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Mt. Sinai Hospital 1985. Upper East Side.

Mt. Sinai Hospital early 1900’s. Upper East Side.

By Paul Goldfinger, MD, FACC  (original post 2015.)

Charles K. Friedberg was Clinical Professor of Medicine at the Mt. Sinai Hospital and School of Medicine in New York City during the 1960’s until his death in a car accident in 1972. He was also the most famous cardiologist in the world, being the sole author of Diseases of the Heart, the “bible” of cardiology—–a textbook of over 1,000 pages that was translated into 6 languages.

Charles K. Friedberg, MD

Charles K. Friedberg, MD  Paul Goldfinger photo  ©

He was the Chief of the Cardiology Department at “Sinai” when I took my cardiology residency there. Dr. Friedberg was famous not only as an author, scholar, editor, researcher and teacher, but also as a brilliant clinician, so it was a great privilege to make rounds with him at the hospital.

In 1985, Nanette Wenger, MD, from  Emory University School of Medicine, who trained under Dr. Friedberg, wrote a tribute to him and said, “Author of the classic textbook of cardiology, Diseases of the Heart, his knowledge was encyclopedic; and his eloquence in describing and his skills in analyzing, organizing, and categorizing clinical cardiac problems remain unparalleled.”

“CKF” was the man to see if a patient had a problem that no one could solve.   Many of his patients were captains of industry and celebrities, but they all deferred to him as they lay in their hospital beds, literally looking up to him. I recall rounding on Gus Levy, the president of the New York Stock Exchange, and seeing this extraordinarily important man chatting amiably with Dr. F. and basically adopting a “Yes, sir” attitude.     I recall rounding with him on Pearl Bailey, Frank Sinatra’s father, and many New York titans. 

But he wasn’t mainly a doctor to the stars. He rounded on the “teaching service” regularly to help the residents with their toughest cases. He always stressed talking to the patient and taking a careful history, a talent that is in danger of evaporating these days. He would walk into the room, pull up a chair and sit next to the head of the bed to have an intimate conversation with the patient, while the house staff, med students and nurses crowded around at the foot.

One time he asked me to accompany him; he was giving a lecture at St. Vincent’s Hospital in lower Manhattan. A “car” picked us up, and when we arrived, I walked into the auditorium of this Catholic hospital with him. There were nuns around and crosses on the walls.   I was wearing my “whites” and on the jacket sleeve was the red Mt. Sinai emblem, complete with Hebrew writing. It was a bit ironic, and I felt like I was accompanying a great rabbi on a Papal visit.

At Mt. Sinai, a hospital created in 1852 to provide healthcare for immigrant Jews, the medical staff was mostly Jewish, although there were many exceptions. Jim Dove was a very Waspish kind of guy, but he went out of his way to become a resident there, and the other residents would always kid him about it. Jim eventually became president of the American College of Cardiology.

I loved the jokes and the cultural references that were quite a change for me, coming from a med school where there were more Mormons than Jews. Both our sons were born at Sinai, and Eileen had a room in the “private” Guggenheim Pavilion where they gave her lobster. She didn’t want to leave.

Charles Friedberg, MD was from an era when creative doctors at medical centers could do research and teaching, while still maintaining a private practice. It was hard to imagine how he found the time to write his book all by himself, and we used to speculate who might have secretly helped him, but we never could prove the point.

One time he invited all the attendings and residents (and spouses)  from the Cardiology Dept. to his elegant Fifth Avenue apartment which was spacious and grand. It had many rooms and even its own elevator. He and his wife were gracious hosts, and his library had a row of his books in multiple editions and in multiple languages.

It was the art of medicine that distinguished Dr. Friedberg’s  approach to patient care—something that you can’t get from a text book or a medical journal, and despite today’s emphasis on practice guidelines, physician assistants, controlled trials, and electronic medical records, doctors will not be as effective if they lose that special doctor-patient connection that has been handed down from Hippocrates to teachers like Dr. Friedberg. Let’s hope that the upstarts who are taking over healthcare get to appreciate that point.

ADDENDUM:   Woody in Hannah and her Sisters gets cured of a brain tumor at Mt. Sinai Hospital.

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newest-ama

Good Morning Dr. Paul Goldfinger. Here are today’s top stories. Friday, September 23, 2016.

 

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The CBS News (9/22) website reports that “falls are the number one cause of fatal and nonfatal injuries among adults over 65,” researchers concluded in a report published in the CDC’s Morbidity and Mortality Weekly Report.

The report found that “in 2014, older Americans fell 29 million times, leading to seven million injuries” that sometimes landed people in the emergency department. Unfortunately, “more than 27,000 falls led to death.”

In a press statement, CDC Director Tom Frieden, MD, MPH, said, “Older adult falls are increasing and, sadly, often herald the end of independence.” Dr. Frieden went on to emphasize that falls can be prevented.

Below is the  link to the excellent CBS News article on this subject.

www.cbsnews.com/news/falls-leading-cause-of-injury-and-death-among-older-americans/

Blogfinger medical commentary by Paul Goldfinger, MD, FACC:

These stats are impressive, and the article describes certain elements that we might not ordinarily think of.  Once someone falls, there are a variety of variables that need to be evaluated in order to prevent more falls.   For example, is the patient keeping his falls secret for fear of losing independence? Family members must think of this if, for example, bruises are seen or balance problems noticed.

Falls can be minor or terrifyingly dangerous.  Falling down even a few steps can result in horrible injuries. And that damage can be made worse by coexisting factors such as chronic therapy with blood thinners, causing traumatic bleeding to be worse than expected.

Don’t forget the need to have an “I fell down and can’t get up” button around the patients neck. I had a patient who fell and got wedged between the toilet and the bathtub, and she could not reach a phone; luckily a friend came by to pick her up for her regular card game.   And how about a cell phone to be worn in a holster all the time? There are exercises to improve balance, and make sure to check the lighting in the house.

Head injuries can be deceptive, and, if one occurs, an ER visit and then subsequent observation are essential.

Some of the prevention  factors include safe footwear, regular eye exams,  and getting rid of throw rugs.

If a senior gets in a car accident, don’t allow him/her to just go home and rest.  Always take them to the hospital to be checked. And if they do go home make sure that someone provides oversight to look for emerging signs of trouble.

As we have pointed out in our BF articles, seniors are often on multiple medications, and those may be overdosed, mixed up,causing side effects, or interacting with each other. The end result might be a fall, due to dizziness or a drop in blood pressure. There are other medical issues, such as cardiac rhythm disturbances, that could cause falling, so if someone falls, have them checked even if there is no obvious injury and be sure to have his medication list reviewed—-bring all the meds with you.

We have also reported on drug dependency in seniors, and that might be a factor.

For some seniors, they tend to rush around, and that can cause quick turns and loss of balance.   My mother was like that, so I stuck a big sign on her fridge:  “Slow Down.”  Of course, she gave it back to me by saying, “You talk too fast and not loud enough.”    She used to say, “Stop mumbling.”  At least she didn’t put any signs on our fridge.

The psycho-social issues resulting from falling are very important as well.  Patients sometimes lie about what happened in order to avoid unpleasant consequences such as  neurologic findings which could result in loss of a driving license and thus loss of freedom.  A neurologist might pick up a problem with peripheral vision which could result in a car accident.

Families of elderly patients must be vigilant.

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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.

The latest development, currently  being perfected is that of wireless pacemakers, meaning no wires into the heart.  This will revolutionize the field since about 250,000 permanent pacemakers are placed yearly in the US, and about 750,000 around the world.

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

Editor’s note  10/30/20:  Thanks to Dr. Eran Zacks, FACC, FHRS   (Fellow  Heart Rhythm Society) of Monmouth Cardiology for updating us on new rhythm monitoring techniques and wireless pacemakers.

 

THE TIMETONES

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OG boards. May 31, 2020. This is a Sunday morning,  and board walking is OK.  If you walk on the beach on Sunday morning, no one will stop you.   Paul Goldfinger photograph. ©

 

 

Blogfinger Medical Report.   Paul Goldfinger, MD, FACC.

This  headline* is from Reuters Health covering the opinions of some Canadian professors in an article in the Annals of Internal Medicine.  They said, ” While there is no direct evidence yet that cloth masks can reduce  SARS-CoV-2 transmission, the collective evidence indicating that mask wearing by infected people reduces contamination is convincing and should inform policy.”

They say that “there is ample evidence that the masks can prevent infected droplets from getting into the air or onto surfaces.”

The article  said, “There was also evidence, though not as strong, that cloth masks might protect wearers as well.”

A professor in the trial,  Dr. Catherine Clase, from the McMaster University in Ontario, said, “While the evidence shows that masks can help, they are no substitute for social distancing and handwashing but should be used along with those measures.”

Dr. Supratik Guha, Professor at the Pritzker School of Molecular Engineering  from the University of Chicago said, “I have been stressing that simple reasoning and evidence indicates that the use of a decent cloth mask in indoor or use public places will reduce infection transmission.  If most of the population practices this, the multiplicative benefits can be enormous in reduction overall infection rates within a community.”

CDC says:    “A cloth face covering should be worn whenever people are in a community setting, especially in situations where you may be near people. These settings include grocery stores and pharmacies. These face coverings are not a substitute for social distancing. Cloth face coverings are especially important to wear in public in areas of widespread COVID-19 illness.

 

Blogfinger commentary: By Paul Goldfinger, MD.   I have observed a significant lack of compliance outdoors in Ocean Grove;  probably because people are not sure that the invisible terror will be eliminated by mask practices, and there is some confusion regarding when and how to make use of masks.

Official guidelines by the Camp Meeting Association of Ocean Grove are evasive and unconvincing.  They say on their web site:  “Wearing masks is strongly encouraged.”

So, to practice masking, one needs some faith in the scientific guidelines, such as they are.  I have always tried to practice evidence-based medicine, but the science here isn’t so clear,  and maybe we need to believe somewhat in good judgement and even in magic.

I am not convinced that we should wear masks if we are outdoors in open spaces where we can stay away from others or when alone in our cars.     But keep in mind that this virus spreads by human to human contact, so you can use some common sense in this regard and judge your situation by that principle and analyze your own environment.

We know that the virus can, under certain circumstances, infect the air we breathe originating in coughing, sneezing and even talking.

So don’t take unnecessary chances.  If there is any possibility that human to human contact might occur in any situation, then put on a mask.

The two ladies walking side by side wore masks, but they could have been somewhat more apart.  If I were walking alone there, I  would be tempted to  wear no  mask, as many were not doing, but I would surely weave my way around any humans walking or biking towards me.

If you don’t wear a mask outside, at least carry one, just in case.

Best choice:  wear the mask on the boards.  The beach will be a more difficult decision.

And don’t forget to wash your masks.

 

ALY AND AJ. “Into the Rush:”

 

 

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Food Store in a strip mall in Ft. Myers, Fla. Blogfinger photo. ©

 

By Paul Goldfinger, MD.  Signs of the Times Editor.  Blogfinger.net

In the past, convenience stores offered a minimum amount of ready-to-eat  food.   Most of their edibles were  pre-packaged like bagels or buttered rolls. But lately, such stores have been selling hot foods like pizza, cooked eggs, and certain sandwiches.  And now they are promoting  “hand crafted fresh subs,” as seen above in Florida .

A Grover I know loves to go the the 7-11 outside the Grove “gates.” He says that they create good sandwiches for a few dollars.  He also enjoys going to the Pathway Market where they have an actual cook on-site making a variety of hot and cold selections.  He says that their “fresh”  foods are quite good.

“Fresh” food is dictionary-defined as  “food that is not preserved by canning or dehydration or freezing or smoking.”    So spoiled food can be considered “fresh?”  They also promote  “fresh breakfast” to go.  What is a “fresh breakfast?”

Maybe they need to say “subs and breakfast made to order.”  That way they avoid the confusing “fresh” word.  And let the buyer beware.

And since when does one “hand craft” a sandwich?   Were they machine made before?

Once again we see abuse of language by businesses trying to turn something ordinary into something extraordinary by the word usage on their signs.  So, what do they mean by “fresh?”

Stores like this used to be called   “convenience stores,”  but now they are “food stores.”  But of the “fresh” foods, how are they defining “fresh?”

If  they made the potato salad that morning can you call it fresh 8 hours later?  24 hours later?    Can they call it “fresh made” if it’s still in the cooler the next day?  Are they labeling such items with dates?

These stores are just convenience stores with a microwave and a willingness to make sandwiches to order.  Can we trust them for freshness?  Who is protecting the public?

Wegmans brings in”fresh” fish daily..  They will keep it overnight one night and then dispose of it the next day if it doesn’t sell by the end of that day.  If the fish was caught the day before it arrives on ice, then it is one day old when Wegmans gets it.  Maybe they should label their fish as “one day old” or  “two days old.”  Their sushi is never kept over-night.  And they never say “fresh sushi.”  A store like Wegmans is meticulous regarding freshness, but the public needs to be informed about freshness at all food stores.

Typically, when it comes to sea food, unfrozen fish is called “fresh.”  And frozen fish when it is defrosted is called “what?”    “Defrosted?”  Public needs to know.  If there are no signs to clarify, ask some questions.  Be careful where you buy “fresh” foods.

I heard that Japanese tuna fisherman slice off a piece of sushi grade meat as soon as the fish flops on the deck.  I would say that that is definitely “fresh.”

But, for those who have limited funds, disabilities, and no cars, these sorts of food stores provide some appreciated sustenance, so the Township needs to protect such citizens.

However,  since we do not have a clear definition of “fresh” whoever uses that word needs to find something more precise to say.  Hopefully the Township is keeping an eye on convenience stores who are self-proclaimed purveyors of “fresh” food.

 

 

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Internet graphic.

 

Interestingly, the latest recommendations for in-office readings suggest electronic devices for more accuracy rather than this type or mercury machines.

 

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

 

Blogfinger has  reported on diagnostic and treatment guidelines for systemic hypertension. (“High blood pressure”).

In 2017, the American Heart Association and the American College of Cardiology came out with new parameters.   They reported that the diagnostic cutoff had been reduced from the long-time standard of 140/90 down to 130/80.  That means that the diagnosis of hypertension would be made if one’s blood pressure stabilized at over 130/80.

There remains controversy over these guidelines, plus there are many variations on the theme, such as when to start drug therapy, factoring in age,  and how to judge success.

The stakes are high,  because so many have this diagnosis, and hypertension poses an increased risk of a variety of complications including coronary heart disease, congestive heart failure, stroke, peripheral vascular disease, kidney failure, and mortality.

Most of the time if the top number (systolic) is high, then the bottom number (diastolic) is often elevated as well.   Doctors have usually focused their attention on the systolic readings, but now, because the normal diastolic cutoff is above 80 instead of 90, physicians are more likely to be concerned about the diastolic as well because more people will carry the diagnosis of diastolic hypertension.

A small percent of patients have “isolated diastolic hypertension”  (high diastolic—over 80 mmHg; normal systolic–less than 130 mm Hg,)  but there is some controversy as to the risk of those diastolic elevations.  Using the new criteria, it is estimated that 6.5% of the population have this issue.

In general, it has been felt that isolated diastolic hypertension is harmless. But there are few long term clinical trials looking at this.

William McEvoy is professor of preventive cardiology at the National University of Ireland and he said in an interview with Medscape, “Our data suggest that there is no harm of having a diastolic pressure above 80 mm Hg if the systolic is below 130 mmHg and that the new 80 mmHg diastolic threshold means that 12 million adults in the US will be labeled as hypertensive but will not benefit from the diagnosis and may be given unnecessary treatment.”

In another quote he said, “If an individual has normal systolic blood pressure (less than 130 according to new guidelines,)  our data suggest that it doesn’t really matter what the diastolic blood pressure is.”

But Paul Whelton, MD, chair of the 2017 AA/AHA guideline committee said he agreed that systolic pressure is the more important measure for predicting cardiovascular risk and for making drug treatment decisions. But he felt that a diastolic of over 90 should be treated, especially in high risk patients such as those with prior cardiovascular disease.

I saw my own eminent cardiologist recently. I brought my record of home readings for his review, and he noticed that my systolic was fine at 110-120 but he raised his eyebrows above the top edge of his computer screen when he saw that my diastolic readings were 80-85.  He was reacting to the new guidelines for diastolic pressure, but he could not bring himself to raise my anti-hypertensive drug dosing.

His decision was totally correct, independent of my opinion,  since trying to lower that number could produce some unpleasant side effects, and, as noted above, the evidence for his changing my treatment for this is simply not compelling enough.  And the best doctors react to more than just numbers.

Here is a link to our 2019 review of new guidelines and related topics:

BF guideline review for hypertension. March, 2019.

If you check our search box. (above right) you can find our recent 4-part series “Confessions of a High Blood Pressure Doctor”

 

BOB DYLAN: A musical tribute for those doctors and researchers who maintain normal blood pressures to the brain and prevent strokes:

 

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anatomy jpg

 

Dysfunction of the lower esophageal sphincter can cause GERD. Internet graphic.

By Paul Goldfinger, MD, FACC

Most people get “heartburn” at least once in while.  Some get it often and  have significant problems with it.  The term refers to a form of indigestion where acid stomach contents regurgitate  (reflux) back from the stomach into the esophagus and/or throat.

GERD means “gastroesophageal reflux disease,” and regardless of the cause, it usually  results in chest and/or throat burning (“heartburn.”)

The term “heartburn” is an oxymoron, because this complaint has nothing to do with the heart.   The Italians call it “agita.”  And both words can have broader meanings such as the way Nora Ephron named her novel about a broken marriage, “Heartburn,” and  “agita” can mean a broad sense of upset.

“Heartburn” is a general term for that burning, but there are a variety of specific causes and/or triggers which have the same end result.  On the other hand, reflux can occur with symptoms other than heartburn.

Ordinarily, swallowed food (solid or liquid)  heads south to enter the esophagus from the throat.  It passes a muscular sphincter at the top of the esophagus (the upper esophageal sphincter) then moves through the esophageal tube to the open lower esophageal sphincter to enter the stomach. Then the sphincter closes to prevent regurgitation back into the esophagus from the stomach.

If the lower esophageal sphincter re-opens (relaxes) when it shouldn’t, acid fluid and partially digested food can go back into the esophagus—a process called gastroesophageal reflux, or GERD.  Acid in the esophagus can be propelled all the way north to enter the throat area.

That acid, which is manufactured by the stomach, can irritate and damage the lining of the esophagus, can irritate the throat,  and can upset the delicate balances which control swallowing in the throat.

If the stomach pushes its upper portion past the diaphragm into the chest, it is called a hiatus hernia which can cause GERD.

hiatus hernia

The result of GERD may be heartburn, but it may not cause that classic complaint while instead causing throat symptoms such as sore throat, chronic throat irritation (causing recurrent clearing of the throat,) recurrent cough and/or asthma, and other throat complaints including the sense of something “stuck” there, a “lump” in the throat,  mucus in the throat, and swallowing problems.

These throat problems might warrant a sub-diagnosis of GERD called”laryngopharyngeal reflux.” There is debate about the exact nature of this diagnosis. Ask your doctor about it—ENT or GI.

Many people are walking around with such varied throat symptoms who never get the proper diagnosis and curative therapy.

GERD may occur only at night, and that is very worrisome if it is frequent.  Nighttime acid damage to the esophagus lining can lead to permanent tissue injury and even cancer, and infected acid can be sucked into the lungs—aspiration.   Also, nighttime symptoms can result in serious sleep disorders.

There are many factors which can cause or trigger GERD and all its symptoms and complications:  Throat disorders such as thickening of throat muscles, dysfunction of upper and/or lower esophageal sphincters, esophageal disorders such as out-pouches called diverticuli, over-weight, pregnancy, lying flat in bed, overeating, going to bed too soon after dinner (allow 3-4 hours,) straining with constipation,  pressure on the abdomen as with tight clothing, eating the wrong foods (eg fried, fatty, onions, coffee, tea, spices, citrus, mint, tomato based, and chocolate among others).  Caffeine, alcohol, smoking and stress may also be factors.

In any given patient, one or more of these factors may be important.  Patients should pay attention to their individual symptom profile and write them down for review with a doctor.

For many, GERD is infrequent and easily treated even without medication. Certain life style changes may be all that’s needed.  If needed, there are medications and there are even some invasive/surgical approaches.

GERD/heartburn is a complicated subject, and if you go to a doctor because of recurrent symptoms,  he should consider it as a potentially complex situation.    If he does not,  see a gastroenterologist to be sure that nothing is being missed. Specialized tests may be needed.

Sometimes heart problems can be confused with GERD, so a cardiologist may be involved.  Also there is sometimes overlap with ENT and pulmonology.

GERD is becoming a sub-specialty of its own–let’s call them esophagologists.

Treatment:  In Part II we will discuss diagnosis and treatment.  Suffice it to say that new therapeutic approaches are now available, so most patients don’t need to suffer with GERD.

 

DIONNE WARWICK. “Alfie”. by Burt Bacharach for the movie.

 

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Unknown-1

 

Paul Goldfinger, MD, FACC.  Editor@Blogfinger.net.

In the 2011 edition of our book* on preventing heart disease, we have a section on particular foods such as nuts, chocolate, red wine, tea, coffee, salt, and eggs. Regarding the latter, this what we said then:

“The egg industry says that eating eggs is healthy, because eggs contain no fat and do not raise cholesterol blood levels. The American Heart Association disagrees, pointing out that each egg yolk contains 185 mg of cholesterol, and research trials have shown that eating cholesterol promotes heart disease, even if the cholesterol levels do not rise (Nutrition Action Healthletter, July 1997.)

“According to Jeremiah Stamler, a world expert on prevention, eggs do raise total and bad (LDL) cholesterol levels.”

“The AHA recommends that individuals eat no more than four egg yolks per week.  They also say that we should eat no more than 300 mg. of cholesterol from all sources each day.  Other experts advocate reducing egg intake to only one or two eggs per week (JAMA 4/21/99)”

In the 1990’s, at Dover General Medical Center (NJ) where I worked, one of our gastroenterologists, who was a gentleman egg farmer, loudly asserted that eggs posed no risks despite their cholesterol content. He stressed that eggs have no fats in them, so he brought eggs to the hospital frequently, peddling them in the coronary care unit.

Then in 2013, the British Medical Journal came up with a study that found no risk with one egg per day.  So the pendulum was swinging.

Now, in the Journal of the American Medical Association, an impressive study appears looking at 30,000 individuals over 17 years.  They found that there was an increased risk of death, stroke and cardiovascular diseases associated with eating eggs.  They suggested that eating even 3-4 eggs per week is bad.  But the study is subject to criticism of its methodology.

I can conclude that our egg intake should be limited to some extent, perhaps no more than 4 per week, but the verdict is still not in despite this JAMA article which looked at a large number of people and their dietary habits and heart disease risks.

Here is a link to a prior  (2016)related post on Blogfinger, and in that post is another link.

eggs and health 2016

And here is an excellent short video from a physician at McGill University.  This doctor is brilliant in his assessment of the situation:

CAST OF OLIVER:

 

* prevention-does-work

 

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American sponsors of the 2017 hypertension guidelines.

 

By Paul Goldfinger, MD, FACC  and Editor  @Blogfinger.net

Part III: Who Cares?

Almost all doctors believe in treating hypertension, but how many will be enthused about following the new guidelines?  We’re talking about the American Heart Association/ American College of Cardiology 2017 guidelines for the diagnosis and treatment of high blood pressure.

If you were a doctor, would you spend hours going through piles of hypertension guidelines, looking at all the intricate details, and trying to resolve the controversies? Or would you just do whatever it is that you normally do to treat the most common cause of death in the US ?

And even if a physician were trying to wade into the weeds and trying to figure all this out, he might emerge confused, because in the end, he will have to use his best judgement. Guidelines are supposed to provide consistency not controversy.  But when it comes to hypertension, knowledge has been evolving since the 19th century when a device to measure blood pressure was invented.

I have hypertension and I keep my finger on the pulse of advances in cardiology. My own cardiologist is an eminent and respected doctor in this area. But he is fairly conservative, and when I press him about the new guidelines, he usually falls back on his own judgement which doesn’t try to push too hard on drugs. Last time I saw him, it appeared that he was beginning to adopt the new American guidelines, yet he didn’t change my treatment, although he might have. He was going to take his time figuring out how to use the new guidelines.

But my biggest concern is that not only will physicians pay little attention to the guidelines, but probably half of their patients with high blood pressure are not under good control.

However, in the new world of medical practice in America, we have new ways to practice, and that involves mid-level practitioners such as physician assistants and nurse practitioners. Also we have electronic medical records and fabulous new technologies to help accomplish our goals. And there is a welcomed trend to use home BP measurements to guide diagnosis and treatment.

The new corporate style of practice involves a team approach to try and improve the track record in hypertension. And when a patient is put into the hands of such “teams,” those teams will be forced to use the latest guidelines, taking it out of the hands of doctors.

And we know that perhaps up to 800 entities such as the Mayo Clinic, the Cleveland Clinic, Summit Medical Group, Monmouth Cardiology, etc. across the country have already established this new approach, and more will jump on the bandwagon.

Then, it is hoped that the success rates of hypertension care will become much better. But I am also suspicious of corporate motives in such circumstances. Insurance companies, healthcare entities, and Big Pharma are interested in this topic.

I am skeptical of turning over the care of our patients to corporate managers, mid-level teams, and one-size-fits-all algorithms. It is a recipe for reduced quality of care, failure to properly evaluate patients, and higher risk of complications.

I would be more enthused if the system were returned to the control of physicians.

So, having expressed that concern, we will proceed with the nitty-gritty of providing successful care for the millions of hypertensives in America. Watch for Part IV.

 

DIANA KRALL  from her album Turn Up the Quiet

 

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Reuters reports that a study suggests “more babies could be born with heart defects in the future as global warming puts pregnant women at greater risk of exposure to dangerously high temperatures.”   Currently, “congenital heart defects affect about 40,000 births per year.” The research was published in the Journal of the American Heart Association.

From the authors of the study:   “The burden of congenital heart defects (CHD) across the United States may increase as a result of climate change.” 

“As global temperatures continue to rise, more intense, frequent, and longer‐lasting heat events are expected.12 Significant gaps remain in understanding the potential impact of climate change on maternal heat exposures and the associated CHD burden.”

“In conclusion, our findings reveal a potential nationwide increase in future maternal heat exposure in the United States.”

 

Dr. Dianne Atkins, Professor of Pediatrics at the University of Iowa in Iowa City, cautions that “the data from the study is preliminary and is based only on estimates.”

“We cannot be certain that heat exposure will increase the risk of congenital heart disease, but it would be prudent for women to avoid becoming overheated during the early weeks of pregnancy,” Atkins, who was not involved in the study, told Reuters Health by email.

 

The author of this paper, not an MD, is a Professor of Public Health at the University of Albany, and he concluded by saying, “Although this study is preliminary, it would be prudent for women in the early weeks of pregnancy to avoid heat extremes similar to the advice given to persons with cardiovascular and pulmonary disease during heat spells.”

Blogfinger medical commentary:   Paul Goldfinger, MD, FACC

This “research” is mostly speculation, not science.  The American Heart Association published this study in their Journal of the American Heart Association.  Nothing here is certain including the projections due to global warming. I’m surprised they accepted this paper without an editorial explaining their decision. 

A medical journal like this one should be a holy temple of medical science and not a place to camouflage speculation and political correctness as health science.  This paper belongs in a journal of public health or environmental science where torturing statistics and speculation might be more at home.

There is no doubt that excessively high temperatures should be avoided by pregnant women, but the same is true for patients with heart disease, lung disease, and any  elderly person.  As for global warming, that topic should have been barely mentioned and not emphasized.

The AHA should keep its focus on clinical medicine and what can be done to help physicians keep our people safe through evidence based research.

Allowing political correctness to creep into their work is a mistake and will erode the confidence of physicians and patients.

 

CRAIG OGDEN   “Cavatina”   from the Deer Hunter

 

 

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