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Archive for the ‘Blogfinger Medical Reports’ Category

The generator is under the skin. A wire is passed into a vein and into the right side of the heart (the tip is positioned in the right ventricle). This technique has stood the test of time.

Permanent pacemaker configuration.   The generator is under the skin. A wire is passed into a vein beneath the clavicle and into the right side of the heart (the tip is positioned in the right ventricle). In this example there is a second wire in the right atrium.

I saved this 1970's unit made by Cordis. The surgeon would place it into a

I saved this used 1970’s single lead unit made by Cordis in Miami.  The surgeon would place it into a “pocket” under the skin and attach it to an electrode in the heart.   Paul Goldfinger photo. ©

The opposite side of the unit shown.

The opposite side of the unit shown.  Cardiologists would go into the OR with the surgeon when a pacemaker was placed. Now, surgeons are usually no longer needed for this procedure. ©  Paul Goldfinger photo

A tiny modern version of a permanent pacemaker.

A tiny modern version of a permanent pacemaker.

Current model.

Current model.

By Paul Goldfinger, MD, FACC,  Dean at the Blogfinger  Off-shore School of Medicine .   Re-posted from Feb. 2016 on Blogfinger.net

My career spanned the remarkable history of permanent cardiac pacemakers. In the early 1970’s, those devices were as a big as a can of tuna fish. They had limited functions and a variety of technical problems. Today they are miniature electronic marvels.

The story began around 1930 when an Australian researcher found that the heart could be stimulated with a localized electrical shock delivered from a wire.

1949: The Medtronic Company, pioneers in pacemakers, was begun in a garage in Buffalo by an engineer and a physician.

1952: At the Boston Beth Israel Hospital, a patient was admitted with fainting spells due to drastic slowing of the heart. These are called Stokes-Adams attacks. This was the first case to be treated with a temporary pacemaker. A wire was attached to the external wall of his heart, while the pacemaker generator was outside his body.

1957: The first battery powered unit was developed, and, in 1958, the first permanent pacemaker was implanted in a dog, consisting of a generator under the skin and a wire attached to the outside wall of the heart.

1960: The first permanent pacemaker was implanted in a human. In 1961, the first in New Jersey was performed by heart surgeon Victor Parsonnet at Newark Beth Israel. Dr. Parsonnet is one of a core group of doctors world-wide to get credit for pioneering work in permanent pacemakers.

1973- 1980: The era when my own career began, the technology of permanent pacemakers evolved strikingly, with smaller and more complicated  “generators,” longer lasting batteries, and better electrode (wire) systems.  Medical electronics had been evolving thanks to the invention of the microprocessor.

When a patient only needed a temporary pacemaker, a cardiologist such as myself would pass a wire into the right ventricle through a vein in the arm or neck and attach it to an external pacemaker which hung from an IV pole at the bedside.  Eileen sometimes kids me by saying, “If you can put a wire into somebody’s heart, how come you can’t…….(fill in the blank)”

The permanent units could just only control slow heart rates at first, but later, more functions were developed and could be programmed (changing the settings) from without.

At first, pacemakers had to be routinely changed every two years because of battery life, but later the batteries were improved.

In the early 1970’s research with a nuclear powered pacemaker was performed by Dr. Parsonnet and his team at Newark’s Beth Israel Hospital . They were trying to increase the battery life.   That technology did not work out.

During this phase, techniques for monitoring the battery life and functions of a permanent pacemaker were developed. Eventually a patient could be followed by the use of a telephone, so hospitals throughout NJ had a setup where they could check their patients by phoning into NBIH for monitoring allowing doctors to predict when a pacemaker had to be changed and how well it was working. In-person visits to a pacemaker clinic were also required to check a variety of other functions .

In late 1970’s, at Dover (NJ) General Hospital and Medical Center, Jean Wiarda, RN ( a cardiac nurse) and myself,  with the cooperation of Medtronic, set up the first free-standing pacemaker clinic in north Jersey. After that, many other hospitals followed suit and broke away from the NBIH connection.  Later patients were able to phone in  their pacemaker signals from home  to the clinics. They also had to come for in-person evaluations intermittently depending on what we wanted to measure or program.

A major development, evolving in the 1970’s, was the transvenous lead for permanent pacemakers which eliminated the need to open the chest and sew an electrode into the heart muscle.   Instead, an electrode could be passed through a vein under the collar bone and into the right ventricular chamber, eliminating the need for heart surgery.

Now that continues to be standard, although the pacemaker generators are much smaller, and the electrodes have been refined, and sometimes more than one wire is used. Even though the generators are now tiny (you can’t even tell that someone has a unit,) they can perform all sorts of miraculous functions and are totally adjustable from without using a device called a programmer.

Surgeons used to install permanent transvenous pacemakers, but now these complex devices are placed by electrophysiologists, cardiologists who specialize in electrical diagnostics and therapeutics including implantable cardio-defibrillators.

The future of electrophysiology is huge, and progress is made every day in this field.

Around here, Jersey Shore Medical Center and Morristown Medical Center have first rate electrophysiology departments.

THE TIMETONES

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FROM THE AMA:    STAT reports the flu season “is off to an early start this year” and could “peak over the holidays,” a new CDC indicates. The piece says the “wildly unpredictable” flu viruses leave experts uncertain of precisely how extensive the season will be, but the CDC’s weekly flu reports offer updated predictions and data, with the most recent report showing “that Louisiana and Oklahoma already have widespread flu activity and some nearby states are heating up too.” According to CDC influenza epidemiologist Lynnette Brammer, who leads flu reporting, “If it continues to go up like it has the last couple of weeks, yeah, we could have a fair amount of activity right at Christmas.”

 

BLOGFINGER MEDICAL REPORT:  By Paul Goldfinger, MD, FACC

From the Nov.  29, 2017  NEW ENGLAND JOURNAL OF MEDICINE:     “Seasonal influenza epidemics cause 3 million to 5 million severe cases and 300,000 to 500,000 deaths globally each year, according to the World Health Organization (WHO). The United States alone sees 140,000 to 710,000 influenza-related hospitalizations and 12,000 to 56,000 deaths each year, with the highest burden of disease affecting the very young, the very old, and people with coexisting medical conditions.  (BF bold print)

“However imperfect, though, current influenza vaccines remain a valuable public health tool, and it is always better to get vaccinated than not to get vaccinated. In this regard, the CDC estimates that influenza vaccination averted 40,000 deaths in the United States between the 2005–2006 and 2013–2014 seasons.2 Yet we can do better.”

It is difficult and unpredictable to get the virus profile to be accurate, because the profiling is done early in the year, and virus mutations can appear, leaving your flu shot to have a reduced efficacy.  Usually flu shots are 40% to 60% effective, but this year, according to the New England Journal of Medicine,  “The preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%.”  They are referring to the Southern Hemisphere  experience earlier this year in Australia.  H3N2 is the main offender so far, although there may be others emerging now.  The transmission of the influenza virus has been accelerating sharply in the US at this time.

So, if you haven’t yet had a flu shot, rush out and get one.  Most drug stores offer it.  If you are  a member of a high risk group, such older folks  (over age 65) or those with chronic illnesses, try to avoid exposure in places with many people in close contact.  And stay away from anyone who has a “cold” or, especially, has flu-like symptoms including fever, cough, chills, muscle aches, congestion, runny nose, headaches, and marked fatigue.

If you have such symptoms, your doctor may prescribe an antiviral medication, such as Tamiflu,  if you call early in the course of your illness.

And don’t forget frequent hand washing.

 

 

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Cup-a-joe at Nagle’s. Paul Goldfinger © Note the OG ads under the glass.

 

 

Reuters  (11/23)  reported researchers found that “people who drink three to four cups of coffee a day are more likely to see health benefits than harm,” according to a paper published in the British Medical Journal.

The Atlanta Journal-Constitution (11/24) reported the researchers also found that people who drink three to four cups per day appear to be at lower risk for “diabetes, liver disease, dementia and some cancers,” including endometrial, liver, prostate, and skin.

The researchers “examined 201 observational studies analyzing the health of coffee drinkers.” Forbes (11/24) reported the researchers also found that coffee consumption was linked to lower risk for Parkinson’s disease, metabolic syndrome, kidney stones, and gout.

The Telegraph (UK) (11/22) reported the researchers found that drinking up to seven cups of coffee per day was linked to a lower risk of early death.

 

BLOGFINGER MEDICAL COMMENTARY by Paul Goldfinger, MD, FACC:

We have posted two articles in recent years about the health aspects of coffee drinking.  The link below is good discussion. This AMA post above brings us up to  date.

My advice is, as before, do not fear coffee drinking except remember that caffeine can be addictive and can cause cardiac dysrhythmias, fast heart beat, tremors, nervousness, and insomnia.

Regarding insomnia, some people are especially sensitive, so some experts say that  they should not drink coffee after 2 PM.  And if you are a regular drinker of coffee, and then you don’t have any, consider that as a cause of an unexplained headache.  Also, coffee can increase alertness due to its effects on the brain; that is why people like me really need that morning Joe. (And I don’t mean Scarborough)

Some drink coffee to stay awake, such as during exams, driving and doing careful tasks.  Whenever I had to show up at the coronary care unit in the middle of the night, the nurses greeted me with coffee. In fact my office supplied free coffee for that unit so that they all could stay awake.  But when I got home, I could fall asleep instantly despite the caffeine.  The same was true of a phone call from the hospital while I was asleep.

BF medical article about coffee 8/15

 

BERTIE HIGGINS    “Key Largo”   Do you think that Bogie  (“Here’s lookin’ at you kid..”) and Bacall were drinking coffee that winter in the Keys?

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A nice array of local produce including blackberries, blueberries, broccoli,mushrooms, and radishes. Ocean Grove display. Blogfinger photo © 7/15/17  Click  book cover to enlarge the text.

 

By Eileen and Paul Goldfinger at  @Blogfinger.net.

Most major prevention trials have concluded that fresh fruits and vegetables will help the process due to their nutritional content of  fiber and micronutrients including vitamins, minerals and antioxidants.  This dietary approach is one of the major reasons why the Mediterranean Diet has been found to be so beneficial.

There is a reason why New Jersey is called the Garden State.  Local farms are turning out a great crop for 2017 including big, beautiful beefsteak tomatoes and a record breaking peach crop.

This is the first generation in America where we can look forward to fresh produce all year round, instead of only in season, thanks to advances in packaging and shipping.  And that includes fresh seafood.

So take advantage of using these healthful Garden State ingredients over the next couple of months.  (Hint: Point Pleasant scallops–Here is a link to Eileen’s Pt. Pleasant scallops with tomato and scallion sauce)

Pt. Pleasant scallop recipe by Eileen

SHYMAN MOSES:

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By Paul Goldfinger, MD, Editor @Blogfinger

Do you find flaws that indicate a deterioration in some aspects of our healthcare system? We often do and yesterday we stumbled on another one.

We were at a local medical group for an office visit. When we went to the desk to schedule our next visit, the face behind the glass asked for our credit card information. She assured us that they would only use the card if we had an unpaid balance, for example if there was a copay or a balance after insurance paid.

When we refused the idea that we should give them open access to our checking account  (ie a blank check), she informed us that she could not schedule our next visit without that card. In other words, they were willing to lose two patients who had no history of payment issues over this “policy.”

We were handed a statement in writing which explained that the “insurance industry makes patients responsible for high deductibles, co-payments and non-covered services.” In other words, they didn’t trust their patients to take care of outstanding balances and they hate to wait.

The statement said that if an unpaid balance exists, they would send us an email statement, and if we did not pay within 5 days, they would charge our credit card.   They also worried that we might change our credit card, so they concluded by warning that “you may cancel your credit card, but we will be unable to continue your care without an active credit card on file.”

Although we have been happy with our medical care with this group, this policy, which was willing to let us  leave without a subsequent appointment, casts a dark cloud over that medical provider.  To be honest, we were furious.  They are entitled to establish rules for collections, but this policy has a tinge of abandonment and coercion, something which is unethical among physicians.

For one thing, the policy makes our credit card available to anyone in the office who is interested in getting a new TV, for example.  It also makes it much more difficult to negotiate or discuss a billing issue once they have snatched your cash from your account.  And you need the time to do that because sometimes medical bills contain errors or even fraudulent charges.

Is this legal?  Evidently it is.  (quote below is from Cleveland.com)

“An AMA spokesman said, ‘Employers are offering health plans that require their employees to shoulder a greater share of health care costs. Total cost-sharing for the average patient from deductibles, co-payments and coinsurance has increased from $422 to $747 between 2004 and 2014, according to the Kaiser Family Foundation.’

“He said the cost-sharing trend is accelerating because of the health insurance exchanges opening up. Those often come with high-deductible plan options that people choose to keep their premiums down.

“Meanwhile, overhead for doctors’ offices has soared, he said, in part because of time spent complying with government regulations and health insurer policies.

“To lower overhead costs,” Mills said, “medical practices are focusing more on streamlining patient payment collections. Some practices do take credit card numbers for this purpose.”

“He added that the AMA does not offer guidance to doctors’ offices on this issue, except to say that doctors who do it should get advice from an expert because of the security risk of keeping this type of information on file.

“So the bottom line: If a doctor’s office won’t treat you  because you won’t give the office a credit card number to keep on file, then I’d find a new doctor. Period.”

We are not yet sure what to do, but this feels like blackmail and definitely affects our doctor-patient relationship.  The policy shows disrespect for the group’s patients, and a basic tenet of physician values is to always put the best interest of the patient first.

 

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This is about the Canadian Supreme Court ruling that made Teva’s sildenafil available there.

 

 

Paul Goldfinger,  MD, Editor @Blogfinger.net and Professor at the Blogfinger Off-shore School of Medicine in Ocean Grove, NJ.

Men who use Pfizer’s Viagra for erectile dysfunction know how expensive that little blue pill is. In 2012, Pfizer made over $2 billion with it.

But the FDA has now approved low cost generic Viagra (sildenafil) to be manufactured by the Israeli company Teva, but that won’t begin until December, 2017 (and maybe sooner.)

The generic version (sildenafil) has been sold in Europe since 2013, so we know that it is a viable generic. It also has been for sale in Canada since 2012.

You can actually buy sildenafil now in the U.S, under the name Revatio, which is a drug approved for a lung/heart problem.  It comes in a dose of 20 mg (unlike Viagra which is in doses of 25 mg, 50 mg, or 100mg). The generic version of Revatio has been approved recently by the FDA.

If you are considering buying that generic, you might want to have a conversation with your pharmacist first.

Or, if you are anxious to get generic Viagra pricing, you can order from a legitimate Canadian company, and there are some, but that will be your responsibility to make that contact, and  you will need a prescription.   Your doctor may or may not cooperate with you for that.  And those Canadian companies often take weeks to get your prescription to you by mail, and sometimes their drugs are made in Turkey or India or other places.  That doesn’t mean that those drugs are a problem, but you need to get all the facts.

Be careful ordering on the Internet. The price will be enticing, but only use sites that you know are legitimate; and only those which require a doctor’s prescription.   There are some fraudsters patrolling the Web.  And don’t buy those non-Viagra supplements.  They are useless.

I also want to remind you of the significant side effects and drug interactions that are part of the story. Do not try any of these forms of sildenafil without discussing your treatment in great detail with your physician.

MARISA MONTE:  (She’s from Brazil where the Viagra patent ran out in 2014)

“I know a man ain’t supposed to cry.”

Well, Marisa’s funky intro means that you need at least 30 minutes for sildenafil to take effect, so if you want to surprise someone, be sure to plan ahead.

Marisa Monte.

 

 

 

 

 

 

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By Paul Goldfinger, MD, FACC

As you may know,  blood pressure measurement consists of a top number (systolic) and a bottom number (diastolic.) Both numbers are important, but recent research trials and guidelines have been focusing on the systolic end points. The exact way to express a BP reading is 120/80 mm Hg. But for this article we will just use the number–e.g. 120/80.

Blood pressures are usually taken in the sitting position.  Some doctors ask their patients to sit for 5 minutes before taking a measurement. This will result in a number that is often about 10 points lower than an immediate office reading and may be different than readings obtained at home.

I recommend that all patients with hypertension (“high blood pressure”)  buy a device and keep track of readings at  home.  I suggest an initial reading and then another after 5 minutes.   Keep a written record for your doctor with the measurements, date, time and circumstances  (eg “just had an argument with my spouse”)   Remember that blood pressure readings do vary, so show your physician all your readings when you go for an office visit.

Experts have been disagreeing lately regarding  the “target” systolic  (top) numbers that physicians should aim for when treating older patients  (over age 60) for hypertension  (high blood pressure.)

No one disagrees that treatment should begin for readings over 170, but most physicians will begin therapy for readings averaging over 150/90. Studies show benefits of treatment even for those over age 80.    Doctors will legitimately differ in deciding when to start therapy, depending on the circumstances.   The current treatment  guideline controversies surround the question of how low to go.

The basic concept is that BP control will prevent stroke and cardiac events as well as reduce cardiac mortality rates.  In older individuals, there is a special concern regarding lowering the systolic number too much.

If the BP is caused to be too low, quality of life issues may take center stage including important problems such as fainting, dizziness, cognitive impairment, depression, hip fractures, impotence, and  fatigue.   Sometimes patients will stop their meds due to such reactions. Tell your physician if you suspect side effects.

There are a variety of  drugs that doctors use to treat hypertension and they are often utilized in combination.  If you doctor wants to use beta blockers, keep in mind that this class of drugs may not be as effective for prevention as others and may be associated with significant side effects.*

One recent discovery is that statin drugs, added to anti-hypertensive drug therapy, will improve the prognosis regardless of LDL (“bad”) cholesterol levels.

The JNC 8 (Joint National Committee) guidelines came in 2013,  after not revising the recommendations for over 10 years.   They decided to lighten up on their target systolic reading concluding that up to 150  was OK for “seniors” instead of the prior goal of 140.

But some experts would prefer to see the pressure lowered to below 140,  and even to 130 if tolerated by the patient, especially if the patient is at higher risk, such as diabetics and those with prior stroke, TIA, known heart disease or significant risk factors.

Another recent trial called Sprint advocated a target below 120 for patients 75 and older. The study found that patients with a target of 120 did better than those with 140, but that study was criticized on procedural grounds, and that goal could be risky in older patients who run a significant risk of side effects with such low readings.  Even 130  may be associated with problems. The doctor has to be very careful when aiming for those aggressive targets.

So what is the physician to do given all these disagreements?    The answer is to be knowledgeable regarding research  trials and  official guidelines, but to decide each case individually.

Dr Franz Messerli , a BP specialist and Clinical Professor of Medicine at Columbia U. School of Medicine is quoted on Medscape Cardiology  2/28/17.:    “After JNC 7, it took 11 years to get one more set of guidelines. Now we have six or seven, and they all tell a different story. It has become very confusing to the practicing clinician.

The patient in front of you never quite conforms to the patient in the trial or to the patients from whom the evidence was derived for the latest guidelines. Despite all the guidelines, you still have to be a doctor, and you have to individualize therapy and continue to learn.

Dr. Messerli concluded by saying, “Most physicians know that guidelines are more for lawyers than for doctors.”

*Prof. Messerli:  “Despite lowering blood pressure, there is no— and I repeat, no—evidence that beta-blockers reduce heart attack, stroke, or death in hypertensive patients ≥ 60 years. Ironclad evidence has been put forward that beta-blockers are not acceptable antihypertensive drugs in this age group.”  

Here is an important link from our series on treating hypertension. It is from 2013.  You can read our other posts in that series by typing “hypertension” into our search bar (above).

https://blogfinger.net/2013/12/23/confessions-of-a-high-blood-pressure-doctor-part-ii-controversy-emerges-regarding-the-jnc8-practice-guidelines-for-hypertension/

 

 

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'Have a seat, the doctor will be with you in two hours.

“Have a seat, the doctor will be with you in two hours.”      Blogfinger.net photo. February, 2017.  By Paul Goldfinger ©

By Paul Goldfinger, MD, FACC

In many ways, our healthcare system is better than ever, and that is largely due to advances in medicine on the part of physicians partnering with new amazing technologies. More cancer victims are surviving and for longer times —–some are being cured while others are being stabilized.  HIV has become a chronic disease, and our hospitals produce miracles on a daily basis.

There is no question that the ACA  (Affordable Care Act) has resulted in many benefits, including, as we have been reporting, the greater availability of treatment for addicts and guaranteed insurance coverage despite pre-existing illnesses.  There also is the option to keep grown children, up to age 26, on a family’s plan.

The American healthcare system, workers and facilities, often produces remarkable high quality care.

However, despite certain advantages, the ACA is flawed in a variety of ways, including rising costs and inconsistent quality and will likely be replaced or changed in the future.

One important  element in the equation  is that more people than ever before have obtained health insurance, bolstered by government subsidies.  Supposedly the number is 20 million more who have insurance thanks to the ACA. Medicaid has also been expanded across the country, but these rising numbers stress a system which already is over-burdened and short-staffed, and this effect will diminish quality unless the issues are addressed.

The marketplace for insurance availability is too narrow and needs to be widened to bring down runaway costs and increase consumer choices. One factor that increases cost is that the ACA requires too many mandatory clinical elements  (one-size-fits-all), many of which are not necessary in certain instances.

People should be able to design a plan that suits their needs. And they should be able to band together to shop for group prices across state lines.  One idea is to “de-link” insurance coverage from employer mandates. This will create more options for consumers.

From a physician’s point of view, the arm twisting created by the ACA makes life more difficult for doctors and secondarily for their patients. On Blogfinger we have been especially interested in the quality of the doctor-patient relationship.

Here, for example, is a quote from Medscape Cardiology:   

“During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR  (electronic health records)  and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work.

“The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.

“Two hours of documentation at the office for every hour of face-to-face patient time, plus the additional couple hours at night, are ample fuel to add to the burnout fire which increasingly consumes our profession.”

The huge numbers of additional patients with insurance are causing excessive pressure on physicians who lately often pedal too fast and delegate too much.

Currently,  on a day to day basis, patients often run into sour notes.  For example a person with a problem might have to wait months to see a  specialist or have a particular surgery. If they feel ill, physicians may refuse to see them due to crowded schedules, and patients are then sent to emergency rooms when such an ordeal could  be avoided.

Many doctors have become employees, and managers with no medical training sometimes get in the way of the traditional doctor-patient relationships.

Physician offices are potential  trouble spots where carelessness and poor communication may  cause quality of care to diminish. It is often  difficult to get a doctor on the phone because their offices  have erected barriers to that happening.

Poorly trained desk jockies answer the phone and stumble as they try to deal with medical issues.  This places the patient at risk of serious mistakes.     True medical personnel such as nurses should be manning points of triage for patients.   Evidently the new style of corporate healthcare management is placing  too much emphasis on efficiency and cost cutting, and quality medical care doesn’t always lend itself to such an approach.

As our government tries to sort out the wheat from the chaff, let’s hope that they keep the patient at the top of the priority list and the doctors in charge of medical care.

HAYLEY WESTENRA   from Celtic Treasures

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3-d portrayal of the H3N2 influenza A virus.    CDC

3-d portrayal of the H3N2 influenza A virus. CDC

The NBC Nightly News (1/6, )  briefly reported that the Centers for Disease Control and Prevention “says this [flu] season is worse than last,” with “more than 10,000 cases reported nationwide.” Physicians are saying, however, that the “flu shot is a good match for this year’s dominant strain and it’s not too late to get one.”
USA Today (1/6) reported that federal epidemiologist Lynnette Brammer said “while it’s too early to tell if the annual flu vaccine is effective, it closely matches the strains of flu commonly in circulation, which suggests it will be effective.”
Meanwhile, the Washington Post (1/7) said that according to the recent CDC report, “only 2 out of 5 Americans have received the shot so far this flu season.”

NJ.com :    During the closing week of 2016, Monmouth County had the most number of positive flu tests, followed by Essex, Bergen, and Ocean counties.

Blogfinger medical commentary.  Paul Goldfinger, MD:

Monmouth County has been among the most seriously affected in New Jersey with the flu.  The virus which is responsible, the H2N3 strain of Influenza A ,is the same as the strain which caused many people in 2014 to get so ill.  Now the flu attacks tend to be more severe and more sustained.  The peak season is December through February, and there is still time to get the vaccine.  The most severely affected tend to be the very young and the very old.

The demand for the vaccine is quite high now, and everyone, all ages,  should get it unless there is some specific reason not to (such as egg allergies.)

 

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Getting back to basics…Medicine 101

By Paul Goldfinger, MD, FACC.  Dean of the Blogfinger Off-Shore School of Medicine in Ocean Grove, NJ.

She was a tall, thin blond, 22 years old, from East Germany.  She had long graceful legs and she was a good looker.  But she was more than just that; she was an international elite high jumper and she was exhausted.  Beside muscle weakness, she had leg cramps and she had passed out a few times.

I admitted her to the internal medicine teaching service at Mt. Sinai Hospital, located on the upper east side of Manhattan, facing Central Park. The year was 1967 and I, a first year medical resident, was struggling to come up with a diagnosis.

She seemed perfectly healthy. Her history was unrevealing, and her physical examination was unremarkable. Doctors like to say “unremarkable” for normal,  but she was anything but unremarkable. She denied taking any drugs, being on a crazy diet  or vomiting to lose weight.  We ran tests on her, and there was only one salient abnormality:  her blood potassium level was very low.  In other words, she was hypokalemic.

The second year resident,  the chief resident, and the attending physician could not figure out the cause of her electrolyte disorder.  “Electrolyte” refers to the minerals in the blood such as sodium, potassium, chloride and calcium.  We ruled out kidney disease and metabolic problems.

Dr. Solomon Berson, the Chief of the Department of Medicine, said that he would order an experimental serum insulin level from his lab—a test that would eventually win the Nobel Prize in Medicine.  But that didn’t help either.

Finally I decided to go back to basics and take another history.  It’s like those cop shows when they keep interrogating the suspect until something squeaks out to solve the case. In the 1960’s, a great deal of emphasis was placed on talking to patients, because our testing methods were so primitive compared to today’s.

It seemed that we would have to lower the talking bar for this high jumper. We discussed her life and her habits.  Finally the truth popped out:  she was a secret user of thiazide diuretics.  It wasn’t clear why she was doing that. She didn’t know that diuretics cause your body to be depleted of potassium.  We took away the diuretics, and she was cured.

Next stop was the psychiatry department.  Meanwhile I got a case report out of it in the Mt. Sinai Journal of Medicine plus a bit of notoriety there which lasted about two days.

History taking is becoming a lost art. Electronic medical records encourage doctors to use checklists, and often the history is obtained by a medical assistant or “physician extender.”  There is an old saying in the profession: “Listen to the patient; he is telling you the diagnosis.”  The great Sir William Osler, one of the founders of the Johns Hopkins Hospital, is credited with those words of wisdom.

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