regulate the pressure changes in your ear during a flight.
Avoid Sleeping During Descent: Stay awake during the descent, as swallowing helps equalize ear pressure.

Conclusion
Eustachian tube dysfunction can cause significant discomfort and pain, especially during changes in altitude or weather. Understanding the anatomy and physiology of the Eustachian tube, as well as knowing the triggers and methods for managing symptoms, can help those affected by ETD lead more comfortable lives. With proper care and preventive measures, it’s possible to reduce the impact of this condition, even during challenging situations like air travel.

Carotid Doppler/Ultrasound Tests: Who should have this test done?

Michael Melgar, MD — Wed, 19 Jun 2024 16:12:32 +0000

What is a Carotid Doppler Test?

A Carotid Doppler test is a non-invasive ultrasound exam used to evaluate the blood flow through the carotid arteries in the neck. These arteries supply blood to the brain.

During the test, a technician applies gel to the skin over the neck and uses a handheld device called a transducer to emit sound waves. These sound waves bounce off cells and create detailed images of the carotid arteries, showing any buildup of plaque or narrowing of the vessels.

Current Recommendations by the USPSTF

The US Preventive Services Task Force (USPSTF) provides guidelines on who should undergo carotid Doppler testing. Currently, they recommend this test for individuals who are in one of the following groups:

Prior Stroke or Transient Ischemic Attack (TIA): People who have had a stroke or TIA may benefit from carotid Doppler testing to assess the severity of artery blockage.
Symptoms of Carotid Artery Disease: This includes symptoms like sudden weakness or numbness in the face or limbs, difficulty speaking, or temporary blindness in one eye.
Cardiovascular Risk Factors: Individuals with multiple risk factors such as high blood pressure, high cholesterol, diabetes, or smoking history may be considered for testing if they are at higher risk for carotid artery disease.

You can access the full recommendations at the USPSTF web site HERE

Why Carotid Doppler Testing Isn't Recommended for Everyone

The USPSTF does not recommend routine Carotid Doppler screening for everyone. This is because most individuals without symptoms or multiple specific risk factors would not benefit from this test. The main principle guiding this recommendation is that medical tests and interventions should only be pursued if they are likely to change how a patient is treated or managed in such a way that the treatment will result in a better outcome.

In the case of carotid artery disease, if the test shows significant blockage or narrowing, it might prompt interventions like medications to lower cholesterol or blood pressure, lifestyle changes (such as quitting smoking or improving diet), or in some cases, surgical procedures to open or bypass the blocked artery. However, for individuals without symptoms or specific risk factors, the likelihood of finding significant disease that would alter treatment is low and treatments may actually increase the risk to the patient.

Routine screening in these cases could lead to unnecessary tests, anxiety, and potentially even unnecessary treatments or procedures which have significant risks. For patients with asymptomatic disease, the harms of surgical interventions appear to outweigh the benefits. And most of the medical treatments such as antihypertensives, cholesterol medications, and smoking cessation are things that would likely have been recommended regardless of the findings on the sonogram.

Therefore, the USPSTF guidelines emphasize a targeted approach to screening based on individual symptoms and in some cases certain risk factors. This approach aims to balance the benefits of early detection and intervention against the potential harms of overdiagnosis and overtreatment.

Another reason that Carotid Doppler testing or any screening for stroke risk is not universally recommended is because these tests are not particularly accurate at predicting who is most likely to have a stroke. Strokes don't necessarily occur as a result of the biggest plaques or the narrowest arteries and sometimes very small plaques in wide open arteries are the ones that cause a stroke so the amount of blockage seen on a scan does not always correlate with the potential risk for a stroke. If you want to read more about why this is true click on the article listed below "How Do Heart Attacks Happen". This article explains why this is the case in arteries for the heart, but the same principal applies in arteries throughout the body including the ones where strokes sometimes originate.

How Do Heart Attacks Happen

Summary

In summary, a Carotid Doppler test is a specialized ultrasound used to evaluate blood flow in the neck arteries. It is recommended for individuals with symptoms of carotid artery disease or certain risk factors. The USPSTF advises against routine screening for most individuals who have not had symptoms of carotid stenosis such as a stroke or transient ischemic attack. Efforts to reduce the risk of stroke should instead be focused on reducing the risk factors that increase the chances of a stroke such as cholesterol, high blood pressure and smoking.

Cologuard vs. Colonoscopy: Which is the Best Colon Cancer Screening Test?

Michael Melgar — Mon, 10 Jun 2024 07:00:00 +0000

There have been a lot of ads on TV lately promoting a new colon cancer screening test called Cologuard which is presumably a more convenient way to screen for colon cancer but is it a good substitute for a colonoscopy?

Colon cancer is a significant health concern. It's the 3rd leading cause of cancer deaths in men and women in the U.S.. The fact that almost all colon cancers begin years before as precancerous polyps means that there is a valuable opportunity to screen early and prevent this cancer and many of the deaths it causes. Current recommendations suggest that average risk individuals start screening at age 45. High risk patients may need to start earlier.

There are two primary methods for screening that stand out in this regard: Cologuard and Colonoscopy. Both have their benefits and drawbacks, which are important for patients and healthcare providers to consider when choosing the most appropriate screening method.

Cologuard: A Non-Invasive Screening Option
Cologuard is a non-invasive stool DNA test designed to detect the presence of blood and genetic mutations associated with colon cancer and precancerous polyps. Approved by the FDA in 2014, it offers several potential advantages.

Benefits of Cologuard:

Non-Invasive Nature: Cologuard does not require any invasive procedure. Patients can collect the stool sample at home and send it to a lab for analysis. This ease of use makes it a possible option for those who don't want to or can not undergo a colonoscopy.
No Special Preparation: Unlike colonoscopies, which often require dietary restrictions and bowel preparation, Cologuard does not require any special preparation.
Accessibility and Comfort: Cologuard is accessible to those who might have limited access to medical facilities or those with mobility issues. The comfort of home sample collection can lead to higher screening rates for these people.

Drawbacks of Cologuard:

Lower Sensitivity for Precancerous Polyps: One significant drawback is Cologuard’s limited ability to detect precancerous polyps. While it is relatively effective at identifying cancerous cells, its sensitivity for advanced adenomas, the type of precancerous polyps most likely to develop into cancer, is much less. This limitation means that Cologuard might miss early precancerous changes that could be detected through colonoscopy.
False Positives: Cologuard has a higher rate of false positives compared to colonoscopy. This can lead to unnecessary anxiety and additional follow-up procedures, such as a colonoscopy, to confirm the findings.
Frequency of Testing: Because of its limitations, Cologuard needs to be repeated every three years if the results are negative, whereas a colonoscopy is typically repeated every ten years for average-risk individuals if no abnormalities are found.

Colonoscopy: The Gold Standard
Colonoscopy is considered the gold standard for colon cancer screening. It involves a direct visual examination of the colon and rectum using a flexible tube with a camera. This method allows for both detection and removal of precancerous polyps during the same procedure.

Benefits of Colonoscopy:

High Sensitivity and Specificity: Colonoscopy has a high sensitivity for detecting both cancerous and precancerous polyps which means cancer and precancerous lesions may be detected years earlier than they are with Cologuard. This comprehensive view allows doctors to identify and remove polyps before they turn into cancer, significantly reducing the risk of colon cancer.
Diagnostic and Therapeutic Capability: During a colonoscopy, if any polyps or abnormal tissues are found, they can be removed immediately. This dual function of detection and treatment makes colonoscopy a powerful tool in the prevention of colon cancer.
Longer Screening Interval: A clear colonoscopy result generally means the patient does not need another screening for ten years, providing long-term peace of mind and reducing the need for frequent testing.

Drawbacks of Colonoscopy:

Invasive Nature: Colonoscopy is an invasive procedure that involves inserting a long, flexible tube into the rectum. The test is generally done with conscious sedation. Patients sleep through the procedure so there is no pain but for some patients there may be anxiety which may deter them from undergoing the procedure.
Preparation Requirements: The preparation for a colonoscopy is often cited as a significant drawback. Patients need to follow a specific diet and use strong laxatives to clean out their bowels, which can be uncomfortable and inconvenient.
Risks of Complications: Although rare, complications such as perforation of the colon, bleeding, and adverse reactions to sedation can occur. These risks, although minimal, are a concern for some patients. When done by a highly experienced gastroenterologist these complications are very rare

Conclusion
Both Cologuard and Colonoscopy may play a role in the early detection and prevention of colon cancer.

Cologuard offers a non-invasive, convenient, and accessible option, but its lower sensitivity for precancerous polyps and higher false positive rate limit its efficacy and may result in delayed detection of precancerous polyps and the resulting cancers.

Colonoscopy, while more invasive and requiring extensive preparation, provides a more comprehensive examination, allowing for immediate removal of precancerous polyps and a longer interval between screenings.

Ultimately, the choice between Cologuard and Colonoscopy should be based on individual risk factors, patient preference, and discussions with healthcare providers. Balancing the convenience and comfort of Cologuard with the thoroughness and preventive potential of Colonoscopy can help achieve the best outcomes in colon cancer prevention and early detection. As with al medical decisions patients should discuss these options with their physician before making a decision.

Abdominal Aortic Aneurysms: What You Need to Know

Michael Melgar — Mon, 27 May 2024 08:34:42 +0000

Abdominal Aortic Aneurysms (AAA) might sound like a mouthful, but understanding them is important for your health. Picture your aorta as a big, stretchy hose carrying blood from your heart to your belly and legs. If there is a weak spot the pressure in the aorta can cause it to balloon out and if it stretches far enough it can rupture. This is an abdominal aortic aneurysm. It can be dangerous if it bursts, so catching it early is key.

Why Screening Matters
The United States Preventative Services Task Force (USPSTF) recommends screening for AAA for certain people at higher risk. This includes men over 65 who are or were smokers and some men over 65 even if they never smoked if they have other risk factors, women who are or were smokers, but not for women who never smoked unless they have a family history of AAA. Screening means checking if your aorta is healthy and catching any issues before they become big problems.

The Screening Process
Screening for AAA is simple and painless. Doctors often use an ultrasound, like the ones used to check babies in pregnant bellies. You just lie down, and a small device is moved over your belly to take pictures. These images help doctors see if your aorta is healthy or if there's a problem.

Benefits of Screening
Getting screened helps catch any issues early, so you can take action to keep yourself healthy. If a small AAA is found, your doctor can keep an eye on it and make sure it doesn’t grow. They can also recommend lifestyle changes like quitting smoking or managing high blood pressure, which can help prevent AAA from getting worse.

Risks of AAA and Rupture
AAA can be scary because they often have no symptoms until they burst. Imagine a water balloon getting bigger and bigger until it pops. That's what can happen with an AAA. If it bursts, it can cause sudden, severe pain in your belly or back, and it's a medical emergency that needs surgery right away. Sadly, many people don't survive if this happens. If the sonogram detects that the aneurysm has reached a critical size then your doctor may recommend that you have a procedure to repair the aneurysm. Sometimes its possible to achieve this goal with a stent that is introduced through an artery in the groin. This non-surgical approach may not always be an option due to the size and location of the aneurysm or for other technical reasons. In those cases surgery may be recommended.

Balancing Risks and Benefits
Like everything in medicine, screening for AAA has both risks and benefits. The main risk is finding something that might not actually harm you. Sometimes, small AAAs are found that never cause any problems. And there is also the risk of finding something that doctors call "incidentalomas". These are incidental abnormal findings which are usually harmless but require additional testing that may require x-ray exposure or even invasive testing but which turn out to be nothing and yield no significant health benefits. On the other hand without the sonogram there's the risk of missing something important. If an AAA isn't found until it's big or bursts, it can be very dangerous. The goal as in all testing is to identify which people who are at greatest risk and would gain enough benefit to out weigh the risks of the tests.

What are the main risk factors?

There are a number of factors that increase the risk of developing a AAA. No one risk factor alone will determine if someone will develop a AAA but the more risk factors a patient has the greater their lifetime risk.

Age: The risk of AAA increases with age, especially in individuals over 65 years old.
Gender: Men are at higher risk of developing AAA compared to women.
Smoking: Smoking is one of the most significant risk factors for AAA. Smokers have a much higher risk of developing an AAA compared to non-smokers.
Family History: Having a close family member, such as a parent or sibling, who has had an AAA increases your risk of developing one yourself.
High Blood Pressure (Hypertension): Chronic high blood pressure can weaken the walls of the aorta over time, making it more prone to developing aneurysms.

Who Should Get Screened?
The decision to get screened for AAA depends on your risk factors and age. If you're over 65 and have ever smoked or have a family history of AAA, talk to your doctor about screening. Even if you don't have any risk factors, it's good to ask your doctor about AAA during your regular check-ups. (See USPSTF link below for specific recommendations)

What You Can Do
Whether or not you get screened, there are things you can do to keep your aorta healthy. Quitting smoking is one of the best things you can do to lower your risk of AAA. Eating a healthy diet, exercising regularly, and managing conditions like high blood pressure and cholesterol also help keep your blood vessels strong.

Final Thoughts
Abdominal aortic aneurysms might be hard to say, but they're important to understand. Screening for AAA in high risk individuals can help catch any issues early and prevent them from becoming serious. If you're at higher risk, talk to your doctor about getting screened. And remember, taking care of your overall health is the best way to keep your aorta and the rest of your body happy and strong.

USPSTF: Abdominal Aortic Aneurysm: Screening Recommendations

Understanding Sinus Infections: Beyond the Common Cold

Michael Melgar — Thu, 23 May 2024 20:34:52 +0000

Sinus infections, also known as sinusitis, can be a complication of a cold or allergy. But what exactly are sinus infections, and why do they often follow weeks of sinus congestion from a cold or allergy?

Firstly, what are sinuses? Your sinuses are air-filled cavities located behind your forehead, cheekbones, and nose. They're lined with a thin layer of mucus-producing cells and are connected to your nasal passages by small channels. Sinus cavities may be as large as a walnut but the openings to them are only a few millimeters in diameter. Normally mucous is produced in the sinuses to help warm and humidify air that we inhale and also to help trap dust and other pollutants so we don’t inhale them into our lungs, but when a cold or allergies inflames the linings the opening can become narrowed and even blocked leading to problems.

Sinus infections typically occur as a secondary infection following prolonged sinus congestion from a cold or allergy. When you have a cold or allergies, the lining of your sinuses becomes swollen and produces excess mucus. This congestion impairs drainage from the sinus cavity causing pressure and pain and in some circumstances it can create a breeding ground for bacteria, leading to an infection. In some respects a sinus infection is like an abscess, a closed space filled with fluid and bacteria.

Now, let's address a common misconception: the color of the mucus. Many people and even many doctors believe that the color of their mucus, particularly if it's green or yellow, is a sure sign of a sinus infection. However, this is not the case. Mucus color can vary for a variety of reasons, including how old the mucous is, hydration levels, diet, and the presence of certain cells in your immune system but the presence of infection has not been found to correlate well with mucous color.

Another misconception is that prolonged congestion is a sign of an infection. While weeks of congestion can be very frustrating, the length of time that congestion has been present does not by itself mean that there is an infection. Allergies can commonly cause congestion that can last for weeks and even months. Viruses can also cause very prolonged congestion as well. Prolonged congestion by itself is not a sign of infection unless it is followed by specific new symptoms.

Symptoms, such as worsening facial pain, pressure, and a new fever after prolonged congestion lasting a week or more, are the best indicators of a sinus infection but the key factor is a significant change in symptoms after a prolonged period of congestion, especially if the change in symptoms includes a fever.

The best way to treat a sinus infection is not to get one in the first place. Most sinus infections can be prevented if you treat the congestion that precedes it. As mentioned above a sinus infection is similar to an abscess and the treatment for an abscess is drainage. Preventing sinus infections starts with good sinus hygiene. Stay hydrated, as this helps keep your mucus thin and easier to expel. Use a humidifier to add moisture to the air, particularly during dry winter months. Avoid irritants like cigarette smoke and strong chemicals, as these can further irritate your sinuses. If you have allergies make sure you treat them appropriately (see Allergy Treatment here). Also practice good hand hygiene to reduce your risk of catching colds or other respiratory infections.

So, how can you tell if you have a sinus infection? If you were feeling fine a few days ago and are now congested you don’t have a sinus infection. As mentioned above, sinus infections take time and are characterized by the development of certain specific new symptoms after a prolonged period of congestion usually caused by a virus or allergies

Contrary to popular belief, sinus infections do not always require the use of antibiotics and can often be treated with conservative measures at home with rest, hydration, and over-the-counter medications to alleviate symptoms. Just as with prevention, treatment should focus on things that can be done to improve drainage. Nasal decongestants and saline nasal sprays can help reduce congestion and promote drainage, while pain relievers like ibuprofen or acetaminophen can help ease discomfort, but if you think you have already developed an infection you may want to see your doctor. In some cases, your doctor may prescribe antibiotics if your symptoms are suggestive of a true bacterial sinus infection.

Sinus infections can be an uncomfortable consequence of sinus congestion from a cold or allergy. Understanding how they occur and debunking common misconceptions, such as the belief that green mucous color or prolonged congestion on its own indicates infection, can help you better manage your symptoms and avoid the potential side effects of unnecessary antibiotics. By taking care of your sinuses and recognizing the signs of infection early on, you can minimize discomfort and get back to feeling your best as fast as possible.

The Whole Truth Behind Whole Body MRI Scans – Overhyped, Overpriced, and Overrated!

Michael Melgar, MD — Tue, 21 May 2024 21:45:14 +0000

A number of companies are currently marketing whole body MRI's directly to the public. They claim that these tests can detect cancer and other diseases at an early stage and they imply that this test can save lives. They often showcase futuristic offices and equipment reminiscent of a luxury spa or a scene from Star Trek. Some of their promotions feature dramatic stories from individuals who claim their lives were saved after tumors and other ailments were detected with this device.

Regardless of the promotional hype, there is no evidence to support the claim that these tests can actually save lives or lead to better outcomes. Moreover, there are reasons for caution. Many perfectly healthy individuals who undergo a whole-body MRI will receive reports that include abnormal findings necessitating further testing. Often these additional tests will expose patients to a fair amount of radiation and in some cases they will lead to invasive procedures and biopsies, along with the associated pain and risks that come with those procedures. For many patients anxiety may also accompany the initial report and the additional testing. While in most cases, these additional tests will yield normal results, patients will have experienced all the negative effects and risks without any demonstrable benefit.

There is also a financial cost. These MRI facilities charge between $1500-$2500 for a scan and insurance companies do not cover the cost.

One final note is that a "normal" test does not mean everything is OK. There is the risk that patients who have no abnormal findings on their scan may come away with the false impression that they have gotten a "clean bill of health" and that other proven screening tests are not necessary, or that they could at least be postponed for now. That is not true and this misperception could lead to missed opportunities for early cancer detection and ultimately lead to worse outcomes.

It's worth noting that no expert radiology association recommends these tests. No expert medical association of any specialty recommends these tests. In addition private insurance and Medicare do not cover these tests. The lack of expert support and insurance coverage is entirely due to the complete lack of data supporting their purported life-saving results. Until such data exists, these tests are not recommended. I personally discourage my patients from doing them.

Lung Cancer Screening - Is it time to get a CT scan?

Michael Melgar — Tue, 14 May 2024 13:03:00 +0000

The United States Preventative Services Task Force (USPSTF) has come out with a preliminary recommendation in support of low dose chest CT scans to screen for lung cancer in certain high risk individuals. The recommendation can be viewed below.

The recommendation does not cover all people who are or were smokers, only those who are considered high risk. For the purpose of this recommendation the definition of high risk includes all patients who meet the following criteria.

20 pack years or more of smoking- Pack years are calculated by multiplying the number of packs smoked per day times the number of years of smoking. For example, someone who smoked 1pack per day for 30 years or 2 packs per day for 15 years would have 30 pack years of smoking.
Age 50-80
Current smoker or stopped smoking no more than 15 years ago

These criteria were developed after review of several studies and consideration of the benefits and harms of screening.

The benefits of screening obviously include the possibility of detecting lung cancer at an earlier more treatable stage. Although this would not prevent all lung cancer deaths, studies indicate significant reductions in mortality can be achieved with a properly designed screening program.

All screening tests have potential risks for the patients who undergo them. In the case of Chest CT's the risks include false positives resulting in further scans, anxiety, and invasive biopsies, as well as radiation exposure. One study estimates that if all former smokers in the 50-75 age range were to receive annual chest CT scans it would result in a 1.8% increase in the number of lung cancers per year or about 640 extra cases of lung cancer. The earlier a person begins screening the greater the cumulative lifetime radiation exposure and the greater the risk.

Additionally, the CT scan may detect some harmless cancers. Despite common perceptions, some cancers can remain in the body for life and never cause harm. We do not have a good method for separating these cancers from the harmful ones so screening may result in the detection and treatment of harmless cancers and some patients will suffer side effects from these treatments.

Another potential drawback to lung cancer screening is that some proportion of screened patients who are current smokers will incorrectly assume that a negative scan means they are cancer free and use this as a license to continue smoking. A negative scan does not rule out the possibility that cancer is present. A small tumor may still contain millions of cancer cells yet be too small for the scan to detect. Smokers should be made aware that a negative scan has no diagnostic value at all and is NOT "a clean bill of health".

All of these factors were considered before making the current recommendation which was designed to best balance risk and benefit. If you feel you may be a candidate for lung cancer screening discuss this with your doctor.

USPSTF Lung Cancer: Screening Recommendations

The Drip Dilemma: Why Healthy People Should Steer Clear of IV Therapy

Michael Melgar — Mon, 13 May 2024 09:50:33 +0000

In an era where wellness trends are everywhere, IV therapy has emerged as the latest fad promising to provide everything from enhanced energy levels to boosted immunity in a spa like environment. But before you roll up your sleeve for that trendy drip, lets look at the facts. Despite the glossy marketing and celebrity endorsements, there's a stark truth: There are no proven benefits for healthy people and there are potential risks

Let's break it down. IV therapy involves the intravenous administration of fluids, vitamins, and minerals directly into the bloodstream. Proponents claim it offers a quick fix for everything from hangovers, to colds, to fatigue, but the evidence tells a different story.

First and foremost, there is zero scientific evidence to support the notion that IV therapy provides any benefits for healthy individuals. If you can consume liquids and nutrients orally then getting them by way of IV offers no benefit at all. In fact, for those who are already adequately hydrated and nourished, IV therapy is not only unnecessary but possibly risky which is why we in the medical field never order IV fluids for patients who are able to consume and absorb fluids, nutrients, or critical medications orally.

There are several potential risks to IV therapy. One of the risks is infection. Any time you puncture the skin and introduce a foreign substance into the bloodstream, you're opening the door to potential pathogens. Even in the most sterile environments, there's always a risk of bacterial contamination, which can lead to serious infections such as sepsis. In a hospital or medical office setting we do everything to reduce this risk but even then we only accept that risk in situations where a patient faces another greater risk such as infection, severe dehydration, or cancer.

But there's more. IV therapy isn't just a gamble with infection; it can also throw off your body's delicate balance of electrolytes. When you consume fluids or nutrients orally your body has some control over what fluids and nutrients it absorbs and how quickly it absorbs them. This allows it to take in only what it needs. In addition, if it absorbs too much the slower rate of absorption allows the body’s other organs more time to compensate and prevent those things from rising to dangerous levels. When you flood your system with excessive amounts of fluids, vitamins and minerals, you run the risk of throwing off the carefully calibrated equilibrium that keeps your body functioning properly. Too much of a good thing can quickly turn bad, leading to electrolyte imbalances that can cause muscle weakness, irregular heart rhythms, and even seizures.

And let's not forget about the financial cost. IV therapy doesn't come cheap, with sessions often costing hundreds of dollars. Yet, despite the hefty price tag, you're essentially paying for nothing more than a glorified placebo. Any perceived benefits are likely nothing more than the result of the powerful placebo effect, rather than any physiological changes induced by the IV cocktail.

So, to all the healthy individuals out there tempted by the allure of IV therapy, save your money, protect your health, and stick to hydrating and nourishing your body the old-fashioned way—eat a healthy diet and drink when your body tells you to. There are no shortcuts to true wellness, and IV therapy is nothing more than a potentially dangerous detour on the road to health.

GMO's (Genetically Modified Organisms) - Are they truly "Frankenfoods" or our best hope for feeding a hungry world?

Michael Melgar — Mon, 06 May 2024 09:46:00 +0000

Genetically Modified Oragnisms (GMO's) have been in the news the past few years as activists in the U.S. and Europe have mounted a campaign to rid our diets of foods that have been altered using the new techniques of genetic engineering. Recently they have pushed for legislation to require labeling of all foods that contain GMO's

Opponents of GMO products believe that all foods should be labelled "GMO free" or "Contains GMO's" so consumers will know what they are buying. They believe its only logical and right to provide consumers with more information so that they can make informed decisions. The problem with this approach is that more information is really only useful when it makes us more knowledgeable. If the information in fact misinforms us then it is worse than no information at all. Labelling products that contain GMO's creates the false impression among consumers that these products may be less safe than products which don't contain them, otherwise why would the government require such labeling? But if you look at the facts, there is no evidence that GMO's are less safe than other foods and in most ways they are no different than the foods we have all been eating for centuries.

What are GMO's?

GMO's are not new. The term Genetically Modified Organism refers to the new techniques that scientisits have developed which allows them to transfer genes from one ogranism to another but humans have been modifying the genetic makeup of plants and animals using cruder techniques for thousands of years. Broccoli for example did not exist in nature before man came along and created it. Broccoli is a man made organism which was created by "genetically modifying" a member of the cabbage family over 2,000 years ago through selective breeding. Native tomatoes and corn similarly are nothing like the human modified versions we all consume today. Both of these foods existed in nature only as small barely edible versions of their current day selves before man began tinkering with them.

While the techniques our ancestors used to modify the genetic makeup of these foods are different from the techniques we are using today the end result is not much different. In both cases we are tinkering with the organisms genes so that they express traits which make the plant more useful or desireable. By doing this the plant may produce larger fruit or different flavors. We may change it so that it produces higher amounts of important nutrients like vitamins or proteins. In other cases we may transfer a useful trait from one plant to another so that an important food crop learns how to survive with less watering, or how to make its own fertilzer, or how to defend itself from pests so less pesticides are needed.

As an example, modern corn which is the result of hundreds of years of selective breeding has much bigger kernels with far more starch and sugar than native corn. More recent strains created through modern methods of genetic science have added qualities that allow them to survive drought and pests.

So whats the difference between the way our ancestors changed the genetic makeup of their foods and the way we do it today?

How are GMO's different from organisms produced the "Old Fashioned Way" through selective breeding?

Selective Breeding and hybridization
For thousands of years our ancestors used a technique called selective breeding to artificially alter their plants and animals. They would breed organisms and then select the ones with the desired traits and discard the others. Over time this process would produce the product they wanted. On a genetic level what was happening is that undesireable genes were being extinguished and desireable genes were being selected for. Crossing one desireable organism with another would sometimes bring new genes together creating hybrids that had never before existed with unique combinations of genes that might provide even more useful traits. This approach is somehwat hap hazard as the breeder has to work with existing genes or wait for new mutations to occur sponatenously. It can take decades or centuries to improve an organism this way and some traits may never be attainable through this random process. In addition, the random somewhat blind process in which selective breeding alters the genetics of an organism means that the new breed may contain genes and traits that are undesireable.

Modern Genetic Engineering Techniques
Todays techniques build on the work of our ancestors but are more precise and rely less on luck. Scientists can now identify genes that bestow useful traits to plants and with the use of sophisticated genetic engineering techniques they can transplant these genes into other organisms so that the new organism may acquire the desired trait.

For example a scientist may find a wild grass plant that is especially drought resistant. With a lot of hard work they may identify one or two genes that are responsible for the plants natural ability to survive with less water. Scientitst have tools that allow them to isolate the gene and then transplant it into the chromosome of a useful plant like wheat for example. Often the transfered gene may not work in the new organism so this process requires a great deal of trial and error. When it does work the new organism has acquired a trait that may allow farmers to grow more food per acre and may allow food production on land that was previously barren. In parts of the world where land is not as fertile or growing seasons are shorter these new traits can be critical to feeding the local population.

Modern methods are less haphazard and more direct than the older methods of selective breeding but the outcome is not that much different. We change the genetic makeup of an organism so that it is more useful in some way.

GMO's are not new

About half of all the foods consumed today contain genetically modified organisms including fruits , vegetables, cereals, and meats. Without this technology we would scarcely be able to feed a fraction of the worlds current population and those who could afford to feed their families would probably have to pay more to do so. GMO techniques have allowed us to create food plants that can survive in dryer and colder conditions and resist pests better than older varieties.

in recent developments scientists developed a new GMO potato that may actually be safer than unaltered potatoes. As they exist now when potatoes are fried the sugars in the potato interact with an amino acid called asparagine to form a chemical called acrylamide. Acrylamide has been shown to cause cancer in animals although research in humans is still incomplete. Using modern genetic technology scientists have developed a potato that produces less asparagine and as a result less acrylamide. In theory this potato should be less likely to cause health problems than non-GMO potatoes. Unfortunately because of the current public preceptions about GMO ingredients this potato has been rejected by retailers including McDonalds. This leaves consumers with less choice rather than more.

I am concerned that GMO labeling proponents aren't really interested in in giving us choices or "educating" the public in the traditional sense. They have a heartfelt belief that all GMO products are harmful despite a lack of evidence that this is true. Rather than trying to inform the public I believe their goal is to persuade people not to use these products. They know that if a product is labelled "GMO free" people who are unfamiliar with the term or the details of the debate will naturally begin to assume that GMO's are harmful. Why would anyone care if something were GMO free unless GMO's were harmful? The label does not simply impart information. It is an implied warning that products which use GMO's are unsafe. The proposed legislation to require GMO labeling is an effort by GMO opponents to get politicians to spread the fear for them through these new laws and end the debate before it ever gets started.

Why are some people concerned about GMO's?

GMO opponents' concerns about GMO's have taken several forms

Allergies - There have been claims that GMO's can cause allergic reactions in some people and while this is true, so can strawberries and mangos made the old fashioned way. Any food is capable of causing allergies in some people. GMO's are no less likely to trigger allergies but they are also no more likely to cause allergies than any other food. Introducing a new protein into our foods always presents this risk but the same is true anytime a person consumes a new food for the first time whether its a GMO food or a non-GMO food.

GMO's are too new and haven't been tested enough? - Yes some of these foods are new but the same could be said for any new apple or tomato that is discovered or create through old fashioned techniques and no concern has ever been raised about those food items. GMO's are tested extensively by manufacturers for safety and quality. In addition the FDA has set up a voluntary consultation process to engage with the developers of genetically engineered plants to help ensure the safety of food from these products. This is not required with foods created through the more random process of selective breeding. GMO's have only very small changes made in their DNA. 99.99% of the DNA is unchanged. New organisms should be studied carefully before being released into the wild but only to the same extent that these rules are also applied to varieties produced by selective breeding or through importation from other parts of the world.

GMO's may be harmful to insects and other organisms in the environment. - Some GMO's do have modifications allowing them to produce new proteins. Some of these proteins are harmful to insects and while they may harm useful insects as well as the destructive ones these plants do not require the use of insecticidal sprays which travel over a wider area and kill more insects. It is possible that these organisms may have unintended effects on important insects so we need to study such things before putting new GMO plants into widespread use but again, this should be done in a way that is consistent with past practices. On a daily basis we use pesticides and herbicides which have the potential for causing harm to the environment but we do so in a way that balances the risk with the benefits. This is the approach we need to take with GMO's rather than throwing the baby out with the bath water as many GMO opponents propose.

Concerns about Glyphosate. Glyphosate is a herbicide that works by inhibiting an enzyme essential for plant growth called EPSP synthase. This enzyme is involved in the synthesis of amino acids, the building blocks of proteins. When glyphosate is applied to plants, it disrupts this enzyme, leading to the death of the plant. Some plants have been genetically modified so that they possess a different enzyme which is not inhibited by glyphosate.

Benefits of glyphosate include its effectiveness in controlling weeds, which helps farmers increase crop yields by reducing competition for resources like water, sunlight, and nutrients. Additionally, glyphosate allows for conservation tillage practices, which minimize soil disturbance and erosion, leading to improved soil health and reduced greenhouse gas emissions.

However, concerns have been raised regarding the potential health and environmental impacts of glyphosate. Some studies suggest a possible link between glyphosate exposure and health issues like cancer and disruption of the endocrine system. Environmental concerns include the impact of glyphosate on non-target organisms like bees and aquatic life.

The strength of the evidence regarding glyphosate's safety is a point of contention. While some studies indicate potential risks, regulatory agencies like the EPA and WHO have deemed glyphosate as unlikely to pose a carcinogenic risk to humans when used as directed.

Comparatively, farming without GMOs and glyphosate-resistant crops may require more intensive tillage and increased use of other herbicides, potentially leading to greater soil erosion, loss of biodiversity, and higher greenhouse gas emissions. Additionally, non-GMO crops may have lower yields due to increased competition with weeds and susceptibility to pests.

Overall, the decision to use glyphosate and GMO crops involves weighing the potential benefits against the possible risks, while also considering alternative farming practices and their comparative impacts on human health, the environment, and food security.

The bottom line is that any new organism can have qualities that cause allergic reactions or which may harm other organisms, but nature introduces new organisms and changes existing organisms all the time. Although nature does this more slowly it also does it in a random fashion with no safety testing at all. GMO's are created with a great deal of thought and testing so that these food items are as safe to eat as possible and the effect on the environment is minimized. Its understandable that we should expect new food items to be tested for safety and GMO's are the most highly tested of new food items on the market, but GMO opponents seem to want a guarantee of safety that would never be attainable for any food, not even the ones they eat every day without a second thought. Instead of fighting to have these products banned a more appropriate response might be to advocate for more testing and more independent testing of all new foods by whatever means they are created or imported so that we can all feel safe about the foods we eat.

NOTE: By the way. That "Frankenfood" vegetable above may look like an alien vegetable but it was created the old fashioned way through selective breeding. We shouldnt judge a food by its appearance or by a meaningless label that is put on it.

What is the harm in labeling products that contain GMO's?

If producers are required to label products containing GMO's many will find themselves forced to switch to food sources that do not contain these products because the public will believe incorrectly that GMO's are not safe. The result will be a reduction in food production, increased prices, more hunger especially among groups that are already food insecure, and no real benefit to anyone. The next time you hear a GMO activist refer to these foods as Frankenfoods look at a head of broccoli and compare it to a head of cabbage. If we're not afraid of that type of genetically modified food created 2,000 years ago by selecting completely random mutations then why are we afraid of an ear of corn that can withstand a dryer growing season because a scientist carefully added one or two genes whose properties we know well?

Where can I read more?

Ozempic - Obesity cure or panacea?

Michael Melgar — Fri, 03 May 2024 15:08:58 +0000

Are weight loss drugs a good option for you?

Ozempic, Wegovy, Zepbound and Mounjaro have all been in the headlines a lot lately. These drugs are all members of a drug category called GLP1 agonists. They were originally designed to treat diabetes but over time it was noticed that they also resulted in significant weight loss among diabetics who were taking them.

What is a GLP1 agonist and How Does it Work?
GLP1 agonists are medications primarily used to manage type 2 diabetes. However, recent studies have shown that they can also aid in weight loss for individuals with or without diabetes. Glucagon-like peptide-1 (GLP-1) receptor agonists work by mimicking the action of a hormone called GLP-1, which helps regulate blood sugar levels, slows down digestion, and reduces appetite.

Benefits of GLP1 agonists for Weight Loss

Effective Weight Loss: Clinical trials have demonstrated that GLP1 agonists can lead to significant weight loss when combined with a healthy diet and regular exercise. On average, patients may lose around 5-10% of their body weight within a few months of starting treatment.
Improved Metabolic Health: Apart from weight loss, GLP1 agonists may also improve other aspects of metabolic health, such as reducing blood sugar levels, lowering blood pressure, and improving cholesterol levels.
Convenience: GLP1 agonists are typically administered once a week via injection, making it convenient for many patients to incorporate into their routine.

Considerations and Challenges
While GLP1 agonists offer promising benefits, there are some considerations and challenges to be aware of. Getting a prescription may not be as simple as you might think.

Cost: One of the significant challenges associated with GLP1 agonists is their costs. Without insurance coverage, the medication can be expensive at about $1,200 per month. While, many insurance plans do cover GLP1 agonists, copays or deductibles may still apply. In addition, patients must fit certain criteria for BMI and medical conditions in most cases before they will be eligible for coverage. Some insurance companies do not pay for GLP1 agonists under any circumstances
Insurance Approval: Getting approval from insurance companies for GLP1 agonists can sometimes be a lengthy process. Your healthcare provider may need to provide documentation to support the necessity of the medication for weight loss. The added work load may delay your prescription.
Lifelong Treatment: It's essential to understand that GLP1 agonists are not a temporary solution. To maintain its benefits, you may need to take the medication for the long term or even life long.
Side Effects: Like any medication, GLP1 agonists can cause side effects. Common side effects include nausea, vomiting, diarrhea, and constipation. These side effects usually improve over time as your body adjusts to the medication but some patients are never able to adjust to the side effects.
Unknown Risks: While GLP1 agonists have been extensively studied, there may be long-term risks associated with its use that are not yet fully understood. It's essential to discuss any concerns with your healthcare provider. For this reason the use of these drugs should be limited to people whose weight is sufficiently high enough that it creates health risks which are greater than the risks presented by the life long use of a drug which may have unknown long term side effects
Medication Shortages: It's been common for some drugs or some dosages of some drugs to be unavailable for weeks or months. This may require patients to use a different dose or stop the medication completely for some period of time
Note: The difficulties related to the prescription of these drugs has created such a burden for some physicians and their staffs that some offices no longer prescribe these medications at all.

Conclusion
GLP1 agonists can be a valuable tool in your journey towards weight loss and improved health. However, it's essential to weigh the benefits against the potential challenges and discuss any concerns with your healthcare provider to determine if a GLP1 agonist is the right choice for you and develop a comprehensive plan to help you achieve your health goals.

Cheap Drugs - How to stay healthy without putting your Piggy Bank on life support.

Michael Melgar — Mon, 22 Apr 2024 00:00:00 +0000

Not too long ago I met a new patient who had come to me after her previous doctor had retired. She was a very pleasant older woman who was retired herself and on a fixed income. She was relatively healthy but had a number of chronic medical conditions such as high blood pressure, high cholesterol, diabetes and an underactive thyroid that were well controlled with the use of six different medications which she took daily. During the visit she related that she did not always take her medications because the cost had gotten so high, amounting to more than $600 a month.

Modern medicine has worked miracles. People today can expect to live longer and better than ever before. We have drugs now that can cure infections that used to kill thousands, prevent hear attacks and strokes, cure cancer, and help diabetics live normal lives. But with all of this success and long life comes a cost. Medications can be expensive. The good news is that they don't always have to be. With a little planning a savvy consumer can often purchase the medicines they need for a fraction of the cost and stay healthy without hemorrhaging money.

So how can a smart consumer save money? There are a number of tools available to help us cut our medication bill down to size.

Generic Drugs

The first tool is no big secret. Its generic medications. Generic medicines have the identical active ingedient that the brand name has but often at a much lower price. The only difference between the two will be the shape and color of the pill and perhaps the binders that hold it together. Despite fears that generics will not work as well as the branded drug there is no scientific evidence to support this concern and in fact the FDA regulations require generics to have equivalent doses of the active ingredients. Some generic drugs are actually manufactured by the same company that makes the branded drug but they chaneg the look and repackage it without the brand name.

Use a Similar Drug if no generic drug is available

Even though some drugs may not be available in generic form they may be members of a class of very similar drugs and another member of that class may be available as a generic. "Statin" drugs are used to treat cholesterol. Most people are familiar with Crestor which is a statin. Crestor was not available in generic form a few years ago but several other members of that class such as Zocor, Lipitor, Mevacor, and Pravachol were and still are. With few exceptions, most patients can switch from one statin to another statin and do just as well. The same is true for many blood pressure medications and diabetes medications as well as medicines used for other conditions

GoodRx.com

GoodRx.com is a program available online that provides cheaper prices for nearly all generic drugs through your local pharmacies. No membership fee or other fees are required to use this service. You simply enter the drug, the number of pills, and you zip code. You then get a table showing how much the drug will cost at a number of pharmacies near your location. You can not use your insurance to pay when you use GoodRX. You just print the coupon and tell the pharmacist you will be using GoodRx instead of your insurance. In many cases this is cheaper than using your insurance and if you are uninsured it will be much cheaper than paying out of pocket on your own.

Another advantage using GoodRx is that you won't need to get an approval from your insurance company and you can get past the limits on the number of pills some companies allow.

Switch Pharmacies to one that has a low cost Generic Drug Plan

Neighborhood pharmacies are more convenient but they don't always have the best prices. Both Target and Walmart have generic drug programs that cover a long list of common drugs. These drugs can be purchased at very low cost. For most drugs on these lists a 30 day supply is only $4 and a 90 day supply is $10 even even with no insurance. If you do have insurance its important to tell the pharmacy you do not want to use your insurance for these prescriptions otherwise you may actually be charged a copay which could be higher than the cash price or you may be told that you can not get a 90 day supply through your insurance plan. Just tell them you will be paying cash out of pocket for your medications if the medicine is on their Generic Drug Formulary. Click on the links below to see if your medications are on these lists. Each pharmacy has a slightly different list so if you don't see your medication on one list check another. If your medication isn't on the list but a similar one is ask your doctor if it makes sense to switch medications.

Target Generic Drug List
Walmart Generic Drug List
Costco Drug List - Costco also has the lowest prices by far on some over the counter drugs like generic versions of popular allergy medications Allegra and Claritin. They also have great deals on Acid Reflux medications like Prilosec.

Local pharmacies like CVS and Rite Aid have similar plans although some of them require a small annual membership fee and have slightly higher prices.

These first three tools can result in significant savings. As an example, lets look at what happened with the woman I mentioned in the opening paragraph. We sat down and looked at the medicine bottles she had and I asked her if she would be willing to switch consider generic medications or switch to some similar medications if it would help her save some money. She happily agreed. As it turned out most of her medicines were brand name medicines for which generic equivalents were available. Two medications were not available as generics but there were alternatives that we could use which were just as good and they were available as a generic. In addition she was getting all of her medications through the local pharmacy at regular retail prices. By switching all of her medicines to generics or to similar medicines that had generic equivalents and transfering her prescriptions to a pharmacy with a generic drug plan we managed to get a 90 day supply of all 6 of her medicines for a grand total of $60. That was just $20 a month compared to the $600 monthly drug bill she had before. Her annual medication bill had been over $7,200. Now it was $240. Even better was the fact that her chronic medical conditions eventually were under better control because she didn't have to skip her medications.

These aren't the only tools you can use to lower drug costs. A few more are ilsted below.

Splitting Pills

Its an odd quirk of drug pricing that doubling the dose does not double the price. In fact in many cases a 100mg pill of a drug costs exactly the same as a 50mg pill. This is often true whether we are talking about the generic or the brand form of a drug. The cost for 30 pills of brand name Lipitor cholesterol medication at an one drug store at the time of this posting is $256 for the 20 mg pills. The same store charges the exact same price for the 40 mg pills. Buying the 40mg pill and cutting it in half would save a cash paying customer $1,536/year. Even if the patient has insurance and only pays a $30 copay they could save $180/year which isn't peanuts.

The generic version of the same drug is $15 for the 20mg pill, while the 40mg pill is only slighlty more expensive at $17. Buying the higher dose here woud bring the annual bill from $180 to $102. Not a lot but still $72 is enough to take a big bite out of the check at a nice restaurant. Better in your pocket than the pharmaceutical company.

While it is certainly a huge cost savings to split an expensive branded drug it will almost always save you money if you split pills. Most pharmacies sell pill cutters for just a couple dollars that make the job a snap.

One caution, capsules and time release medications can not be split. Check with the pharmacist to see if the drugs you are taking can but cut without changing their effectiveness.

OTC (Over The Counter) medications

Most people assume that getting medications through their drug plan is going to save them money but as I already mentioned above that is not always true. Sometimes co-pays can be more expensive than just paying for a drug out of pocket. This is also true of drugs that are available both with and without a prescription.

Common examples are antireflux drugs like Prilosec and Prevacid. These drugs are available in brand and generic form without prescription. It often pays to look at the non-prescription form on the shelves and compare it to the prescription price before purchasing. Sometimes the savings can be significant and it never hurts to ask if there is a similar drug that does not require prescription. The added benefit of nonprescription drugs is that it does not require an office visit or a phone call to get a new supply of these medications, and if you forget your medicine when you travel you can easily pick up a new bottle at the local pharmacy. Always check with your doctor first though to see if the OTC version is acceptable for your condition.

Many allergy medications that used to require a prescription are also available over the counter now and can often be significantly cheaper if purchased OTC.

Note: I recently checked the price of Nexium ( a popular drug similar to Prevacid and Prilosec for refluc and acid conditions). The price for the precription drug was $500 for 60 pills. The price for the exact same medication OTC ( brand not generic) was about $50 ! It pays to check.

Canadian Pharmacies

The question of purchasing through a Canadian pharmacy does not seem to come up as often today as it did 5 or 10 years ago. Perhaps because ther are other options now. Still I do get occasional questions from patients about this option. There are concerns with this approach.

First it is illegal to import drugs from Canada. Doing so violates federal law and any company that is doing this is knowingly breaking the law. This alone has to make a consumer question the company's ethics and if they are willing to break the law in one circumstance they may be willing to do it in ways that may not benefit the consumer.

These pharmacies are not under the juristiction of any U.S governmental agency and therefor are not liable if there is a problem wth the product they sell to you. There have been incidents of counterfeit drugs being sold through Canadian pharmacies to American citizens. Since they have chosen to break the law by exporting drugs illegally it should not be surprising that some of these companies would have less than perfect ethics about what they are selling.

Since there are other alternatives I would avoid purchasing drugs from Canadian pharmacies.

EPIC

The Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York State program that is designed to help older New Yorkers afford their medications. There are several plans based on income which can pay part or all of the out of pocket expenses involved in the Medicare Part D drug coverage plan. There is a link down below if you would like more information about this program.

Useful Links

Antibiotic Resistance - Why this is important to everyone now

Michael Melgar — Sun, 19 Jul 2015 17:22:00 +0000

Antibiotic resistance is a problem that we have been aware of almost since penicillin was first developed. Its the natural outcome of natural selection when bacteria are exposed to antibiotics, but now we are facing a moment when resistance may disarm even our newest and best antibiotics leaving us vulnerable to infections once again.

In the pre-antibiotic era infections were the most common cause of death. Pneumonia, Tuberculosis, and even infections from minor wounds were beyond the help of physicians. Even something as simple as strep throat could result in injury to the heart and death. Antibiotics changed that so successfully that people today forget what it was like to live in fear of even a small cut or fever. In 1900 Tuberculosis was the second leading cause of death in the U.S. yet only yesterday when I mentioned that I had to test a young woman for tuberculosis her response was "whats's that?". Antibiotics have been that successful.

Antibiotics have turned once deadly diseases into minor nuisances but they have been over used to the point that some of those bacteria are once again beyond the reach of modern medicine. New antibiotics have been developed but we are at a disadvantage. At most there may be a few thousand scientists around the world working on new antibiotics and it takes many years to discover, test, and bring a new antibiotic to market. Those physicians and scientists can only work so many hours. They need to sleep and eat and even occasionally take some time off. But there are trillions of bacteria working on defeating our efforts. They never get tired. They never go home, and they are willing to die for their cause by the billions to produce just one successful offspring who can defeat us and then multiply to produce trillions of its own offspring to spread this new drug resistant trait around the world. We reproduce every 20 years. They reproduce every 20 minutes. We are massively outnumbered and outgunned.

Why did antibiotic resistance occur?

So why did this happen? Some level of antibiotic resistance was inevitable. In fact there were antibiotic resistant bacteria before we even knew what an antibiotic was. Most antibiotics are derived from molecules that bacteria use to attack other bacteria. In this battle for supremacy among bacteria the bacteria which were under attack developed defenses against these weapons. When man discovered these molecules which we call antibiotics, there were already some bacteria in the world that had genes which made them resistant to the effects of these drugs, but they were relatively few in number.

Once we started using antibiotics routinely thousands of species of bacteria that normally reside in our bodies would occasionally get exposed to these drugs. Most would be killed but some would have the resistance gene which would allow them to survive and multiply to become the predominant bacteria. Natural selection would allow the resistant bacteria to survive and pass on their genes to the next generation. Although humans and other animals can only pass genes to their offspring, bacteria can pass genes on to other bacteria and even to bacteria of other species. For this reason antibiotic resistance can travel quickly within and between different types of bacteria once it is established.

What caused resistance to become such a big problem?

Antibiotic resistance has probably been around for billions of years but it wasn't a big problem until the past few decades. There are several reasons why antibiotic resistance has become so widespread.

Use of antibiotics in livestock - 80% of all antibiotics manufactured are used to fatten perfectly healthy livestock. This encourages the rise of resistant organisms which then enter the food chain and our bodies.
Unnecessary use of antibiotics in people - Many of the antibiotic prescriptions written for people are written for illnesses that will not respond to antibiotics. As mentioned above, this encourages antibiotic resistance to develop among the bacteria that live harmlessly in and on our body and these bacteria may later pass that resistance gene on to bacteria which are causing an infection.

What can the average person do to help?

There is a lot people can do to help stem the wave of drug resistant bacteria.

Look for meats and fish that say they are antibiotic free or grown without antibiotics
Encourage your legislator to push for laws to reduce the use of antibiotics in livestock and fish and to prevent the importation of such products. Let them know this is important to you.
Ask your physician if the antibiotic prescription they are writing is necessary or if its instead possible to take a more conservative approach and only use the antibiotic if the condition worsens.
Don't pressure your physician to give you an antibiotic. Many prescriptions are written for things like colds and other viral illnesses which will not respond to an antibiotic because the physician feels its easier to just write the prescription than to fight with a patient who wants the antibiotic. Some patients with colds will say "but I just can't afford to be sick". The virus doesn't care. It's not going to die in the presence of an antibiotic just because you can't afford to be sick.
Don't save or share unused antibiotics
Don't throw antibiotics in the garbage or toilet. Discard them by bringing them to the pharmacy to be destroyed

Where can I learn more?

98.6 - What's a normal body temperature?

Michael Melgar — Thu, 04 Dec 2014 17:41:00 +0000

When trying to figure out whether you have the flu or a cold its often important to know whether you have a fever but what qualifies as a fever? The recent COVID-19 pandemic has made this question more critical than ever. When is a temperature abnormal? When is it a fever?

What is a normal temperature?

From the time we are young we are tought that a normal temperature is 98.6. Most people would assume that something like 101 is therefor a fever and they would be correct, but when does the temperature become a fever as it rises from normal to 101?

First we need to discuss what a normal temperature is. While 98.6 is the often quoted number that is not completely correct. If we were to take the temperatures of 100 healthy people we would find that most would not be 98.6. A 1992 study of 148 adults showed that oral temperatures in healthy individuals can range from 96.0ºF to 100.8ºF with a average of about 98.2. Normal rectal temperatures are about 1.0ºF higher.

Figure 1

The study also found that the lowest temperatures were in the mornings around 6am with peak temperatures generally occuring around 6pm in the evening.

Figure 2

How high does the temperature have to be to be considered a fever?

From these studies, a morning reading >37.2ºC (98.9ºF) or an afternoon temperature of >37.7ºC (99.9ºF) would be above average, but as you can see from Figure 1 above, there is a lot of variation from person to person so even normal healthy individuals can sometimes have a temperature of just under 101 and sometimes a sick individual will have a lower temperature. For this reason its important to take the temperature several times over the course of the day. Normally an individual's temperature varies by about 1ºF during the course of a day but when ill the temperature might vary by twice as much.

The standard medical definition of a fever is a temperature of 100.4 or more but obviously this has to be used as only a rough guide. When we say that someone has a fever what we are really saying is that their temperature is higher than normal, but what is normal varies depending on the time of the day and the person who's temperature we are taking.. The reason we want to know if someone has a fever is because it can be a clue to whether the person is ill and also because a temperature that is too high can be dangerous at times.

What causes a fever?

Fevers can have several causes. The great majority of fevers are caused by infections but there are occasional other causes.

Infections: Viral and Bacterial infections can both cause fever
Heat exhaustion/ dehydration
Malignant tumors
Medications -Sometimes antibiotics and certain seizure medications can cause a fever
Vaccines - Some people will develop a mild fever for a day or so after vaccination
Inflammatory conditions such as rheumatoid arthritis
Burns
Damage to the hypothalamus - very rare

Why do we get a fever?

Thats a good question actually. Why do we get a fever? The best answer at the moment is that we don't really know. We know how it occurs, but not exactly why. Some experts believe that fever is part of the body's defense mechanism against infection since viruses and bacteria may not be able to function and reproduce as well if the body is too warm. This seems logical since many enzymes work best in only a narrow temperature range and enzymes are important for many cellular functions that viruses and bacteria depend on in order to reproduce and metabolize. If this were true we would expect people to be sicker longer if they took measures to lower their body temperature but this is not the case. Taking Tylenol or Ibuprofen does not seem to prolong or worsen the outcome for most illnesses. For the moment its not clear whether a fever is an adaptation by the body to deal with the infection or just a necessary side effect that arises when our immune system goes to battle an infection, similar to the way our body heats up when we run or do other physical work. The heating up serves no purpose and can even be harmful. Its just the natural result when our muscles burn fuel and do work.

Interesting Fact

Sometimes I will hear a patient say. "It doesn't make any sense. I feel hot but when I take my temperature its normal" or "I've been freezing but now I have a fever". It sounds odd but this actually is exactly what you would expect when you undertstand what's going on.

Lets say the body is trying to raise its temperature. How does it accomplish that? Well it does it the same way you would raise the temperature if you were trying to warm your house. You can either turn up the furnace or you can close the windows and insulate it better to keep the heat in. The same thing happens in your body. The only difference is that the body has to convince you to do these things even though it can't actually talk to you. It communicates with you by the only method it has. It makes you feel cold or hot. It does this by changing the internal thermostat in a gland called the hypothalamus. When you feel cold you naturally do things to try and get warm. You involuntarily start to shiver. When you shiver your muscles contract and relax vigorously generating heat (this is like turning up the furnace in your house). In addition you may put on a sweatshirt or dive under the blankets (This is the same as adding insulation to your home or closing the windows to keep the heat inside). So in response to feeling cold you generate more heat and do everything you can to hold onto the heat you are generating. In a little while the temperture begins to soar and you have a fever. You're freezing but your temperature is 101!

When its time to get your temperature down your body makes you feel hot. You stop shivering, peel off all the layers and maybe you even drink something cold. A little while later your temperature goes away. So now you feel hot but your temperature is normal.

This up and down fluctation in the temperature may happen several times during the day when you are sick especially if you are taking ibuprofen or tylenol to knock the fever down, but most of the time it follows the same cycle as when we are healthy. It tends to be lower in the morning and spikes in the evening hours. Sometimes people think their illness has gone away because the temperature is normal in the morning when they wake up only to be disappointed when the fever is back later that evening. This isn't a sign that anything is seriously wrong, its just the normal pattern we expect to see with any illness that causes fever. As the days go by and the illness begins to resolve the temperature will be less and less each evening until eventually there's no more fever even at night.

Temperature pattern during the course of an illness

References:

A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.AUMackowiak PA, Wasserman SS, Levine MMSOJAMA. 1992;268(12):1578.

Vitamin D testing - The USPSTF questions the use of routine Vitamin D testing

Michael Melgar — Tue, 24 Jun 2014 10:38:00 +0000

The United States Preventive Services Task Force (USPSTF) has released its draft recommendation stating that there is insufficient evidence to support the use of routine vitamin D screening. The USPSTF is an expert group of scientists and physicians and they reached this conclusion after reviewing all of the current literature and studies done on vitamin D.

A number of studies in recent years have linked low vitamin D intake or low blood levels to a multitude of disorders. For this reason many media reports and shows like Dr. Oz have suggested that people get their vitamin D levels checked. Requests for vitamin D levels by patients have resulted in a large increase in the number of Vitamin D tests being done over the past few years but there have been no studies evaluating the benefits of such testing.

Despite the great interest in Vitamin D testing there have in fact been few studies which have demonstrated that low levels are the actual cause of any of the problems it has been linked to. This is important. Just because low levels are associated with certain illnesses does not mean they are the cause. We may have the relationship backwards. It is possible that low levels of vitamin D may not be causing the illness but instead the illness may be causing the low vitamin D levels. Or it maybe the low vitamin D is just a marker for poor health habits and its those habits that are causing illness not the low vitamin D.

Even if low vitamin D levels are the cause of some of these illnesses that does not necessarily mean that we can correct or prevent the illness by correcting the vitamin D level. Unfortunately there are few controlled trials demonstrating that supplementing low levels are either beneficial or safe.

One of the most important concerns with vitamin D levels is how we define "low vitamin D". Some studies and my own experience has shown that more than 80% of healthy patients are found to have vitamin D levels that would be defined as low by the current definition. For a level of anything to be considered abnormal it should either be "unusual" compared to the average individual or we should have evidence that when the vitamin falls below or above a certain level it can cause some form of illness or disease (high levels of vitamins can cause illness just as low levels can).

If the average person is 5 foot 6 we would not define 5 foot 7 as being short, but this is what's happening with vitamin D levels. The average healthy person in my own office seems has a vitamin D level of about 19 but anything below 20 is defined as low.

The second criteria for defining a measurement as being abnormal is that such levels have to be shown to cause disease. It is possible that even a level that is average could still be too low for good health. As discussed above though, few studies have really shown a causal relationship between low vitamin D levels and most of diseases for which links have been suggested.

There are also concerns about whether current vitamin D testing actually tell us what the true vitamin D levels are in our bodies. Vitamin D is a fat soluble vitamin. It is mostly stored in our liver and fatty tissues with a small amount circulating in the blood. When we measure the level in the blood we are making certain assumptions that may not be accurate. It is possible to have low blood levels of vitamin D and yet have plenty of vitamin D stored in our tissues and visa versa.

The USPSTF has determined that there are no proven benefits associated with routine vitamin D measurements but there are also concerns about the possible costs associated with routine testing. Not only are there costs associated with the test itself and with possible unnecessary treatments but there is also the possibility that treating levels currently defined as being low could actually be harmful. Many people think of vitamins as essentially harmless but vitamins are medications and it is well established that vitamin supplementation can under some circumstances cause disease and even increase the risk of cancer. Although currently there is no evidence linking vitamin D to an increased cancer risk, such studies can take decades to complete.

What the USPSTF recommendation is saying is that we may some day have evidence to support the use of vitamin D measurements and treatment but much more research needs to be done to answer this question. Without such evidence caution is advised because we don’t know if the benefits outweigh the real risks of doing these tests and possibly using treatments that could potentially be harmful.

USPSTF Vitamin D screening recommendations

EyeWire -Now you can help scientists discover how the eye sees the world and have fun doing it.

Michael Melgar — Wed, 28 May 2014 16:37:00 +0000

The brain is the most complex structure known to man. There are almost 100 billion nerve cells in the brain, each with up to a thousand connections to other nerve cells. That means there are over a trillion connections in the human brain.

The holy grail of brain research is to map something called the “Connectome” ( see The Human Connectome Project). The connectome is the complete map of all the connections in the brain. Mapping the connectome would give us an understanding of the brain that would allow us to find the causes of many neurologic and psychiatric disorders just like the human genome project and mapping of the chromosomes is providing scientists with the tools to uncover the genetic causes behind many diseases.

While the ultimate goal is to map the human brain connectome, we need to start with something a little less complex. Mapping the nerve connections in the retina will be an important first step in understanding the more complex connections of the brain itself and will also help us better understand diseases of the eye.

Until recently it was thought that the thin layer of nerve tissue at the back of the eye known as the retina had just one job, to sense light coming into the eye and send those signals on to the brain. It was thought that the brain did all the processing to turn the signals form the eye into the final image that we experience as sight. It is now known that the retina is not just a sensor but also does some of the image processing, sort of like a small additional brain. It processes some of the information before it is sent on to our big brain to make the final image. Scientists have discovered for example that the eye has circuitry which is capable of detecting motion before the signal is even sent to the brain. Understanding how the eye processes information and how all the connections in the retina work is an important first step to understanding the larger connectome of the brain itself.

Now everyone can make a contribution to this important area of science and have fun doing it by playing a game at Eyewire.org. The game designed by scientists at MIT is like a 3D puzzle. The game takes advantage of the human brain's strengths. Despite all the advances in computer technology, humans are still much better at detecting certain types of patterns and the game takes advantage of that skill. In a bit of an ironic twist, by working through the puzzle humans become the eyes of the computer so the computer can figure out how our eyes work.

Eyewire has been designed to be somewhat social as well. If you like, you can participate in competitions (this part is completely optional) and they even hold a weekly online happy hour during which you can chat with other participants although it is strictly BYOB and optional as well. So if you are interested in science, would like to contribute to an important project that may help expand our understanding of our own brain, help cure diseases and have fun while doing it check out Eyewire.

For more information about Eyewire.org and about the game you can view the video below or go to http://blog.eyewire.org/about/

Tick borne diseases - Don't let them take a bite out of your summer.

Michael Melgar — Wed, 07 May 2014 21:45:00 +0000

The summer is a time of increasing outdoor activities and with that comes an increased chance of exposure to insects and in particular ticks. While its possible to be bitten by ticks even in the depths of winter boths ticks and people are more active in the warmer months. This means the summer is a time when they are more likely to come into contact with each other so this is a good time to go over some of the illnesses that ticks carry. Its also an opportunity to dispell some of the myths and discuss a few precautions we can take to stay healthy when we are enjoying the outdoors.

Most people have heard of Lyme disease but how many have heard of Human Granulocytic Anaplasmosis or Babesiosis or even Rocky Mountain Spotted fever. Lyme disease has grabbed all the headlines in recent years but ticks can cause other illnesses besides Lyme and not all ticks carry the same diseases. Avoiding serious illness from tick borne diseases is a matter of preventing tick bites when possible, removing ticks as soon as possible, identifying the type of tick, being aware of the symptoms, and getting appropriate medical attention.

Avoiding Tick Bites

There a number of things one can do to avoid tick bites. Some of these things are easy and obvious. Others are more difficult and maybe impractical.

Ticks feed on animal blood. They bite all sorts of animals from tiny little mice to squirrels, deer, and humans. In order to catch their prey, ticks like to perch themselves on bushes or long blades of grass ready to cling on to any passing animal. For this reason one of the best ways to avoid ticks is to avoid areas with deep grass or brush. Trails with heavy brush along the sides are a common place for ticks to place themselves.

Some authorities recommend wearing long sleeve shirts and long pants with the cuffs of the pants tucked inside of boots. The idea here is that the more covered up we are the harder it will be for ticks to find exposed skin to bite into. This may be reasonable in cool weather but in the hot summer months tight fitting long sleeve shirts and pants with heavy boots will quickly lead to overheating and dehydration. Wearing such clothing will also make the wearer miserable and defeat the purpose of spending a day outdoors hiking or playing. Ticks are also very persistent and resourceful. A nymph deer tick is extremely small and given enough time they can find their way through even the heaviest clothing. Unless we are going to wear a space suit outdoors clothing is unlikely to defeat a determined tick.

Some experts have recommended wearing light colored clothing so that ticks will be easier to spot and remove but there have been some studies suggesting that certain types of ticks are actually attracted to lighter colors.

For all these reasons I don't usually recommend dressing to avoid ticks. After living on Long Island for my entire life and spending a lot of it hiking through wooded and grassy areas I have found that after spending the day outdoors, doing a good thorough body check at the end of the day has been a more practical approach that allows me to enjoy outdoor activities while at the same time avoiding tick bourne illnesses.

The best way to do a body check is to take a shower at the end of the day. Before going in the shower do a visual inspection in front of a full length mirror if possible. You obviously won't be able to see everywhere but thats OK for now. Once you finish looking everywhere that you can see go into the shower. Get the hands wet and soapy and then as you soap up the body feel for anything unusual. Soapy hands are very sensitive to small defects. You are feeling for something about the size of a sesame seed that is attached to the skin. Be sure to pay special attention to skin folds and areas with hair since these are locations that ticks seem to prefer but they can attach anywhere so start at the head and systematically work your way down examining every inch of the body right down to the feet. If done properly this shouldn't take much longer than a normal shower.

Most tick borne illnesses can be avoided if the tick is removed within 36 hours of attaching to the skin so make sure you do this at the end of any day when you spend a significant amount of time outdoors.

Tick Removal

There are lots of myths and folk lore about how to remove ticks but the truth is that the best method is the simplest. Removing a tick is not much more complicated than removing a splinter. You want to get as much of the tick out as possible but beyond that there is nothing special about the method. You will need a pair of tweezers and if possible, a small container that you can seal the tick inside of. A glass jar or even a zip lock bag will do.

Once the tick is found the best approach is to grab the tick by the head as close to the skin as possible. Rock the tick gently back and forth while pulling until it breaks free and then seal it in a container. If there are small parts of the tick that remain behind leave them. Do not try to dig them out. Mouth parts from the tick do not carry disease so leaving them in will not increase the risk of contracting Lyme disease or any other illness. They will gradually fall out on their own over time. Trying to dig them out will only damage the surrounding skin and increase the risk of bacterial infection of the skin.

Once the tick is removed clean the area with an antiseptic, make an appointment to see your physician and bring the tick with you.

DO NOT use a lit match, peanut butter, vaseline, or any method other than the one described above to remove the tick. Those methods do not work, they can be dangerous, and they delay tick removal which increases the risk of disease transmission.

Ticks

There are several types of ticks found in North America. In the Northeast the most common types of ticks seen are the Deer Tick, the Brown Dog Tick, the American Dog Tick, and the Lone Star Tick. Each type of tick carries different illnesses so it can be helpful to identify the type of tick one was bitten by in order to know which diseases we need to be alert for.

Deer TIck - Lyme Disease, Human Granulocytic Anaplasmosis (HGA), Babesiosis
American Dog Tick and Brown Dog TIck - Rocky Mountain Spotted Fever
Lone Star Tick - Ehrlichiosis, Tularemia

The link below will take you to a page on the CDC website which has photos and more information about these ticks.
Tick Distribution in North America

Tick Bourne Illnesses

Lyme Disease
Lyme disease is probably the most common tick bourne disease that the public is aware of. Unfortunately a lot of the information found in the lay media is sensationalized or incorrect.

Symptoms:
Contrary to popular belief Lyme disease is not a universally disabling disease. Some people who contract lyme disease recover on their own without ever knowing they had an illness. Others are only mildly ill. In nearly all cases a 2-3 week course of oral antibiotics will completely eradicate the illness

Some of the the typical symptoms of early Lyme disease are a rash known as erythema migrans, joint pains, fatigue, chills, headache, and sometimes a fever. The rash is the classic bulls eye rash that usually occurs around the site of the tick bite and may expand and spread over time. While this is the classic presentation more than 30% of patients who get Lyme disease do not get the rash. When diagnosed at this stage oral antibiotics are usually given for 2-3 weeks with complete recovery.

Late stage lyme disease can cause damage to the nervous system, heart, and joints but even these cases usually respond very readily to antibiotics.

Post Lyme Disease syndrome or Chronic Lyme disease as it is sometimes called is a subject of some controversy. There are people who appear to have chronic symptoms and positive Lyme tests but there is little evidence that the symptoms they are experiencing is due to a chronic Lyme disease infection. the confusion arises from the fact that the Lyme disease test is not in fact a test for Lyme disease. What the test is checking for are antibodies to a protein on the lyme disease bacteria. We do not have a test for the bacteria itself. This is a problem because other conditions besides Lyme disease can cause the test to be falsely positive. In addition, if the person had a Lyme disease infection when they were younger and which they were treated for or unaware of, the anitbodies may remain positive many years after they recover from the infection. As a result, a positive Lyme test does not mean the person has an active Lyme Disease infection. The media frequently reports on patients who have difficult and long courses of Lyme disease requiring years of antibiotics but there is little or no evidence that these people actually have a persistent infection with the Lyme disease organism and even less evidence that long courses of antibiotics help with these conditions.

Human Granulocytic Anaplasmosis (HGA)
HGA can cause symptoms such as fever, chills, headache, muscle aches, and fatigue. The symptoms can vary significantly from one patient to another and the similarity of HGA symptoms to other illnesses like influenza can make diagnosis difficult. HGA should be considered in anyone who develops these symptoms within a week or two after being bitten by a deer tick.

Diagnostic testing is not always reliable and often will not be positive untl 7-10 days after infection. Since treatment needs to be started early to be most effective, diagnosis often rests on clinical symptoms and suspicion.

HGA usually responds rapidly to oral antibiotics but it can be a serious illness resulting in death in less than 1% of patients who contract it.

Babesiosis
Babesiosis can also cause flu like symptoms such as fever, chills, sweats, headache, body aches, loss of appetite, and fatigue just like HGA which again makes diagnosis difficult at times. It can be a serious life threatening illness in some individuals especially those with immune system defects, chronic illnesses, or those who have had their splens removed.

Diagnosis requires examination of a blood sample under a microscope or newer tests that can detect Babesiosis DNA.

Treatment requires the use of special antibiotics but requires confirmation of the diagnosis with lab tests

Rocky Mountain Spotted Fever (RMSF)
Like the other tick borne illnesses patients with RMSF also have many of the flu like symptoms including fever, chills, headache, and muscle aches but they may also get nausea, vomiting or abdominal pain. The one symptom that sets RMSF apart is a rash. About 90% of patients with RMSF will have a spotted rash but sometimes it does not develop until late in the illness when treatment should have already begun.

RMSF is a serious illness and can be fatal. For treatment to be most effective it must be begun within 5 days of first symptoms but diagnostic tests are often not revealing until 7-10 days into the illness. For this reason as with HGA physicians must rely on symptoms and clinical suspicion when treating patients with RMSF

Erhlichiosis
Erhlichiosis is also accompanied by fever, chills, headache, malaise, and muscle pain but can also be accompanied by abdominal pain and confusion in some patients. A rash may be present but is only seen in about 30% of adults.

As with some of the other tick borne illnesses mentioned above treatment works best if started early but tests often don't turn positive for 7-10 days meaning that physicians must start treatment based on the history, symptoms, and physical exam alone using diagnostic testing only to confirm the diagnosis later on.

Why do perfectly heathy people pass out sometimes?

Michael Melgar — Wed, 12 Mar 2014 15:11:00 +0000

How many of us have been in this situation? Its a beautiful June day and you're sitting in church while a happy couple is taking their vows. The groomsmen are lined up on one side and the bridesmaids on the other when one of the bridesmaids begins to wobble. Only seconds later her knees buckle and in an eyeblink she slumps to the floor. Across town a police officer is in his doctors office for a physical. The nurse comes in to the room. She preps his arm to draw some blood, inserts the needle, and "THUNK". She looks up to see him slumped against the wall his glazed eyes staring at the ceiling. Later that afternoon a carpenter is framing a house. He swings the hammer but hits his thumb instead of the nail he was aiming for. Its not the first time he's done this but today is different. Nerve cells carry the pain signal up to his brain as usual but this time an overwhelming sense of nausea sweeps over him, he breaks out in a cold sweat, his eyes go black, and down he goes.

Most of us have witnessed one of these situations either in real life or in the movies. They elicit laughs in the movies and gasps in real life. Those nearby run to help. They often try to prop the person up. They may also fan them and give them something to drink in and effort to revive them. Usually in the movies someone throws a pitcher of cold water on the persons face and they magically wake up spitting and gasping to audience laughter.

So what are these events? Why does someone pass out at a beautiful event like a wedding? Why does a cop who has seen far worse pass out when he sees a small needle in his arm? Why does a carpenter who has sustained more than his share of injuries in his career suddenly hit the ground just because he hit his thumb? What causes these things to happen and more importantly, are they dangerous?

The medical term for someone passing out is syncope. Although many things can cause syncope, the events I am describing above are a specific but very common situation called a vasovagal event or vasovagal syncope. In each case a part of the nervous system known as the parasympathetic nervous system has been activated. When that happens the heart rate slows down and the blood vessels dilate leading to a drop in blood pressure. If conditions are right these changes make it more difficult for the heart to pump blood to the highest point in our body. Since that is where the brain usually is, the brain doesn't receive enough blood and oxygen so it begins to shut down. This can lead to symptoms like nausea, lightheadedness, cold sweats, and disturbed vision. If the problem is not recognized and addressed quickly the decreased blood flow eventually causes complete loss of consciousness and the person passes out.

There are many things that can trigger a vasovagal event. Pain, Emotional upset, dehydration, warm stuffy rooms, and for some reason getting up to urinate in the middle of the night seems to be a trigger for some people. The odd thing is that many times the trigger is something that has happened before without causing loss of consciousness. Why do the triggers sometimes cause a person to pass out and other times have no effect at all? It may be that there needs to be a combination of factors which predispose the patient to the event for the trigger to set it off. Perhaps the person is a little dehydrated. Maybe they have a viral infection. Perhaps they skipped breakfast or didn't get enough sleep the night before. It may be any one of these things or a combination of them. There may be factors we aren't even aware of that put the body in a condition where the trigger is just the final straw that causes the lights to go out.

Its not really clear why the nervous system reacts in such a way as to cause our heart to slow and our blood pressure to drop or what advantage it might provide, but fortunately the problem usually fixes itself. When the person loses consciousness they tend to slump or fall to the ground which means the head is lower down, blood flow is restored and consciousness returns. In most cases the person usually wakes up quickly. Loss of consciousness often lasts only a minute or two and frequently less. Unlike a stroke where there is a permanent complete loss of blood flow resulting in damage to brain tissue, vasovagal events only involve a very brief partial reduction in blood flow so there is generally no injury to the brain. For this reason vasovagal events are not considered to be dangerous as long as the person doesn't strike something after they pass out or fall from a high place when they lose consciousness.

The key to avoiding injury is recognizing the warning signs and taking steps to interrupt the event before loss of consciousness occurs. Most vasovagal events will be preceeded by some of the symptoms described above, nausea, cold sweats, darkening vision, dizziness, blurry vision, or spots in the vision. Some people describe a pounding in their ears prior to an event. The first event is usually difficult to prevent because the person has never had one before and they are caught entirely by surprise. Before they know what hit them they are on the floor. The second event is usually much different because the moment the warning signs appear a lightbulb goes on that says "Hey this has happened before". Once that happens it becomes a race against time. If the person takes action in the next couple of seconds they can stop the event in its tracks but they have to know what to do.

So what do you do when you feel like you are about to go down or if you see someone else who is on the way down or already on the floor? Remember this is a blood flow problem. We need to increase blood flow to the upper body to reverse the effects of a vasovagal event. There are several ways we can do that.

What to do:

Lay down on the floor. Sometimes people are too embarassed to lay down on the sidewalk or in public but you only have seconds. The time it takes to find a private place is often the difference between passing out and not. If you are afraid or embarassed to lay down you should consider what's more embarassing, laying on the floor voluntarily or crashing into it face first, because one or the other will definitely happen.
Once on the floor raise the legs to increase blood flow to the upper body
If there isn't enough room to lay down, bend over and put your head between your legs to get it as low as possible.
Heat causes blood vessles to dilate and blood to pool in the extremities. Cold does just the opposite. Applying cold compresses to the body will constrict blood vessels in the arms and legs and push more blood towards the head. Opening a door or window to let cool breeze in can also help.
Drinking cold liquids will also cause blood vessel constriction and help shift more blood flow to the head. Fluids will have the added benefit of treating dehydration if this is a contributing factor.

What not to do:

Do not try to find a private place to lay down. You wont make it.
Do not try to hold a person up when they are passing out. You will only prolong the time it takes to restore adequate blood flow to the brain and you will delay the recovery of consciousness.
Do not pour cold water on the persons face. They will wake up quickly enough on their own. Pouring liquid on the face of someone who is unconscious runs the risk of having them inhale water into their lungs turning a minor self resolving issue into a potentially dangerous one.

Loss of consciousness is a scary thing and while vasovagal events are generally not dangerous there are other things that can cause someone to pass out which can be more serious. Strokes, seizures, cardiac arrest, and irregular heart rhythms can also lead to loss of conscousness and obviously require a more urgent approach.

If you witness someone who has passed out check their pulse and their breathing. If they have no pulse or they are not breathing begin CPR and call EMS. If they have a pulse and are breathing on their own make sure their airway is clear, raise their legs, and give them a minute or two to wake up. If possible put a cold compress on their limbs and neck. If after a few minutes they do not wake up call an ambulance. If they do wake up resist the urge to help them to their feet right away. Give them a few minutes to recover. When they feel a little better help them to a sitting position. Once they are sitting,If available, give them something cold to drink. Wait 5 or 10 minutes at least and if they are feeling up to it help them to a standing position.

Any time someone loses consciosuness it should be reported to their physician. On rare occasions seizures and irregular heart rhythms can masquerade as something minor. Even if it seems like you have had a simple vasovagal event report it to your doctor so he or she can check you to rule out the possiblity of a more serious problem.

Red Yeast Rice Extract - Its not magic, Its a drug

Michael Melgar — Sat, 08 Mar 2014 10:21:00 +0000

Red Yeast Rice Extract is a Chinese medicine which has been promoted as a "natural" treatement for high cholesterol. Proponents of this treatment ( usually not legitimate medical profesisonals) claim that it offers patients a way to lower their cholesterol without the side effects of medication.

As with many alternative therapies the assumption is that somehow we can magically have all the benefits of a conventional drug without any side effects. Unfortunately as I have stated before in my posts, there is no magic class of substances that can provide benefits with no risk of side effects. Natural is a meaningless and misleading word ( See Natural - What does that word mean?). Anything that you put in your body with the expectation of some beneficial effect is by definition a drug, and anything that has the possbility of producing beneficial changes in your biology is also likely to have an occasional unintended or unanticipated effect. We call these unwanted effects side effects.

Just because a particular treatment is made from something that comes from a plant doesn't mean it is any safer than a conventional treatment that is manufactured under strict quality control standards in a lab. So it comes as no surprise that Red Yeast Rice Extract contains no magic powers to lower cholesterol without side effects. In fact most users are completely unaware that this product works only because it contains one of the same statin drugs that we use to lower cholesterol. Statins are the drugs most frequently used by physicians to treat high cholesterol. They go by names such as Atorvastatin (Lipitor), Simvastatin (Zocor), Pravastatin ( Pravachol), Rosuvastatin (Crestor), and Lovastatin ( Mevacor). Lovastatin is the magic ingredient that allows Red Yeast Rice Extract to lower cholesterol levels, but you wont find that on the label anywhere. Its not magic, its a drug.

For those who are using Red Yeast Rice Extract because they want a more "natural" way to treat their cholesterol, there is nothing about this product that is any more natural than standard treatments. Many people who decide to use Red Yeast Rice Extract do so in the belief that its safer but nothing could be further from the truth. Unlike standard drug treatments which have to meet strict quality control standards and are regulated by the FDA, products which fall into the supplement category are not regulated by any agency. This means that these products do not have to state their actual ingredients and they don't have to post the dose of any active ingredients assuming there are any. The actual dose if they do post it may be much less than claimed, much more than claimed, or there may be none at all. Even worse, these products can be adulterated with any number of other ingredients that may have unwanted effects and the user would never know because no one is checking.

We need to remember that statin drugs require a prescription for a reason. These are powerful drugs and while they are largely safe and very effective there is still a small chance of side effects. For this reason patients on these drugs need to be monitored. An occasional side effect is muscle pains, but less commonly, a small percentage of patients may develop liver inflammation. Doctors screen for this before starting a stain medication and monitor for evidence of liver enzyme elevation with routine blood work periodically when patients are on cholesterol medications. If a problem is detected the medication is stopped and the problem resolves. If however a patient is not properly screened for liver disease before the medication is started or they are not monitored on the medication and a problem is not recognized, severe liver damage can rarely occur. Patients taking Red Yeast Rice Extract are not only getting an unknown dose of a powerful drug with unknown possible contaminants but they are not being monitored. For patients who really care about safety this is the worst of all possible choices to make.

For some patients cost may be the main concern. Some statin drugs, especially branded ones like Crestor can cost as much as $200 a month, but cost does not have to be an issue. Lovastatin, the very statin found in Red Yeast Rice Extract can be purchased at stores like Walmart and Target for pennies a day. A 90 day supply can be purchased without any insurance for as little as $10 which works out to about $40 a year. Lovastatin can significantly lower cholesterol and reduce the risk of heart disease when used properly and monitored but it makes no sense to take a product like Red Yeast Rice Extract when the real Lovastatin is available so inexpensively.

The bottom line is that Red Yeast Rice extract is NOT safer than other statins. It has the same potential side effects as any other statin but has the potential for unknown and widely fluctuating doses from one bottle to the next. Its purity can not be assured. It may be adulterated with other unknown substances. Taking it without proper medical supervision is potentially dangerous, and it doesn't save its users any money.

The only magic in Red Yeast Rice Exctract is the way its manufacturers lighten the wallets of its users while pretending to be the safer natural way to treat their cholesterol.

Why everyone needs to have "End of Life" documents

Michael Melgar — Sat, 08 Feb 2014 14:18:00 +0000

Many people have heard of a Living Will but most have never thought about it for themselves or taken the time to have one prepared. Even fewer have heard of a Health Care Proxy or know what it is. One poll found that among baby boomers less than 36 percent had completed one of these documents. Most in this group report that since they are young and healthy they do not think about or prepare for death. Among younger individuals the number who have completed such documents is even lower.

With recent cases in the news such as Terry Schiavo and more recently Marlise Munoz, it is painfully apparent that life is unpredictable and even the very young are sometimes faced with these difficult decisions. What is obvious from both cases is that when we don't prepare for these decisions our loved ones may be forced to battle the state and complete strangers for the right to make decisions about end of life care. It doesn't have to be that way though.

No legal document can completely protect us from the attempts of others to intrude upon these very personal decisions but having our wishes documented in black and white will usually make it much easier for our family and doctors to ensure that our wishes are respected. Fortunately it doesn't take much time or any money to prepare the documents you will need.

There are two important documents that everyone should have so that they are prepared for the unexpected. They are the Living Will and the Health Care Proxy. Both of these documents can be downloaded through the links below along with a set of instructions to help you fill them out. Both documents are important, but the Health Care Proxy which people are less familiar with is actually the more important of the two.

The Living Will is a document used to outline your prefernces should you be incapacitated and unable to make decisions about important health care issues such as cardiopulmonary resuscitation (CPR), and life support measures like mechanical respirators, dialysis, feeding tubes and any other treatment about which you would like to make your wishes clear. You can also detail in what circumstances you might want things to be done or not done. For example you may want to be on a ventilator if you were suffering from a condition that was reversible but not if you had a terminal disease like end stage cancer.

The Health Care Proxy is a simpler document to complete but probably the more important of the two. As useful as the Living Will can be in these situations its usefulness is limited by the great variety of circumstances which surround end of life. We can not possibly anticipate every situation. In addition, no matter how carefully we prepare our Living Will, it will be open to a certain amount of interpretation just like all legal documents. For this reason we need to designate someone to interpret our Living Will and to provide guidance for those situations which the Living WIll does not cover. This is what the Health Care Proxy does. It gives you the chance to legally assign someone to make these decisions for you in a situation where you are not able to make them for yourself.

Preparing these documents is only part of the process. Its just as important to discuss your wishes with your family and give copies of the documents to the person who is your designated Health Care Proxy and also to your doctor.

The documents provided here are vaild in NY State. If you live in another state you may want to check local regulations. Each state usually makes similar documents available through their own websites. While a lawyer may be able to help you anticipate situations you may not anticipate on your own it is by no means necessary to hire a lawyer to complete these documents. Even if you intend at some point to involve your lawyer you should fill out the documents listed here ahead of time. This can serve as a worksheet when you finally meet with a lawyer and they will also be fully enforceable legal documents should you need them before you get around to seeing a lawyer.

Documents:

Will an aspirin a day really keep the heart attack away?

Michael Melgar — Thu, 12 Dec 2013 20:50:00 +0000

Many of the people reading this may already be taking a daily aspirin to prevent heart attacks and strokes because they heard it was good idea, but is it a good idea for everyone? Like many questions without simple answers, the answer to that question is "It depends".

It depends a lot on what an individuals particular risk is for the illnesses we are trying to prevent as well as their risk for developing the side effects that aspirin can cause. So what are the benefits of aspirin and what are the potential side effects? Aspirins is such a common drug that a whole mythology seems to have sprouted up about its life extending properties and for some it may be true but we need to look at science to separate the facts from the fairy tales.

Benefits:

Heart Attack Prevention
Stroke Prevention (ischemic strokes)

Risks:

Gastrointestinal Bleeding
Stroke (hemorrhagic stroke)

The United States Preventive Services Task Force (USPSTF) is an independent government agency made up of experts in various fields of medicine. They periodically review all of the available scientific literature on a given subject and make recommendations based on the best available evidence. The last review was done in 2009 and they are currently working on an update to the recommendations which should be out sometime next year. Below is a summary of the existing recommendations.

The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.
The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years.
The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms.

For people over 80 it seems that aspirin may not be a good idea because the risk of gastrointestinal bleeding becomes too high as we get older. For men under the age of 45 and women under 55 the risk of heart attack and stroke are too low to justify the use of aspirin. For people in between those age groups the decision is a little more complicated. In order to decide if you should take aspirin you need to calculate your cardiac risk and use the table below.

This table shows the risk level at which benefit ( heart attack and stroke prevention) exceeds harms ( gastrointestinal bleeding). To use the table, men should use the Coronary Heart Disease (CHD) calculator to determine their cardiac risk and women should use the Stroke Risk Calculator. To use these calculators you will need your blood pressure readings and cholesterol levels from your last exam.

Once you have your calculated risk you are ready to use the table. For example if a 62 year old man has a CHD risk of 10% then the benefits of aspirin outweigh the risks and he should consider taking a daily aspirin. The same could be said for a 58 year old woman who's stroke risk is 4%, while a 72 year old woman with a stroke risk of 10% probably should not take a daily aspirin.

A daily aspirin may keep the doctor away but it can also result in serious side effects that could land you in the hospital. Use this information only as a guide. Be sure to discuss the results with your physician before stopping or starting aspirin since medications you are taking may interact with your aspirin and other medical condition which you have may affect your risks of heart disease and bleeding.

11/19/14 - UPDATE: An study done recently in Japan may shed more light on this issue. There was a nice summary in Forbes Magazine which you can access by clicking HERE

References:

Preventing Heart Disease with almonds- Is this study Nuts?

Michael Melgar — Tue, 26 Nov 2013 00:00:00 +0000

A study published today in the prestigious New England Journal of Medicine draws a connection between the daily consumption of tree nuts ( not just almonds) and a reduction in overall deaths from all causes.

Nuts are known to be rich in a number of nutrients including unsaturated fats, fiber, vitamins and minerals. Some previous observational studies seemed to show a correlation between nut consumption and reduced cardiovascular disease.³ Previously a randomized control trial showed that patients at high risk for cardiovascular disease who were put on a Mediterranean diet which happens to also include nuts had a significantly lower risk of cardiac events.⁴ Other studies have shown a connection between nut consumption and a reduction in inflammation, blood sugar and blood pressure as well as some types of cancer.

So are nuts the new miracle cure? Well yes and no. As with most nutrients its a matter of balance. The study published in the NEJM was an observational study. They followed a group of doctors and nurses over many years and documented their diet and recorded their illnesses. What they found is that there was an inverse relationship between nut consumption and death from all causes including heart disease, cancer, and respiratory diseases. Those who ate a serving of nuts once a day had the lowest risk.

As mentioned above, other studies in the past have also suggested that nuts may play a role in reducing many different diseases and nuts are now a recommended part of a balanced diet to reduce heart disease.

So where is the "No' part of the yes and no. There are two things we should bear in mind with these results. First, this was an observational study. It was not randomized and therefor there may be other factors not accounted for that resulted in fewer deaths. Its possible that people who eat nuts are more likely to participate in other behaviors that are healthy or maybe they avoid certain unhealthy behaviors or perhaps as a result of eating more nuts they are eating fewer potato chips and its the reduction in potato chip consumption that is really responsible for the reduction in deaths. This is a weakness of all observational studies and it must be kept in mind when we interpret the results.

Second, adding nuts to a poor diet may not improve anything if all we are doing is adding more calories and fat. The people in these studies were most likely eating nuts instead of something else. It would be naive to assume we could continue eating cake and ice cream and expect the nuts to counteract the effects of foods high in saturated fats. If nuts are to become part of a healthy diet the rest of the diet needs to be healthy as well. The nuts need to be consumed as a replacement for something else, not in addition to those things. Adding them to a bad diet may do nothing more than add to our waistlines.

While this study proves nothing it is suggestive and adds to a body of evidence that has been accumulating that nuts can be an important part of a healthy diet. If anyone really wants to improve their overall health and gain the health benefits that nuts may offer it would be best to overhaul their daily food intake to include nuts as part of a well balanced diet (See Choosemyplate.gov) or as part of the Mediterranean diet (See here)

References:

Antibiotics and Probiotics- Why you shouldn't take either without a good reason

Michael Melgar — Thu, 21 Nov 2013 15:27:00 +0000

As most people know, antibiotics are used to kill bacteria in our bodies. Recently products known as probiotics have become popular. For those who don't know what they are, probiotics are meant to promote the growth of bacteria in our body, primarily in our gut. In theory antibiotics are used to kill harmful bacteria and probiotics are meant to promote the growth of good bacteria but is anything ever that simple? We are starting to learn that the answer to that question is a resounding no.

One of the problems with this idea is that our understanding of bacteria has been a bit naive. The microscopic world of living things isn't really made up of good bacteria and bad bacteria any more than the human world is made up of good people and bad people. Some bacteria may be mostly good, others mostly bad, with the majority being somewhere in the middle, but every bacteria may have characteristics that may make it good or bad depending on the situation and the company it keeps just like people.

A Little Background

Its been known for a long time that an astounding 90% of the cells in and on our bodies don't belong to us at all. Most of what we consider "us" is really bacterial cells. Our own cells only make up a small percentage of the total. We call this collection of bacteria living in and on our body the Microbiome which is often shortened to the biome. A recent project called the Human Biome Project used new genetic tools to examine these major cohabitants of our bodies in a way that was never possible before. The results were surprising. What they found was that each of our bodies is inhabited by at least a 1,000 different species of bacteria and possibly many more. They also discovered that the type and amount of bacteria each person carries are so specific that a given person's microbiome might be as unique as a set of fingerprints.

Along with the publication of the Human Biome data there has been a lot of research into the effects that our microbiomes have on our health. There is preliminary evidence that certain combinations of bacteria may be associated with a greater or lower risk of diseases such as Diabetes, Obesity, Inflammatory Bowel Disease, and even Alzheimer's as well as many other conditions. They have also found that the biomes of people living in modern societies are less diverse than those of people living in more primitive conditions. This means that those of us in the industrialized world have fewer species of bacteria living with us than people living in the amazon jungle. While there are many theories about why this is so including exposure to antibiotics, no one knows for sure what has lead to the loss of bacterial diversity among people who live in modern societies. What that means for our health we don't know at this point. This research is all in its earliest stages. We have no idea what bacteria are important, how greater or lesser diversity affects health, whether we can make meaningful changes in the bacteria that live among us, or even if those changes would be helpful or harmful.

So what does this tell us about the use of antibiotics and probiotics? It means that for all of the reasons mentioned above we need to tread carefully when we take antibiotics that may reduce the number of bacterial species in our biome or take probiotics whose effects we really know very little about despite the varied and growing claims of marketers. Anyone who says they understand the microbiome and that they know how to change it to improve your health isn't telling the truth. We just aren't there yet and when you don't fully understand something its generally best to make as few changes as possible unless its done as part of a research study.

Antibiotics

Antibiotics are one of the most important advances in modern medicine, but just as bacteria are not all good or all bad neither are antibiotics. These drugs are invaluable when we need to treat a dangerous bacterial infection. Over the decades since they were invented antibiotics have saved millions of lives. Initially these drugs were used primarily for serious life threatening infections but as the costs came down and they became widely available antibiotics became victims of their own success. Today many people think of antibiotics as a cure all for more minor illnesses and in many cases they are used for conditions where they are not effective at all.

Bronchitis, sore throats, ear infections, and sinus infections are some of the most common conditions for which antibiotics are prescribed today yet 90% of these conditions are caused by non-bacterial conditions like viruses and allergies which will not respond to antibiotics. Even worse, tens of thousands of people with colds are treated with antibiotics in the US alone every year and antibiotics are completely ineffective in treating these viral infections.

When we use antibiotics for conditions that don't require them two things can happen which are harmful to us. First, antibiotics are indiscriminate. They kill many different types of bacteria including many of the ones which may be performing important functions in the body. When these innocent bystanders are killed there can be short term side effects such as severe diarrhea, or yeast infections, but there may be other long term side effects we don't even know about yet like increased rates of diabetes, cancer, or heart disease. Secondly, bacteria develop resistance to antibiotics when they are exposed to them frequently. Every time you take antibiotics you kill off bacteria which are not resistant and leave behind resistant bacteria to reproduce and increase in number. Each round of antibiotics increases the percent of bacteria that contain resistance genes, and bacteria are voracious collectors and traders of resistance genes. When one bacteria develops resistance the gene can then be passed on to other bacteria. They can even be passed on to bacteria of other species. The use of antibiotics when they are not needed can therefor result in the emergence of a resistance gene which will linger in our microbiome and potentially be passed on to a dangerous organism that invades our body weeks or months later.

This doesn't mean we should never use antibiotics. They are crucial and important drugs when used correctly. The key is to use them correctly. Physicians often prescribe antibiotics because they are short on time and find it far more time consuming to explain to a patient why they don't need antibiotics than it is to just write a prescription, especially if the patient is going to leave angry when they don't get what they want.

When patients feel sick and go to the doctor they should remind the doctor that they have come for a diagnosis, not a specific treatment. Do not tell the doctor that you have been sick too long and want an antibiotic. Don't tell the doctor that you "can't afford to be sick". Nothing will bring out the prescription pad quicker than these sorts of comments. Tell the doctor you will take an antibiotic if you really need one, but you would prefer not to if they think the problem will clear up on its own with rest and time. Most physicians are relieved to know they are dealing with a patient who isn't going to pressure them for antibiotics and will be happy to discuss other options especially if the antibiotic is unlikely to help.

Probiotics

The bottom line is that all of this research is extremely interesting and promising but its early days. Selling products such as probiotics and prebiotics at this point is putting the marketing way ahead of the science. Many companies are selling capsules of probiotics and others are putting it in foods like yogurt. Unfortunately most of the claims being made are either exaggerated or have no science behind them at all.

The idea behind probiotics is to take so called "good" bacteria and consume them in such a way as to populate the bowel with them creating a healthier state. There are a number of flaws in this theory based on our current state of knowledge though.

1) We don't know which bacteria are "good" - Some bacteria may be good in certain places and not others or when present in combination with certain bacteria but not others. Remember too that we all have very unique microbiomes and it may turn out that a bacteria which is beneficial in one person may have no effect or even be harmful in someone else.

2) We don't know if we can effectively seed the body with new bacteria - It might seem logical that taking a pill filled with a particular bacteria would allow it to grow inside your bowel like seeding your front lawn but that may not work. The desirable bacteria may be absent because the conditions required for them to grow don't exist in the particular body we are trying to put them in. If you spread seed on a bare dry hard patch of your yard it may remain bare for the same reason it was that way in the first place, not enough water, too little sun or some other condition that wasn't conducive to growth. The same may be true when we try to seed an inhospitable bowel with new bacteria.

3) The microbiome is much more complicated then we thought - A defective microbiome may be missing a lot more than one or two species of bacteria. Trying to seed your bowel with "good" bacteria after they have been presumably wiped out may be like trying to repopulate the rain forest after its been stripped bare by seeding it with a few parrots and rubber trees. You may have a some trees and birds but you wont have a rain forest. Putting probiotics into our guts after our diets or medications have altered the normal collection of species may not return our bowels to a healthy state even if the bacteria are able to grow and fill in the void.

What should you do?

A great deal of research is going on in this field but we have only scratched the surface and there is a lot we still don't know. Until we know more it's probably best not to intentionally alter the normal bacteria that inhabit our bodies any more than necessary unless we have good evidence that the benefits will outweigh the possible harm.

Whenever possible limit antibiotic use to those situations that truly require them and for the shortest amount of time needed to clear the infection. All colds and most cases of bronchitis, sore throats, and sinus infection do not require antibiotics and will usually get better just as quickly with rest and over the counter medications that can relieve symptoms until the illness passes on its own.

Probiotics may have some role in treating diseases related to a disturbed microbiome in the future but current preparations have shown no benefit in many studies and mixed results in others. Most claims made by marketers of probiotics are exaggerated and not based on sound science. Attempts to alter the bacterial species in our bodies with probiotics should be done only under the direction of a physician in the limited situations where this has been proven to be helpful.