The Last Lecture of a Lifetime: Confronting Brick Walls

The Last Lecture of a Lifetime: Confronting Brick Walls

At times during the Holiday Season, and certainly at other times as well, we can benefit from looking beyond ourselves and personal circumstances. I stumbled upon something that I think is truly fascinating. If you have ever confronted a brick wall, or even if you have not, this is a must see!

Please review Jeff Zaslow's moving account in the “Wall Street Journal” of 46-year-old Carnegie-Mellon professor Randy Pausch's "Last Lecture". I will not spoil it by making additional comments. I leave that to you! Professor Pausch gives a fascinating lecture, filled with humor and psychological wisdom, about what he has learned from life. Trust me; this is no ordinary lecture, and this is no ordinary professor. If this doesn’t stimulate your thinking, have someone check your pulse!

I enthusiastically recommend watching the complete video of his presentation. The link to the Google video is:
http://tinyurl.com/2dwtzw.

If like me, you find yourself wanting to learn more about this Professor Pausch after watching the video, view his home page at:
http://www.cs.cmu.edu/~pausch.

All comments welcome....

Do you really need those antibiotics?

In 2007 there were two important studies published that should make all of us think twice about when we REALLY need to take antibiotics. In early December there was a study published in one of the premier medical journals, in which they found that routine antibiotics do not seem to speed the recovery from an uncomplicated sinus infection. Even though more than 90% of the doctors in the US will prescribe antibiotics for sinusitis, it is unclear whether they really help. This study confirmed earlier studies and found that about one-half of the people were better in one week and two out of three people were better in ten days, regardless of whether they took an antibiotic. Interestingly, nasal steroids sprays which are also often prescribed, did not seem to help much either.

Another important update came from the American Heart Association which updated its recommendations for when to give preventive (prophylactic) antibiotics to prevent heart infections. In the past, they recommended that hundreds of thousands of people with all sorts of fairly minor heart problems and heart murmurs should take a big dose of antibiotics before dental work, or certain urinary or gastrointestinal procedures, such as the use of scopes to look in the colon or the bladder. This was thought to be important in order to prevent serious infection of the heart valves (endocarditis). Earlier this year, these experts looked at all the scientific data and concluded that only a small portion of these people really needed the antibiotics. If you want to find out which groups of people need the antibiotics, go to http://www.americanheart.org/presenter.jhtml?identifier=11086 where you can also download a handy wallet card.

Unnecessary use of antibiotics clearly leads to increasing bacterial resistance as well as risks of allergies, potential side-effects, unneeded cost, etc. Many doctors will prescribe antibiotics even when they think that the clinical situation does not call for it because they think the patient really wants the medicines and will insist. Often antibiotics are essential and life-saving, but the next time your doctor recommends antibiotics, especially in cases of sinusitis or for prevention of heart valve infection, it may be reasonable to ask the doctor, “Do I really NEED that antibiotic?”.

Suicide: The Myth of the Holiday Season

Suicide: The Darkest Myth of the Holiday Season Remains Alive and Well!

Several folks have been asking me about Holiday-related stress, and I have recently heard this reported on the national news, so I want to take the opportunity to clear up a popular myth that surfaces this time of the year. Perhaps it was dear George Bailey from the great movie, "It's a Wonderful Life" who started all of this. Who knows, but this myth resurfaces about this time every year.

Certainly, one can feel a great deal of stress and chaos around the Holidays. As mentioned in an earlier blog, Interpersonal and Domestic violence does increase around the Holiday Season. However, contrary to what you may hear or have read, there is good news here: Depression and suicide rates significantly decrease during this time of the year.

This finding is not just in the United States, but all over most parts of the world. A large body of psychological science continues to confirm this. For a number of years, I often have worked in inpatient psychiatric hospitals during the Holiday Season, and always this is the time of lowest census for the entire year. Although this can be a blue time of the year for many, for most people it is not as bad, and certainly not as depressing as we may have learned to expect.

Please, if you are battling with depression or suicidal thoughts, seek help right away, or continue with the help that you are getting. Don't keep it a secret. The fact is that there is NEVER a good Season for Depression!

Healthy and Holiday Cheers to All!
Comments Welcome.

Management of Chronic Angina

For those of you who've been diagnosed with so-called "chronic angina" or stable chest pain that it attributed to mild to moderate heart disease, medical management has become a preferred strategy. Accordingly, be sure that your treatments are optimal. The following points are taken from recently updated guidelines, include both medications and lifestyle techniques, and are to be used long term.

1. Know Your Blood Pressure:
Blood pressure control should target levels at least below <140/90 (<130/80 for patients with diabetes or chronic kidney disease) and preferentially less than 120/80 for all patients. Patients should be treated with the following blood pressure medications whenever possible: beta-blockers and ACE inhibitors, with the addition of other drugs like diuretics (such as HCTZ or chlorthalidone), if possible, and calcium blockers, if needed.

2. Take aspirin:
Aspirin should be taken daily at 81 mg (or 162 mg post CABG), preferably uncoated, unless there is a contraindication.

3. Exercise:
Daily physical activity is recommended for all patients. It should consist of 30 to 60 minutes of moderate-intensity aerobic activity like walking or swimming; additional resistance training 2 days per week is reasonable.

4.Know your Cholesterol Panel:
For LDL-cholesterol reduction, it is reasonable to aim for levels of <70 mg/dL and to use high-dose statin therapy, as we've discussed here on the Blog previously. Metamusil (pysllium) and plant sterol supplements are also helpful. For non-HDL (the total minus the good kind) and HDL (the good kind) optimization, niacin and fibrates (like Tricor) can be useful medication additions along with exercise, monosaturated oils (like olive oil), fish and fish oils, and nuts from trees (the edible kind - not the human kind).

5. Know your Ejection Fraction (EF):
This is tested via echocardiogram. In the absence of significant kidney dysfunction or high potassium, post-heart attack patients with an ejection fraction <40% and either diabetes or heart failure should receive an aldosterone inhibitor (like Aldactone) in addition to therapeutic doses of an ACE inhibitor and a beta-blocker.

6. Know your BMI:
It should be between 18.5 and 24.9 kg/m2

7. Know your Waist Size:
It should be less than 35 (women) or less than 40 (men).

8. Don't smoke. Period.

9. All patients with heart disease should receive an annual influenza vaccination.

10. Chelation therapy may cause low calcium levels and is not recommended for patients with heart disease.

Review these recommendations against your current medication list and lifestyle plan. If you're not taking these medications or achieving these lifestyle goals, ask your doctor why not.

Fasting Is Good for You

As someone raised in a religious family, I have always been fascinated by fasting. It played such an important role in the Bible. I also grew up in the 60s and fasting was a popular way of protesting. In medicine, little credit has been given to fasting, yet it is a way for type 2 overweight diabetics to get their blood sugars down, and fasting is one way to lose weight (live off your body for a day, staying hydrated with water).

The Associated Press today reports on a study by Intermountain Healthcare in Utah that showed that Mormons who fasted once a month had 40% less chance of being diagnosed with clogged arteries, and had fewer heart attacks.

Consider fasting if you are overweight. Check with you physician to find out which medicines you should take during your fast and which you should not. Remember to drink water, so your body can continue its functions and excrete the breakdown products of living off your stored fat. Say somewhat active so your muscles (body protein) gets maintained.

Fasting is not easy, and I think it builds your willpower and personal strength.

Exercise Yourself to Sleep

Occasionally, after a vigorous workout you’ll hear someone say, “I’ll sleep well tonight”. Without a doubt, I have found that I don’t sleep as well on days that I am not able to exercise. But what does the literature have to say about this phenomenon of “exercising yourself to sleep”?

A study published in the Journal of the American Medical Association examined the impact of moderate exercise on sleep quality in older adults with moderate sleep-related complaints. In this study, 43 men and women between the ages of 50 and 76 were split into two groups. One group exercised moderately (30- to 40-minute aerobics classes four times a week) for 16 weeks, while the other group made no changes to their lifestyles. After 16 weeks, the exercisers showed improvement over the control group in general quality of sleep, quicker sleep-onset, longer sleep duration and feeling rested in the morning

Another study conducted at Tufts University took 32, “slightly to moderately depressed” elderly men and women and assigned them to an exercise group or a control group. The exercise group performed three strength training sessions each week. At the end of the 10 week study the exercise group reported not only significant improvement in sleep quality over the control group, but improvement in quality of life also.

Women who have gone through menopause are noted to be at higher risk for sleep problems. Researchers have found that postmenopausal women who performed moderate-intensity exercise for at least a half-hour every morning had fewer problems falling asleep compared to less active women.

Relatively few research studies have looked at the impact of exercise on insomnia. The ones that have support the premise that exercise improves sleep patterns, primarily by increasing total sleep time and decreasing sleep latency. To maximize the benefit of exercise, it appears that the duration of exercise is more important than its intensity. Also, it is preferable that exercise occur 5 to 6 hours (minimum of 3 hours) before bedtime.

Youngsters Under 60: Save Yourselves!

Most Americans know that we have made much progress in decreasing rates of heart attack in recent decades. Indeed, modern insights and medicines have produced an overall 50% decrease in heart attack deaths since 1980. Are we, however, maintaining that decrease appropriately in more recent years. Recent data say "NO."

Specifically, among men between 35-54, the annual decrease in heart attack deaths has slowed from 6.2% (1980 to 1989) to 2.3% (1989 to 2000) to 0.5% (2000 to 2002). Among women age 35-54, the decline was 5.4% from 1980 to 1989 and 1.2% from 1989 to 2000. From 2000 to 2002, however, the estimated death rate increased to 1.5% annually. By contrast, for men and women 55 and older, the rate of decrease accelerated comfortably with time.

Overall then, modern preventative cardiology is working for older patients; for the young, however, especially young women, we need to pay more attention. Loyal Bloggers know what preventative steps to take from our prior posts - so spread the word so that the young can stay "young at heart."

The Doctor as a "Drug"

Michael Balint, MD was a physician who deeply probed the depths of the doctor patient relationship in his book The Doctor, the Patient, and His Illness. In this book, Balint also discusses two other important concepts that reveal much about the nature of the doctor-patient relationship. The first is the consideration of how the doctor functions as a primary therapeutic agent, much like a "drug", and the other is the concept of the "unformed illness". I'll discuss the "drug" doctor in this post and save the other term for later.

Patients visit doctors seeking relief from some problem, symptom or illness. Apart from surgery, the most common intervention used in the office is prescription of medication. Much like the use of medications, doctors also prescribe a "dose of themselves" when patients need relief. This comes, more than anything else, in the form of active, non-judgmental listening to their patients, encouraging them to talk about what "brought them to the doctor" by asking open-ended questions that put the patient at ease to express whatever is on their mind.

If this sounds more like a description of a psychiatric encounter, that's because Dr. Balint was both a general practitioner and a psychiatrist, and recognized that most illness was a highly complex mix of physical AND psychological factors. By serving as a safe, trusting professional who is genuinely engaged in the patient's problem, the solution starts to become the relationship itself. Patients obtain relief from many of their symptoms, particularly symptoms of "unformed illnesses" that may unknowingly have their roots in deep tensions, insecurities, or anxiety by having a good doctor-patient relationship and, thus, receiving a dose of the "drug doctor" in addition to their antihypertensive or diabetic or antidepressant medication.

Dr. Balint felt strongly that this "drug doctor" could not be effectively used without a highly developed degree of self-awareness on the part of the doctor that allowed them to simultaneously attend to the important medical issues while keeping a listening ear open to the life events and problems that contributed to virtually every patients illness.

Do you obtain a dose of your "drug doctor" when you make an office visit? Your comments are always appreciated...

Beware of Vitamin A

Most people think that all vitamins are good, and they are in normal recommended amounts. Sometimes health claims recommend high doses of vitamins. The B vitamins and vitamin C, which are easily excreted in the urine, are generally not dangerous even in higher doses. However, vitamins A, D and E are accumulated by the body and high doses can be dangerous. The most dangerous vitamin in high doses is vitamin A. The recommended daily allowance for vitamin A for men and women is 3000 IU for men and 2333 IU for women). Above 10,000 IU is considered dangerous, and may cause liver damage and birth defects in pregnant women.

A new analysis of the large Nurses' Health Study (over 70,000 women followed by Harvard researchers) has shown that women who consume more than 6600 IU of vitamin A had a higher risk of hip fractures after menopause. It appears that high doses of vitamin A contributes to osteoporosis of the bones.

If you take vitamins, especially multiple pills daily, check the labels carefully for the vitamin A intake. To be safe, do not take more than 5000 IU daily.

Winter colds, winter gastroenteritis, and winter flu

The leaves are almost all fallen. Holiday music comes from the elevator speakers. Winter is nigh and this also means that we face our toughest season for viral infections. Why in the winter? The experts think that this is because people are just jammed in together more than in spring, summer, and fall and people do easily exchange germs.

Certainly, germs can be spread by coughing and sneezing but the infectious disease subspecialists stress washing one's hands as the best defense and the best means of not infecting others. One expert suggests using soap and water for the length of time to sing two verses of "Happy Birthday", although, for the sanity of your family and co-workers, you might want to alternate with songs of roughly the same length or just sing mentally. Whenever washing up is not convenient, hand sanitizers are a good second option.

When one does cough or sneeze, the experts say to do so into one's elbow rather than into one's hands or by spraying the germs unimpeded throughout the room.

The Holiday Season is busy, stressful, and (I hope for all the eDoc clients) personally and spiritually fulfilling. Wash frequently to keep the germs at bay that would love nothing more than to set up shop inside you for several miserable days.

A Thanksgiving Wish List

On this eve of Thanksgiving, I'm glad that I live in a country where the best health care in the world is obtainable. I'm having a total knee replacement in two weeks and am glad that I'll be in a first rate institution with a great staff and great technology and am very fortunate that I have health insurance that will eliminate any financial burden from this process.
Although I am thankful for these things, I also have a Thanksgiving wish list:
--I wish that our health care system had not become such a financial juggernaut that primarily rewards hospitals and physicians who do expensive procedures.
--I wish that patients would learn how to take personal responsibility for their health care.
--I wish that every patient had access to the internet and could routinely interact with a physician online to get answers to health care questions.
--I wish everyone had a compassionate, caring primary care physician who would help them coordinate their health care.
Although I'm sure my wish list is lofty and unrealistic, each of you can make a decision to develop a relationship with a primary physician, hopefully one who encourages you to use the internet to obtain information and interact with him/her about health care. And you can use the information on the internet to help prevent disease rather than dealing later with treatment of conditions (such as diabetes) that may result from failure to address important issues, such as weight control and nutrition.

How do you start?:
1. Work on obtaining optimum weight (Body Mass Index of 25 or less)
2. Normalize your cholesterol (LDL of 100 or less)
3. Exercise (5 days a week of 30 to 40 minutes, combine weights and aerobics)
4. Get a physical (complete history, examination and basic lab tests)
If you have questions about how to do any of theses things, I'd love to hear from you.

Happy Thanksgiving...

An Exercise Tip from Satchel

"I use my single windup, my double windup, my triple windup, my hesitation windup, my no windup. I also use my step-n-pitch-it, my submariner, my sidearmer, and my bat dodger. Man's got to do what he's got to do." -----------Satchel Paige

“Man’s got to do what he’s got to do”. I love that concept. It can be applied to any number of life’s challenges or even to unpleasant, but necessary tasks. Acts of superhuman strength are said to have occurred when someone was required to do what they had to do----think of the woman who lifted a car off her trapped child. Or when the nerdy guy “rises to the occasion” to save the day. On a more mundane level, consider the single, working Mom who demonstrates tremendous ingenuity and multi-tasking skills in order to keep a roof over her family’s head and tend to the needs of her children.

The concept can also be applied to getting the recommended amount of exercise. Exercise for many fits in both the “life’s challenges” as well as the “unpleasant, but necessary task” categories. But taking a cue from Satchel, since you got to do it, you might as well figure out how. First of all, find out what you like to do. If running isn’t your thing, no big deal. There are many ways to get aerobic exercise. Walking, riding a bike, swimming, working out on an elliptical trainer will all allow you to reach a “moderate intensity” level of exercise. If gyms give you the creeps (I can relate to this), get outside. The weather is rarely too hot or too cold to keep you from getting in your 30 minutes a day. If you can’t exercise formally, see if you can walk or ride a bike to work. If you can’t exercise formally or walk or ride a bike to work, exercise in short bouts during the work day.

The point is, you can reach recommended exercise goals if you use some creativity and perhaps a little sacrifice. Very little I’d say, since we’re usually talking about missing a rerun of The Sopranos or missing half of the fourth college football game of the day. Listen to Satchel and mix it up-----walk to work on Monday, work out with weights on Tuesday, do calisthenics and yoga on Wednesday, ride your bike on Thursday, and so on-----“do what you got to do”.

A Sad Part of Holidays: Increased Domestic Violence

I enjoy the festive spirit this time of year. However, domestic violence is an ugly and secretive part of the holidays. Domestic violence significantly increases during major holidays. We can’t always control others, but we always can control the decisions and actions that we take.

During the holiday season, we can all stress about money. We can feel bombarded with unrealistic expectations. Guilt, depression, anger, fatigue, and alcohol are the real Grinch-factors of the holiday season. Triggers to domestic violence can be controlled with a few healthy strategies. Domestic violence never occurs in a vacuum. Few issues affect a family as much as domestic violence, and the negative effects of such violence are incalculable, especially among women and children. All of us have the responsibility to do all we can to prevent domestic violence.

Here are tips to help:

Avoid alcohol. Alcohol is the most significant contributor to domestic violence. If alcohol might be a contributing factor don’t risk consuming it or being around those who do.

Avoid people who contribute to negative interactions. Hang with those who support you and are positive in interactions with you.

Remind yourself that irascible family members will not have changed from the last time you have been with them. Limit your exposure to them. Consider a specific exit plan of how you might handle the provocative relative who gets your goat.

Keep control with your own emotions. Take an emotional-time-out when you feel stress build. Form and activate a specific exit strategy when you begin to feel tired, overly-stressed, and notice negative feelings and anger building.

Remind yourself that the stress of the holidays won’t last forever. Keep YOUR sanity alive and well, regardless of what seems to be going on around you.

Know that domestic violence has devastating effect on you, and those you love. Keep reminding yourself of the real reason behind the holiday season and family activities. Domestic violence is preventable.

Please share your helpful tips on this important topic.