Here is an email from a good friend, Dave. We went through a very intense yoga and vegan phase together in Miami in 1999-2002. And while I still think yoga is great for many people, my views on the importance of diet on health have changed somewhat, certainly towards more moderation. Anyway, here is the email, and I'm interested in hearing other thoughts on Dave's questions.
Dear Spencer,
I'm wondering if these vitamins are duplicative and unnecessary:
1. frozen E3 Live: www.e3live.com
2. New Chapter Every Man's One Daily: http://www.newchapter.com/products/every-mans-one-daily
3.http://www.gardenoflife.com/ProductsforLife/SUPPLEMENTS/DigestiveHealth/PrimalDefense/tabid/638/Default.aspx
How much of this would you say overlaps and is unnecessary? And is it bad to take too many vitamins?
--Long time fan
Brooklyn, NY
Dear Dave,
1. frozen E3 Live: www.e3live.com
This, as you know, is a "live" bacteria extracted from Klamath Lake in Oregon. I looked up research articles and no human studies are available. There was one study suggesting it helped rats' kidneys heal quickly from chemotherapy, another saying it has anti-inflammatory and anti-oxidant properties and another saying it has pro-inflammatory effects. The short answer? You are a healthy guy and this probably is a waste of money. That said, if you feel it has made signifigant changes for the better for you, I see no reason to stop it. But it's not well researched.
2. New Chapter Every Man's One Daily: http://www.newchapter.com/products/every-mans-one-daily
Looks ok. A multivitamin is a good idea. I'm not sure about the iodine though... http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-iodine.html
Read the part about iodine supplementation causing goiter (hyperthyroidism)
3.http://www.gardenoflife.com/ProductsforLife/SUPPLEMENTS/DigestiveHealth/PrimalDefense/tabid/638/Default.aspx
About this we don't know too much. There is growing support for probiotics for certain things, like IBS, chronic and acute diarrhea, prevention of antibiotic-associated diarrhea and yeast infections, but as a daily supplement without a real reason I think it's not needed. Yogurt and cheese have some healthy bacteria, and again in theory your intestinal flora should be "balanced" anyway, as you are not suffering from malabsorption or diarrhea or pain, etc. You might take this every other week or once a month for a few days, but I think daily use is a waste of money.
As for taking "too many" vitamins, I mean, yes some things can be toxic, like iodine as mentioned, vitamin A can be toxic, magnesium can give you diarrhea, etc. You seem to eat very, very well including organic, seasonal, veggie etc, so I think you shouldn't need too many supplements. I'd say take some vitamin D (4000units/day) from Sept to April, take the multivitamin (which has b12, good for vegetarians) and if you feel good then you're not missing anything. I take vitamin D, I take milk thistle whenever I have more than 2 alcoholic beverages, I take omega 3, I take a "very green" supplement from trader joes whn I feel I have not had enough veggies recently, and that's about it. My energy level between 7am and 11pm is as good as it ever has been, and my sense of well-being often varries directly with the amount of exercise and focused relaxation/yoga/meditation I get. But that's me... I'm sure you have a sense of what works for you.
Saturday, October 31, 2009
Friday, October 23, 2009
Post-massage shooting pains and spasm?
Tonight I evaluated a 23 yo woman previously healthy who complained of shooting pain in her right gluteal region that started 3 weeks ago during a massage. She stated that the massage therapist really dug her elbow into the region, causing pain that lingered after the massage, and ever since she has been having episodic, very brief jolts of stabbing, electrical-type pain right in that spot with associated all-over body spasm (ie, when she has the pain her body jerks somewhat violently) and some radiation of the pain down her right thigh. She is pain free otherwise. The episodes occur about 4-5 time a day and can be provoked by lying on her left side. She reports a reduction of symptoms when driving if she puts her left leg up on the dashboard. She reported no red flags. She is a lifeguard and water polo coach who is quite active and has had to limit her activity due to the pain. NSAIDs have not helped very much.
Her exam was basically unremarkable except that the pain was reproducible with palpation of a deep spot in her right gluteal region, probably just lateral to her caudal sacrum which would correlate to a region dense with nerves, including the sciatic. Palpation did not cause the spasms though.
Quite an interesting case. Certainly the only one of its kind I've seen. My best thought is that it was indeed related to the massage and she may have had nervous or muscular injury due to the trauma, but I'm not sure why she would have these intermittent spontaneous jolts as opposed to just ongoing pain. I prescribed flexeril for evening use and suggested she give it another 1-2 weeks and if not improving to come back. If she does I'll probably have her see a neurologist.
Her exam was basically unremarkable except that the pain was reproducible with palpation of a deep spot in her right gluteal region, probably just lateral to her caudal sacrum which would correlate to a region dense with nerves, including the sciatic. Palpation did not cause the spasms though.
Quite an interesting case. Certainly the only one of its kind I've seen. My best thought is that it was indeed related to the massage and she may have had nervous or muscular injury due to the trauma, but I'm not sure why she would have these intermittent spontaneous jolts as opposed to just ongoing pain. I prescribed flexeril for evening use and suggested she give it another 1-2 weeks and if not improving to come back. If she does I'll probably have her see a neurologist.
Wednesday, October 14, 2009
Is this Lyme?
Tuesday, October 13, 2009
Doctor, I'm coughing.
It's that time of year again. Those of us on the front lines will be seeing patient after patient with the chief complaint of cough. The possible causes are many, from post-nasal drip to acute pneumonia to an aberrant innominate artery. Often multiple approaches are utilized on a given day. A few questions still weave their way through my clinical work:
1. In patients with bronchitis or post-viral cough, what interventions best help relieve symptoms?
2. What are recommended antibiotics for community acquired pneumonia?
3. What criteria are used to decide whether admission is needed?
The last two are addressed in a recent update by the British Thoracic Society and can be reviewed here:
http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf
"Amoxicillin remains the preferred choice [for low-severity CAP]". If you have prescribed amoxicillin for pneumonia in the past 3 years raise your hand... I know no one who does this. Many clinicians prescribe a zpak (for convenience to the partient I assume, not to cover atypicals). Respitory floroquinolones are another common choice, again I think becuase we feel comfortable they will treat the pneumonia appropriately, somehow better than beta-lactams. Any thoughts here? What is your approach?
Regarding when to admit, both the British guidelines and the article below give good advice:
http://www.jfponline.com/Pages.asp?AID=5978&issue=March_2008
And here's a link to an online PSI calculator: http://pda.ahrq.gov/clinic/psi/psicalc.asp
And of course, as I am writing this I'm seeing an 86 yo female nursing home resident with 3d of cough, found to have O2 sat = 78% (???) at the home and sent in to urgent care. Her primary doctor is away on vacation, apparently. So ok, her BP os 119/72 and O2 is 92% on RA in my office, RR= 28, she doesn't appear in much distress and is not acutely confused. She has a RML infiltrate on xray. Her CRB65 score = 1. So I spoke to the head nurse at her home and found out they will keep her on 02 there, monitor her fluid intake, BP, temp, etc. I gave her levoquin for a nursing home acquired PNA for 10 days with recommendations that she see her PCP sometime soon after that and to watch her INR. But I also think she could have been easily admitted too. Has the pendulum swung too far, biasing us against costly interventions that might actually be necessary? Thoughts?
Getting back to the first question, what can be done for patients who have acute bronchitis or post-viral cough, here's what I do. First, with acute bronchitis, I usually check a peak-flow and do use bronchodilators for those with >10% reduction in PF from expected values. Where appropriate I offer phenergan/codeine syrup. I use this over guaifenesin/codeine because a) patients can get guaifenesin OTC and b) I think this works better for night-time symptoms. It's generally not for those >65 years old though. Supportive care with humidifiers is also helpful. I also read that naprosyn reduces the production of some of the inflammatory mediators that cause cough, so I recommend that often. The same source also suggested ipatropium in refractory cases.
JFPonline has this series: http://www.jfponline.com/pages.asp?id=7145 which at first looks like a great resource but looking it over has a few limitations. First, it's sponsored by Nature's Way, the manufacturer of a natural remedy named Pelargonium sidoides which is mentioned in every section of the newsletter. Second, it doesn't really offer anything that new. I will say that the studies mentioned there that support Pelargonium sidoides do look pretty good for both URI and bronchitis, but again if the manufacturer of the product is sponsoring the newsletter, I am intinctively skeptical. Anyone have experience using or prescribing this product?
Lastly, those who know me know I've been a bit of a vitamin D maven the past few years, and there is some evidence that beefing up on vitamin D before cold and flu season can reduce one's chances of developing a viral illness. Here's a large retrospective trial finding an inverse relationship betwen serom 25OHVitD levels and incidence of viral infections : Arch Intern Med. 2009 Feb 23;169(4):384-90. I also found a prospective trial that finished earlier this year but hasn't reported results: http://clinicaltrials.gov/ct2/show/NCT00656929 .
For now I'm generally recommending patients try vitamin D supplementation this winter, especially with H1N1 concerns. I recommend 2000-5000u daily of Vitamind D-3, but truthfully one just needs to average this dose, ie 14,000u taken once a week is equivalent to 2000u daily, at least as it pertains to maintaining serum levels. I assume this would apply to the health benefits as well. As alsways, I recommend http://www.vitamindcouncil.org/ for updates on the latest research and thinking among vitamin D "converts."
Please share any pearls you have when approaching the coughing patient.
1. In patients with bronchitis or post-viral cough, what interventions best help relieve symptoms?
2. What are recommended antibiotics for community acquired pneumonia?
3. What criteria are used to decide whether admission is needed?
The last two are addressed in a recent update by the British Thoracic Society and can be reviewed here:
http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf
"Amoxicillin remains the preferred choice [for low-severity CAP]". If you have prescribed amoxicillin for pneumonia in the past 3 years raise your hand... I know no one who does this. Many clinicians prescribe a zpak (for convenience to the partient I assume, not to cover atypicals). Respitory floroquinolones are another common choice, again I think becuase we feel comfortable they will treat the pneumonia appropriately, somehow better than beta-lactams. Any thoughts here? What is your approach?
Regarding when to admit, both the British guidelines and the article below give good advice:
http://www.jfponline.com/Pages.asp?AID=5978&issue=March_2008
And here's a link to an online PSI calculator: http://pda.ahrq.gov/clinic/psi/psicalc.asp
And of course, as I am writing this I'm seeing an 86 yo female nursing home resident with 3d of cough, found to have O2 sat = 78% (???) at the home and sent in to urgent care. Her primary doctor is away on vacation, apparently. So ok, her BP os 119/72 and O2 is 92% on RA in my office, RR= 28, she doesn't appear in much distress and is not acutely confused. She has a RML infiltrate on xray. Her CRB65 score = 1. So I spoke to the head nurse at her home and found out they will keep her on 02 there, monitor her fluid intake, BP, temp, etc. I gave her levoquin for a nursing home acquired PNA for 10 days with recommendations that she see her PCP sometime soon after that and to watch her INR. But I also think she could have been easily admitted too. Has the pendulum swung too far, biasing us against costly interventions that might actually be necessary? Thoughts?
Getting back to the first question, what can be done for patients who have acute bronchitis or post-viral cough, here's what I do. First, with acute bronchitis, I usually check a peak-flow and do use bronchodilators for those with >10% reduction in PF from expected values. Where appropriate I offer phenergan/codeine syrup. I use this over guaifenesin/codeine because a) patients can get guaifenesin OTC and b) I think this works better for night-time symptoms. It's generally not for those >65 years old though. Supportive care with humidifiers is also helpful. I also read that naprosyn reduces the production of some of the inflammatory mediators that cause cough, so I recommend that often. The same source also suggested ipatropium in refractory cases.
JFPonline has this series: http://www.jfponline.com/pages.asp?id=7145 which at first looks like a great resource but looking it over has a few limitations. First, it's sponsored by Nature's Way, the manufacturer of a natural remedy named Pelargonium sidoides which is mentioned in every section of the newsletter. Second, it doesn't really offer anything that new. I will say that the studies mentioned there that support Pelargonium sidoides do look pretty good for both URI and bronchitis, but again if the manufacturer of the product is sponsoring the newsletter, I am intinctively skeptical. Anyone have experience using or prescribing this product?
Lastly, those who know me know I've been a bit of a vitamin D maven the past few years, and there is some evidence that beefing up on vitamin D before cold and flu season can reduce one's chances of developing a viral illness. Here's a large retrospective trial finding an inverse relationship betwen serom 25OHVitD levels and incidence of viral infections : Arch Intern Med. 2009 Feb 23;169(4):384-90. I also found a prospective trial that finished earlier this year but hasn't reported results: http://clinicaltrials.gov/ct2/show/NCT00656929 .
For now I'm generally recommending patients try vitamin D supplementation this winter, especially with H1N1 concerns. I recommend 2000-5000u daily of Vitamind D-3, but truthfully one just needs to average this dose, ie 14,000u taken once a week is equivalent to 2000u daily, at least as it pertains to maintaining serum levels. I assume this would apply to the health benefits as well. As alsways, I recommend http://www.vitamindcouncil.org/ for updates on the latest research and thinking among vitamin D "converts."
Please share any pearls you have when approaching the coughing patient.
Is it DVT?
Last night I saw a 36 yo man who had a worsening painful swelling in his calf and had been lying in bed for the past 4 days due to this concern. His BP was 189/115 pulse 95% and pulse ox 98%. There were discrete, tender 2cm wide palpable cords just below the skin. He also had a tender nodularity on the same side near the femoral vein. I calculated his Wells score = 2 (localized tenderness along distribution of deep venous system + bedridden >3d) and had to refer him to the ED as I had no access to a lab or ultrasound. The ED gave him fondaparinux and scheduled an ultrasound for the next day, today, and it is still pending.
I also had a case last month of a 60 yo man with open hernia repair 9 days prior to the visit with me who complained of right thigh numbness which he had experienced in the past, before his surgery. His daughter, who was at the visit, had had a DVT and PE the year prior and her only complaint was numbness in her foot, so he was concerned. His exam was unremarkable. My suspicion was low and his Wells score = -1 (+1 recent surgery, -2 for alternate diagnosis likely). Still, I gave in to his family's concerns and ordered a D-dimer, which came back elevated, probably due to recent surgery. At Kaiser after-hours, where this was all happening, their practice is also to anticoagulate until regular hours then ultrasound can be done. So we had to calculte his lovenox dose (the patient was obese and could not use fondaparinux), teach him and his reluctant family how to give the twice-daily injections, and schedule the ultrasound, which was negative.
Did I apply current best practice to these situations? I do feel that in the former case a D-dimer (and likely ultrasound) was needed to be sure the patient did not have DVT. In the latter I'm less certain. With a Wells score of -1 I could have been more reassuring and saved the patient and his family the inconveniences of the 24-hours following the initial visit. On the other hand, they were hesitant to be reassured by my clinical assessment.
Any thoughts on how to handle either of these cases differently?
Reference: Is it DVT? Wells score and D-dimer may avert costly workup. Journal of Family Practice Vol 56, no. 12. December 2007. (http://www.jfponline.com/pdf%2f5612%2f5612JFP_Purl2.pdf)
I also had a case last month of a 60 yo man with open hernia repair 9 days prior to the visit with me who complained of right thigh numbness which he had experienced in the past, before his surgery. His daughter, who was at the visit, had had a DVT and PE the year prior and her only complaint was numbness in her foot, so he was concerned. His exam was unremarkable. My suspicion was low and his Wells score = -1 (+1 recent surgery, -2 for alternate diagnosis likely). Still, I gave in to his family's concerns and ordered a D-dimer, which came back elevated, probably due to recent surgery. At Kaiser after-hours, where this was all happening, their practice is also to anticoagulate until regular hours then ultrasound can be done. So we had to calculte his lovenox dose (the patient was obese and could not use fondaparinux), teach him and his reluctant family how to give the twice-daily injections, and schedule the ultrasound, which was negative.
Did I apply current best practice to these situations? I do feel that in the former case a D-dimer (and likely ultrasound) was needed to be sure the patient did not have DVT. In the latter I'm less certain. With a Wells score of -1 I could have been more reassuring and saved the patient and his family the inconveniences of the 24-hours following the initial visit. On the other hand, they were hesitant to be reassured by my clinical assessment.
Any thoughts on how to handle either of these cases differently?
Reference: Is it DVT? Wells score and D-dimer may avert costly workup. Journal of Family Practice Vol 56, no. 12. December 2007. (http://www.jfponline.com/pdf%2f5612%2f5612JFP_Purl2.pdf)
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