Smarter Medical Care

In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, talks about Coumadin (or Warfarin). The goal is to prevent more clotting wherever it may first have occurred, but to achieve that goal without undue risk of bleeding, Coumadin’s major side effect.  It's critically important that monitoring of the blood be frequent.  Interactions between Coumadin and food as well as medicines can easily increase or decrease the effect of Coumadin on the blood. Dr. Rodvien discusses some of these issues in this introduction to Coumadin.

Dr. Jeffrey Sternberg, a colorectal surgeon, discusses abdominal surgery, and describes how decisions should be made by your surgeon about whether or not laparoscopy can be done for any specific procedure.  A few small incisions allow a camera, lights and instruments to be introduced into the abdomen.  The goal of this type of surgery is the same as traditional or “open” surgery. The technique of the surgery and the results should be the same.  All surgeons being trained today are being trained in both laparoscopic and open procedures. After laparoscopic surgery, recovery often occurs more quickly, hospitalization is usually shorter, and you may have a better cosmetic scar. Sometimes, however, for some surgeries such as removal of parts of the colon, the surgery may take longer when done laparoscopically.  As always, the surgeon needs to know about your other medical conditions and the medicines you take. For example, scars inside the abdomen from prior surgery may make a laparoscopic approach unsafe or unwise. A surgeon needs to be experienced about the procedure he is about to do; conversely, if open surgery is being suggested, ask why.

Dr. Shelley Gordon talks about MRSA, an unusual form of a common bacteria — staphylococci (“staph”) — that has become an increasing source of infections world-wide. “A physician can suspect and prove MRSA to be the cause of an infection by culturing the involved area.  Infections by MRSA can begin inside or outside the hospital, and the treatment may vary depending upon where the infection began.  Both circumstances require different antibiotics. MRSA beginning in the hospital usually do not recur once there is a good response to antibiotics, while MRSA beginning outside the hospital more frequently recur once antibiotics are stopped. If recurrent MRSA is a problem, speak with your physician; there are treatments that can lessen the chances of persistent infection.

Colonoscopy is the medical term to describe the procedure to look inside the lower bowel from the anus, through the rectum, to and then through the large bowel or colon. Dr. Jeffrey Sternberg, a colorectal surgeon at California Pacific Medical Center describes the colonoscopic procedure.  First, he describes the different preparations that are used to clean out the bowel.  He also discusses how to take needed medications before the procedure and why physicians use sedatives to make this test almost always pain-free. You should not drive yourself to or from the doctor's office.  Colonoscopy can decrease markedly your chances of getting this very common cancer.  Colonoscopy also allows cancer of the colon to be found early when cure is more likely.  Colonoscopy allows polyps — growths that can become cancerous in time — to be removed painlessly before they have become cancer. Use of this procedure is expected to change colon cancer from the second commonest cancer to cause death in the United States into a problem that can be prevented and treated earlier.

La mayoría de los pacientes con epilepsia pueden ser tratados por los neurólogos generales o los neurólogos pediátricos. Pero si las crisis continúan después de utilizar por lo menos dos medicamentos, se recomienda que el paciente sea referido a un centro especializado en el tratamiento de la epilepsia para explorar la posibilidad si es que el paciente es candidato para un tratamiento quirúrgico (cirugía) o una dieta especializada llamada ketogenica. En estos centros, se pueden realizar estudios especializados como pruebas genéticas o estudios de imagen como la tomografía por emisión de positrones cuando son indicados. En ocasiones, el monitoreo de las ondas cerebras con videografía se utiliza para establecer que tipo de crisis epiléptica sufre el paciente para determinar cual es el medicamento mas adecuado para ese tipo de crisis. Cuando la gente escucha que alguien tiene epilepsia, existe temor de que esta sea causada por un tumor cerebral. Los tumores cerebrales son causas de la epilepsia pero únicamente el 15% de los pacientes con epilepsia padecen de tumores del cerebro y es muy infrecuente el no poder identificar el tumor si este existe. Por ultimo, es importante notar que en California, el departamento de vehículos motorizados (DMV) suspende los privilegios para conducir un vehiculo por un mínimo de 3 meses después de que una persona sufre de una crisis. Para concluir, la epilepsia es una enfermedad neurológica como cualquier otra enfermedad medica; el tratamiento con medicamentos funciona muy bien para la mayoría de los pacientes y les permite tener una calidad de vida normal; y en algunos pacientes en donde los medicamentos no funcionan como se espera, la cirugía puede resultar en el control de las crisis que se desea.

In this podcast, Dr. Rodvien discusses eight separate steps that can enhance your life while you are actively seeking medical treatment for your illness.  Do things whenever possible for yourself. It's important to be honest with yourself. Plan your days to do more than just be a patient. Maintain your friendships, It's equally important to live for today and build for tomorrow, realizing that there may not be a tomorrow. With regard to your medical needs, you can get a second opinion wherever you want, but get care close to home where there are family and friends. Clearly identify what are realistic goals that you want to achieve. In the long run, this path can make you a happier person.

La mayoría de los pacientes con epilepsia tienen que ser tratados con medicamentos por un espacio de 2 a 5 anos; en ciertos casos, el tratamiento es por el restro de la vida del paciente. El los pacientes que han tenido crisis convulsivas provocadas por fiebre, alguna toxina como el alcohol o por alguna otra causa medica y no neurológica, no se recomienda tratar con medicamentos anticonvulsivantes puesto que estos pacientes no tienen epilepsia. El 10% de los niños (10 de cada 100) puede tener una o mas crisis convulsiva con fiebres altas y estas crisis se denominan crisis febriles. En estos niños, el tratamiento consiste en reducir la fiebre, prevenir la aspiración o el movimiento del vomito hacia los pulmones si es que el niño vomita durante la convulsión, y el atender al medico lo mas pronto posible. En muy pocas ocasiones, las crisis epilépticas son mortales y afortunadamente, el tratamiento medico previene mas crisis y resulta en pocos efectos secundarios. Es importante recalcar que la epilepsia en una enfermedad como cualquier otro problema medico, tal como la presión alta o la diabetes, y que no es el resultado de estar poseído por un espíritu. Aun cuando las crisis pueden ser muy violentas, la mayoría de los pacientes no tienen dolor excepto si la crisis resulta en una caída o un golpe. El tratamiento mas importante de la epilepsia es con medicamentos llamados anticonvulsivantes o antiepilépticos y los antibióticos únicamente se utilizan cuando las crisis epilépticas son el resultado de una infección del cerebro. En pocas ocasiones, la crisis resultan por la deficiencia en una vitamina y el tratamiento en esta situación consiste en suplementar al niño con la vitamina deficiente. Los tratamientos alternativos, tal como el uso de hierbas, es o suplementos alimenticios no es recomendable puesto que en ocasiones estos pueden exacerbar el control de las crisis.

La epilepsia es la enfermedad neurológica que se manifiesta con crisis epilépticas. El 3%, ó 3 de cada 100 personas, padecen de epilepsia. Esta es la tercer enfermedad neurológica mas común puedo comenzar a cualquier edad, pero es mas común antes de los 5 años de edad o después de los 60’s. Estas crisis ocurren cuando existe una descarga eléctrica excesiva en las células del cerebro, resultando en la disrupción de la actividad normal del cerebro y en síntomas neurológicos. Existen diferentes tipos de crisis epilépticas y diferentes formas de epilepsias. Las convulsiones son un tipo de crisis epiléptica en donde la persona pierde el conocimiento, puede caer, tiene movimientos involuntarios violentos de los brazos y piernas y se puede asociar con perdida del control de la orina o con el morderse la lengua. La mayoría de las crisis epilépticas son espontáneas puesto que son la manifestación de un problema neurológico como los tumores o infartos cerebrales. Existen otros tipos de crisis epilépticas, como por ejemplo las que involucran la alteración en la habilidad de mantener contacto con el mundo exterior y donde el paciente esta confuso por un minuto o dos. Este tipo de crisis se denomina crisis parcial compleja. Un tercer tipo de crisis consiste movimientos involuntarios súbitos de uno o varios músculos de las extremidades o el tronco del cuerpo, sin perder el conocimiento, y se denominan crisis mioclonicas. Por lo que el tipo de crisis epiléptica depende de que parte del cerebro esta involucrado por la anormalidad eléctrica. El medico puede llegar a un diagnostico correcto de la epilepsia a través de escuchar cuales son los síntomas y signos que el paciente manifiesta durante la crisis. El electroencefalograma (EEG), o el estudio de la actividad eléctrica del cerebro, ayuda a confirmar el diagnostico. La imagen por resonancia magnética (MRI) es el estudio que mejor ayuda a identificar la causa de la epilepsia. En aproximadamente el 20% de los pacientes con epilepsia, el EEG y/o el MRI pueden ser normales por lo que la historia clínica es lo que mejor ayuda al medico a diagnosticar esta enfermedad.

Dr. Rodvien describes the causes of cancer, discussing interactions of our genetic material that we inherited with the environment that surrounds us. More than one event is needed from each of these large groups in order to produce a cancer. Radiation, viruses and chemicals are the major environmental exposures, and amongst these exposures, tobacco is the single most important cause in part because it is commonly associated with several cancers, avoidable, and because even if it has been used in the past, avoidance now decreases the risk of subsequent cancers. Cancer of the lung is the most well-known of the cancers associated with tobacco but there are others as well. Asbestos is another known cancer-causing substance, and there are a number of viruses that can interact with our genetic material to cause still other cancers. Amongst these viruses, there are viruses that cause hepatitis in many of us and liver cancer in a few of us. There is also a virus we all associate with infectious mononucleosis, and that virus causes or is associated with lymphoma.

Dr. Shelley Gordon discusses changes in HIV since it was first identified in the late 1970s. People are living much longer lives, often free of any symptoms. But some medical problems are becoming more prevalent amongst people with HIV, perhaps because of persistent circulating virus in the blood or perhaps because of some effects of the medicines needed to control the virus.  For example, some of the medicines alter cholesterol levels in the blood. People with HIV need to take their medicines on a daily basis.  Especially when they feel so well, people with HIV need to discuss with their doctor how their  medicines might be causing problems.  The goal in caring for people with chronic HIV is to place the disease and the drugs controlling the disease in the background of their lives, not the foreground.

Dr. Shelley Gordon discusses the ways you can and cannot get HIV.  This virus is transmitted through sex or contact with blood. It is not spread by more casual interactions such as kissing, hugging, or touching tears. So long as there is no active bleeding. washing sheet or towels by someone who is not HIV positive is safe.  HIV is a chronic illness and in that sense it should be approached as you would approach a person with high blood pressure or bronchitis. Frequently HIV is controllable but not curable with medicines.  People with HIV need to take their medicines on a daily basis.  The goal in caring for people with chronic HIV is to place the disease as well as the drugs controlling the disease in the background of their lives, not the foreground.

Dr. Shelley Gordon defines what swine flu is, how common fever and muscle aches are. For example, regular flu and swine flu occur at different times of the year. Like all flu viruses, many more people get “infected” than become sick as the virus spreads in the community.  Blood tests are not always needed if the swine flu has been widespread in your community. Early diagnosis helps you and your neighbors. Then, appropriate medicines can be begun to shorten your illness and decrease the risk that you will spread it to others. However, the best way to “treat” the swine flu is to get vaccinated; but a vaccine against swine flu will NOT be available until October 2009. So far, swine flu has affected a younger part of the population. Still, people at risk for infection based on other illnesses or certain medicines, and pregnant women need to be sensitive that they might have the flu; medicines are essential in these groups and these groups are the ones who should receive the vaccine first once it is available. Like any of the vaccines made in eggs, the dangers of the flu far outweigh the dangers of getting the vaccine, even in pregnant women, though the vaccine should not be given to those allergic to eggs. If people have the swine flu, protect those you live with by good hand-washing and “cough” hygiene”. (The term “cough hygiene” means that anyone who feels sick should cough into their elbow rather than openly into the air should a Kleenex not be available.) People should NOT be isolated from the rest of the family when at home; common sense suggest that there should be good hand-washing and maintaining a distance (perhaps 6 feet) from people who might be coughing up the virus, there is little to nothing to be gained by eating separately or excessively washing linens.

Dr. Shelley Gordon defines what the flu is, and how central fever, the time of the year, episodes in the community and muscle aches are to the diagnosis. Blood tests are not always needed if the flu is widespread in your community. Early diagnosis helps you and your neighbors. Then, appropriate medicines can be begun to shorten your illness and decrease the risk that you will spread it to others.  Medicines that are helpful will vary with the time of year and your ability to take a medicine through an inhaler. The best way to handle the flu is to get vaccinated; but each year’s vaccine does little to nothing for next year’s flu. Older people, people at risk for infection based on other illnesses or certain medicines, and pregnant women need to be sensitive that they might have the flu; those medicines are essential in this group. If people have the flu, protect those you live with by good hand-washing and “cough hygiene”.  Beyond good hand-washing and maintaining a distance from people who might be coughing up the virus, there is little to nothing to be gained by eating separately or excessively washing linens.

Dementia refers to the gradual loss of intellectual ability and function, whatever the cause. An early sign may be a loss of interest in activities.  Conversations or appointments may be forgotten or mistakes made in routine activities. The most significant risk factor is aging. Other illnesses such as alterations in thyroid function, lack of specific vitamins, and vascular disease can also cause dementia. Smoking can contribute to small vessel disease in the brain and worsen the problem. MRI, may show specific areas of the brain involved. Whatever the cause, there is treatment and planning as well as a need for assistance with activities of daily living. Medicines exist now and more are being developed to treat the dementia.

Almost everyone, during their lifetime, will have an episode of back pain. Recurrent back pain does not usually require immediate medical intervention, but a person should be checked with a first episode to exclude a potentially serious problem that might affect the bowel, bladder or the legs. Back pain is usually self-limiting, lasting days to weeks, but often, this pain interferes greatly in your life. For most people with back pain, the key is to get pain relief in the first few days using anti-inflammatory doses of Advil, and combining that with back exercises and local cold followed a few days later with heat. When it comes to back pain there is more opinion than fact about the causes, treatments and the responses to various therapies. Back pain is so frequent that people learn how to take care of themselves often and will very frequently get input from friends or family, many of whom have had back pain themselves. Back pain can rarely be the first sign of a potentially life-threatening problem. Key historical findings to suggest that there is an underlying problem is very severe back pain, back pains that occur in the presence of a fever or unexplained weight loss, or back pain that occurs after trauma. For people with a history of cancer, back pain may suggest that the cancer has spread to the spine. X-rays may not be helpful. Better tests would be to get special CT scans or to get at magnetic resonance imaging study. The basic therapeutic approach is rest for a few days until the pain is under control using narcotics or anti-inflammatory drugs, weight loss if that is appropriate, and the use of cold and then heat on the back along with physical therapy.