Pro-Per™ Herald: Does it Matter Where Your Water Comes From?

You are ready to live a healthy life. You are all pumped up to turn the corner. You see a health adviser. “Start with eight glasses of water per day,” she says. You think of picking up a box of bottled water on the way back home.
You did not think of filling those eight glasses of water out of your faucet. Is it because you think faucet water is not safe? Is it because your favorite celebrity with a perfect physique drinks that bottled water during her workout?

Pro-Per™ Points
- A gallon of bottled water can cost more than six dollars- more than twice the price of (insanely expensive) gas. Compare it to one cent a gallon for your faucet water.
- According to an article in the New York Times, regular bottled water drinker can spend up to 1400 dollars per year on water!
- Regarding the safety of municipal water, your local government is required to tell you the quality of your faucet water. If there is a need for tweaking the quality of your faucet water, what about putting your tax dollars to work toward doing that? People may be losing interest in faucet water quality because nobody seems to care.
- I think there is an access issue too. While the soda cups are monstrous, the water cooler side cups have stayed puny. How is a guy supposed to get his daily eight glasses of water in with those cups? What about buying some inexpensive big cups and putting them by the water cooler/ faucet at your work place tomorrow?

DrChander.com....Correction through action

End of Life Issue: Difficult to Let Go of a Sick Loved One

She had cardiac arrest at home. First responders resuscitated her and brought her to the hospital. The heart kept working, but the brain did not show any signs of recovery. The caring team including a neurologist agreed that the chance of the patient’s recovery was slim (note: nobody could say zero). The family contemplated withdrawing support, but one of the children felt that mom had tried to talk to him. After several weeks, the patient was taken to a long-term facility with a tube to help her breathe.

At times, we have a hard time letting go of a loved one even if we know that the chance of his or her recovery is minimal. This has important implications. One, we can put our loved ones through lot of pain because of our inability to decide. Two, this is an inefficient use of limited healthcare resources.

You can see this issue from two angles.

Patients’ angle:
- Whether a loved one lives on life support or dies without it- is a hard decision to make for most of us.
- I wonder if the health care system has failed to tell us that medicine is not perfect. There are many problems we can take care of, but there are lots more that we cannot do much about. A daily dose of news on medical advancements may be making us feel that death is just an option.

Physicians’ angle:
- Most of the physicians are not quite sure how to answer the question- will this treatment be futile? How do you define futile- less than 1 in 10,000 or less than 1 in one million chance of success? In the absence of a good definition, ‘futile’ can mean different things to different people.
- Most of the physicians are uncomfortable practicing paternalistic medicine. They feel uncomfortable saying, “I think you are too sick for this particular treatment and your chance of getting better is small (what does small mean, doc?).” They feel more comfortable explaining the overall scenario and letting the patient or loved ones make the decision.

Pro-Per™ points
- I think best end-of-life decisions are made when patient and/or family and physician are equal partners in the decision-making process.
- The loved ones find it easy to make these decisions on your behalf if you have expressed your wishes to them in clear terms.
- Should the doctors be paternalistic? I am ambivalent on that. As a physician, I am uncomfortable being paternalistic. On the other hand, if I am the patient, I would like my doctor to give me all the information with a dash of paternalism. I think that will make the decision-making easier for me.
- Various patient advocates- including physicians- should work on defining ‘futile’ in clearer terms.
DrChander.com....Correction through action

Affordable Health Care for All*: Option or a Necessity?

All discussions on healthcare in the US center around 1 in 6 uninsured Americans. We know that there is no easy solution to this problem.

The question is: how important is it to find solution to this problem? If you say it is very important, are you saying that because you think you are a good, conscientious person or because you think there is no way around it?

The research has shown that many uninsured people avoid seeking medical care until it is too late because of financial constraints. At that late stage, it costs more resources to deal with the situation. A stitch in time saves nine.

We know that in a civilized society, every sick person shall enter the health care system at some stage- early or frustratingly late. If the uninsured do it at a late stage, they will cost excessive resources. Based on that, does it mean that providing affordable healthcare to all* is a necessity and not an option?
*Do not read it as universal healthcare
DrChander.com....Correction through action

Is This Atrial Fibrillation Treatment Worth its Cost?

A New York Times article by Barnaby J. Feder talks about cost burden of a procedure (called ablation) used to treat atrial fibrillation. Atrial fibrillation is a heart condition characterized by irregular heart beat and increased risk of stroke for the people afflicted by it. This condition afflicts 2.2 million people in the US.
There are many otherwise healthy patients whose life is severely affected by atrial fibrillation. Many times, their atrial fibrillation does not respond to medicines. Potential cure from ablation procedure is a God-send to such patients.
This Times article investigates how this- increasingly frequently performed procedure- is further straining the limited health care resources. I think this question is being raised because of the following reasons:
- We know that atrial fibrillation is a recurrent disease regardless of what we do. The promise of a cure with ablation has not been delivered yet.
- The results of ablation have not been consistent. Some facilities have reported phenomenal results, but the results can vary to an uncomfortable extent between different facilities
- Many patients with atrial fibrillation tend to have many co-existent medical problems which may adversely affect survival regardless of presence of atrial fibrillation. The question in such cases is: should we try to- or can we- cure atrial fibrillation?
The real (although non-PC) question is: is this procedure being driven by monetary incentives? I think the reason that more of these procedures are being performed is that more than 1 in 150 people in the US have this problem. It is only likely to get worse as the population ages. As this (ablation) technology goes through its usual maturity period, the cost of procedure will inevitably come down. With time, this technique will also find its right place in the treatment of right kind of patients. The question – whether the cost of this procedure is worth it- is harder to answer. Before we get to that part of the discussion, we will have to start discussion on another non-PC topic- healthcare rationing.
DrChander.com....Correction through action

Resistant TB- Andrew Speaker's case

I recently heard the taped conversation between Andrew Speaker and his physician. Andrew is the young lawyer who traveled across the continents while suffering from resistant TB. The young lawyer’s (lawyer) father had taped the conversation during a visit to the doctor. They played part of the taped conversation on Larry King Live to support their point that Andrew’s doctor had not asked him to refrain from traveling. Hearing this tape, I had two questions:
- Is it fair to tape conversation without telling the other party- especially in a (doctor-patient) relationship that is supposed to be based on trust?
-We waste many health care dollars because of defensive medicine. Will an incident like this make health providers across the country be even more leery and defensive?
DrChander.com...Correction through action

Enlarged Heart (Cardiomegaly) FAQ

What is enlarged heart?
One of my doctors told me that I have enlarged heart. But another doctor recently told me that my heart is normal. I am confused.
What should I do if I have enlarged heart?
What could I expect if I have enlarged heart?
If I have an enlarged heart but no symptoms, do I still need to be worried?
Does enlarged heart mean I will die soon?
Can an enlarged heart be fixed?

Stroke Awareness Challenges

If you were to ask people what disease they are afraid of the most, the large percentage of older adults will say- stroke. This is because most of the people have seen someone with stroke’s devastating and disabling effects. Still, most of us are not as aggressive about seeking medical attention for stroke as we are for chest pain. Some of the reasons for this are:

1. The symptoms of stroke can be variable and sometimes confusing. Some of the symptoms of stroke could be non-specific. For example, severe dizziness, a common symptom can also be suggestive of a stroke. This is an understandable challenge. However, we need to be aware of common symptoms of stroke and seek emergent medical attention for the same.
2. The treatment of stroke has conventionally been conservative. Most of the people think that all the hospital is going to do is perform some tests and start physical therapy- so why hurry? Some patients with stroke now can be given clot-buster medicine leading to 100% recovery in certain cases. The ‘clot-buster’ however, can only be given within three hours of onset of symptoms. Like heart attack, time is of the essence in case of stroke.
3. Some of us might have experienced difficulty speaking or weakness of one side of the body that recovered on its own. It is called transient ischemic attack (TIA). We do not see any reason to seek medical attention once the symptoms are gone. This is because most of us are not aware of the fact that the chance of having a big stroke within a few weeks after a TIA is very high.
DrChander.com....Correction through action

Diabetes Medicine Avandia Can Hurt Your Heart- Says Who?

A recent study raises concerns about the safety of Avandia, a drug widely used for diabetes control. This has attracted a lot of (I think too much) attention. Here are my concerns:

- The conclusion that Avandia can hurt your heart is based on a type of research called meta-analysis. The standard wisdom is that conclusions drawn from such data should be viewed with great caution.
- This research studied the population (diabetics) that is already at a high risk for cardiovascular disease. We have to make sure there were no other confounding factors- other than Avandia- that could explain higher chances of cardiovascular disease. I could not see what percentage of people in this study smoked, had high blood pressure or any other cardiovascular risk factors.
- I do not know how much of the publicity for this trial results is driven by stick-it-to-the-man factor rather than real concern for our health. How much of it is because we feel happy that a ‘filthy rich pharma’ bit the dust.
- I am not comfortable with the fates of different drugs being decided in the media. The shares of GlaxoSmithKline tumbled 8% after the results of this study were made public. The medical literature is full of studies that showed the negative effects of drugs soon after they hit the market. Many of these drugs are still being used after the correct dose or indication was determined based on the lessons learned from negative studies. But for systematic and critical evaluation, these drugs may have been taken off the market after the initial brouhaha.
- I am concerned that many patients may stop Avandia after hearing about its ‘scary side effects’. Some of them may become so disillusioned with the medicines that they may decide not to do anything for their diabetes

Pro-Per™ Points
This study has raised an important point about possible bad effects of Avandia on the heart. We need to try to see if a better quality study will raise similar concerns. I am sure many physicians have received calls from their panicked patients on Avandia. Physicians need to continue to be the best advocates for their patients without feeding the frenzy. If they do decide to stop Avandia, they need to make sure that patients get an effective alternative.

I have no financial relation with GlaxoSmithKline, the manufacturer of Avandia
DrChander.com....Correction through action

He has been my patient for several years. My nurse practitioner colleague told me a few days prior that this patient had been diagnosed with terminal cancer. He came to see me today. He looked remarkably calm for a person who knew he had only a few days to live. After my usual evaluation, I sat on my chair. There was a long uneasy silence.

I wanted to say several things. I wanted him to be off all the medicines he was on for long-term benefits. He had a defibrillator that would shock him if his heart were to stop. I did not want him to get painful shocks from the machine when his heart was ready to go in his final moments. I wanted to ask if he wanted his defibrillator turned off. How do I tell him all this without sounding like I had already given up on him? I painstakingly put together some words to convey all that. His response to all those suggestions was quick and matter-of-fact.

Most of the time, when I am finished seeing a patient, I say- I will see you in six months, three months etc. What do I tell a person who is not expected to live more than a few days or weeks? How do I say goodbye to someone I may never see again while maintaining the hope that I just might?

I came back to my office after finishing with him, slumped into my chair, and started staring out of my office window. I had seen him almost every three months. The thought that I will never see him again gave me an odd, empty feeling in the stomach.

I enjoy listening to my patients’ complaints, processing all that data and coming up with some solutions. I had not done any of that to help him today but this visit had taken a lot out of me. Then I heard the thud of a chart being placed on my desk. Time to go see the next patient.
DrChander.com....Correction through action

How Going Paperless is Making Healthcare More Expensive and Lower Quality

‘Electronic medical records’ is the in thing now days. Going paperless is the mantra of our times. There is a concern that some doctors and facilities are not going paperless fast enough. Here is another twist that has much to do with going ‘dictation-less’ as a step to going paperless. There is a push toward providers typing the notes instead of dictating or writing.
Whenever a physician sees a patient, a proper evaluation includes several steps- asking the patient what is bothering him (history), examining the patient (physical examination), assessment of the situation and devising a plan of care based on the evaluation. After a physician sees a patient, these steps are documented for records. This is done by typing, writing or dictating. In addition to being an integral part of good patient care, these records are a great communication tool. Let us say I have to go see a surgeon. A look at my primary doctor’s notes can give this doctor a good idea about my overall health and other pertinent issues. In the absence of that information, my surgeon may end up providing me less than optimal care.
Taking history is an art, and writing an assessment and plan for a patient is a reflection of a provider’s quality of care. These can only be documented in numerous lines. There is a concern that busy providers’ quality of documentation may suffer if they choose to type the notes instead of dictating them as most can not type as fast they can speak. Here are the issues of concern to some people:
- A hurriedly typed record can become a poor communication document with a potential to lead to bad patient care- even jeopardizing patient lives in some cases.
- There is a concern that some doctors are unable to type line after line justifying their plan for patient care- this is easy to do if you are dictating- so they find it easy to order more tests and more consults which can be done by typing only a few words. This might be leading to more healthcare cost. As an example, compare note 1 and note 2 on the same patient.
Note 1- This patient has chest pain. The pain gets worse on breathing so it looks pleuritic. The patient is not high risk for heart disease. There is no sweating or nausea or vomiting with the chest pain. I do not think we need to do any further testing at this time. I have told the patient that if his symptoms get worse, he should go to the emergency room or call my office.
Note 2- C.P. Stress test. Cardiology consult.
Which note will you type when you have twenty more patients to see, they ask? Which line of patient care will prove more expensive without adding much to quality of care?
Some people say that typing instead of dictating saves transcription costs. A case of penny-wise, pound-foolish?
The point is well taken. Here is my take on it. Going paperless should not mean that providers cannot dictate and must type. Dictating is perfectly compatible with a paperless office. You can dictate, send it to transcription and upload it to your records on the computer without using a single piece of paper.
DrChander.com....Correction through action

Are The Doctors a Little Too Cozy With Drug Companies?

An article in April 26, 2007 issue of the New England Journal of Medicine (NEJM) discusses the results of a survey on physician-industry relationships. According to this survey, most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials.

The issues:
- Most doctors’ offices accept lunches from pharmaceutical companies. Here are some of the views I heard: “I am not likely to prescribe a medicine just because someone fed me lunch.” “This is a common routine for the sales people to bring ‘goodies’ to their potential clients. Anybody in a purchasing position is familiar with this practice. It happens whether you are an office manager in charge of office supplies or you are a senator in charge of national policy matters. Why should doctors’ offices then be picked out for criticism?”
- Most doctors like to accept drug samples. They see this as a help to their patients.
- The pharmaceutical companies have devised the methods to monetarily incentivize the doctors that either write their products or who can influence others to use their products. Later are the opinion leaders. They are given consultant fees and speaking fees. However, this is done by filling a niche. The physicians and health care providers need continuing medical education (CME). The pharmaceutical companies pay some doctors for doing just that. As an expected side effect, these speakers may tend to support their sponsor’s products. The companies do this in a sophisticated way by carefully choosing the speakers whose views support their cause.

Pro-Per™ points:
- I do not see any problem with accepting samples as long as they do not influence a physician into prescribing costly meds when there are cheaper alternatives available.
- Most of the doctors spend time meeting pharmaceutical reps over lunch. Their time has a higher dollar value than that of the lunch they are fed. According to a survey, the doctors think that lunch helps their office staff’s morale. But if these free lunches are likely to adversely affect the public perception, should they just say no to lunches or dinners?
- Many doctors are on pharmaceutical companies’ payroll, according to the survey. While it is easy to see conflict of interest, these physicians get paid while providing a service that is in high demand. I do not see an end to this practice till we find someone other than the pharmaceutical companies to foot the bill for these services.
DrChander.com....Correction through action

Do I need antibiotics when I go to my dentist? Some major changes in recommendations

Antibiotics are routinely prescribed prior to a dental procedure if you have a heart valve problem. This is done to prevent infection of the heart valves- disease called infective endocarditis (I.E.). The routine of giving antibiotics to prevent I.E. is called I.E. prophylaxis. Here is the who and when of I.E. prophylaxis according to new guidelines published in the online edition of the journal Circulation on April 19, 2007.
- Who needs it? The I.E. prophylaxis is needed only if you have the following heart problems: an artificial (‘pig’ or ‘plastic’) valve, previous history of infective endocarditis, certain (not all) congenital heart diseases, history of heart transplantation with damaged valves of the transplanted heart. No more antibiotics if you just have thick valves or even mitral valve prolapse (MVP).
- When do you need it? The I.E. prophylaxis is only recommended before dental procedures, procedures on respiratory tract, infected skin, skin structure or musculoskeletal tissue. It is no more recommended for procedures on gastrointestinal or genitourinary tract including endoscopy, prostate biopsy etc.
To read the whole article published in the journal Circulation, click here

DrChander.com....Correction through action

Finding the Cause of Heart Disease- Are We Barking Up the Right Tree?

The blockage of heart arteries is caused by a complex- not completely well understood- process called atherosclerosis. It is characterized by cholesterol deposits in the wall of the arteries that supply blood to the heart muscles. Why do some people have blockage of heart arteries and some do not? It could not just be the cholesterol we eat or manufacture in our body, because we do know that not everyone with high cholesterol has blocked heart arteries and some with perfectly normal cholesterol have heart attacks.

So what exactly causes blocked heart arteries? The simple answer is- we do not know for sure. Several theories have been suggested, however. Could this be due to some infection with a bug? Could this be inflammation? Studies that show that people with high level of C-reactive protein (CRP) are more likely to have heart problems seem to support inflammation theory.

Atherogenics is working on a class of drugs called v-protectants (vascular protectants). The basis for these drugs is that chronic inflammation underlies cardiovascular disease. Results from a phase III trial on compound AGI-1067 developed by Atherogenics were released. The study results reveal that the drug did not meet pre-defined measures of success- decrease in combination of cardiovascular deaths; resuscitated cardiac arrests; non-fatal heart attacks or strokes; need for bypass surgery or angioplasty to clear obstructed arteries; or urgent hospitalization for severe chest pain. The result of this trial prompted sharp fall in Atherogenics’ share price.

The result of this study raises another question- does this trial result simply signify failure of one drug or does it question inflammation hypothesis for development of cardiovascular disease?

Is inflammation a bystander, a result, or a cause of blockages of heart arteries? If inflammation is the cause of blocked heart arteries, what causes inflammation? Does some infection or any other agent cause it or is it there for no real reason? If it is due to a cause, will treatment of that cause be an effective solution for the cardiovascular problem? On the other hand, if it is just unbridled inflammation causing the damage, we should expect vascular protectants to help us attack the number one killer- cardiovascular disease- more effectively.
DrChander....Correction through action

Cheap Medicines Available- Why Doesn’t Everybody Know Where?

I recently saw a patient in my office for the first time. While I was going over his medicines, he told me how he saved a lot of money by buying his medicines from Mexico. Nearly all the medicines he was on were available through Walmart and Target’s four dollar prescription program. He was not aware of this program. We determined that he will save tens of dollars buying his medicines from Walmart or Target- not to talk about expense and hassle going all the way to Mexico.
The chain stores Target and Walmart announced their $4 prescription programs several months ago. Several people around us are still unaware of these cheap prescription options. Some of these people are buying expensive medicines when they hardly have enough for daily needs. Others choose not to take these medicines because of ignorance of these cheaper options. Let us tell everyone around us about these options. Please e-mail this article to at least five people you know.
The list of medicines included in $4 prescription program can be obtained by either visiting local Target or Walmart pharmacies or by clicking here- Target Walmart
DrChander.com....Correction through action

Why Do We Hesitate To Use Generic Drugs?

Despite being much cheaper than brand name drugs, why do we hesitate to use generics? Here are some of the reasons that I heard-

Concern about quality. There is a concern that generic medicines are not of same quality as brand names. Not many people know that generic medicines need to be approved by FDA just like brand name drugs. Read FDA’s statement on generics.

Visibility factor. Let us say there are five products belonging to a class of drugs. Four of them are generic. Only the company marketing the brand name is likely to be in a position to spend money on direct-to-consumer marketing. This can be in the form of TV and magazine advertisements or articles published in the print media and internet. This leads to better visibility. People tend to trust a name that they have heard of more than the one they have never heard of.

Anything less expensive must be lower quality. Human nature: in the absence of knowledge of a product, we tend to use price as an indicator of quality. We tend to think that more expensive must be better. We apply this principle to medicines too.

Just because research showed product A from a group to have beneficial effects does not mean product B, C and D from the same group will have the same effects. Let us say a research study shows that cholesterol-lowering medicine Zocor can dissolve blockages in the heart arteries. Zocor belongs to a group of medicines called statins. Can we safely presume that this is a class effect, and other statins like Lovastatin, Pravastatin will also do the same job? Moreover, nobody is likely to spend dollars on research involving a generic medicine because margin of profit on generics is low. How do you deal with this issue?
- You should compare the price of generic with that of brand name. If the difference is enormous, it may make case for cheaper generic.
- Unless one product from a group has been found to be inferior to another from the same group in a head-to-head comparison, there is no justifiable reason to pay many times over for a brand name.
- In order to find research on a generic drug, look for the research done on this product before it became generic. For example, Zocor is the trade name for the cholesterol lowering medicine Simvastain. You are unlikely to find research on Simvastatin after it turned generic. But you will find plenty of research done during the time it was exclusively marketed under the brand name Zocor.

Some products are generic and less expensive and some are brand name and more expensive. Does this not mean that generics are of inferior quality? When a company develops a new drug, it gets it patented. The patent protection gives the company exclusive right to produce that drug for several years. Once that patent expires, many different companies get to manufacture that drug. That is when drug is said to have gone generic. The cheaper price of generic drug is due to competition and not due to lower quality of the product.

How can you tell that effect from a generic is not just a placebo effect? In other words, how can we be sure, for example, that a generic aspirin pill contains aspirin and not some sugar powder? Before they are allowed to produce generics, the manufacturers have to meet standards set by FDA. As for placebo effect, some studies suggest that up to 30% of effects of all drugs could be due to placebo effect.

Where can we find cheap generic drugs? Unless you shop around, you can end up paying as much for a generic drug as for a brand name. Walmart and Target have programs where they sell a month’s worth of many generics for $4. You do not need proof of insurance for that. Make these pharmacies your first stop. If the drug you are looking for is not included in their $4 program, make sure to look at other pharmacies for best price.
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Curing Health Care System Ills- Uncle Pete Style

I grew up watching my uncle Pete work long hour in his store. He has never gone to school, but is able to do complex number calculations without the help of a calculator. He owned a general store. He had an uncanny ability to make every customer feel special. Every customer would walk out of his store thinking that he got the best deal. My respect for his business acumen has only grown over the years.
He has been hearing about different proposed solutions for the the health care system problems including large number of uninsured and the high cost of healthcare.
“At this time, different groups seem to be rushing to announce a solution to the healthcare system issues. In this race to be the first, they are ready to elbow their competitor with its own proposed solution out of the tracks,” said Uncle Pete.
“I think it will be helpful to see everybody’s proposed solution so we can come up with the best idea. Why would you not want anyone else to propose their solution?” I asked.
“Each group is proposing a solution having given a lot of thought to their own piece of the pie.”
“What is wrong with that?”
“That means many proposals clogging the pipe- none really getting through,” said Uncle Pete.
More of Uncle Pete
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The study makes a convincing case for medical treatment of blocked heart arteries. Why I think it may change nothing, however?

The results of landmark trial COURAGE are in. I will easily give this study 4 PUTS. This study shows that patients with stable heart artery blockages do no better with stents than with medicines. This study deserves 4 PUTS because the results of this study should have a great impact on how we practice cardiology. While it should- I do think that the results of this trial may not change medical practice significantly any time soon- for the following reasons:
- Physicians acting in good faith feel very nervous leaving the blocked heart arteries alone once they are seen on the angiogram. The biggest concern is the possibility of blocked heart artery causing a heart attack
- The studies have shown that the arteries that are less than 50% blocked cause most of the heart attacks. However, we continue to be more nervous about the blockages that look ‘bad’ on the angiogram.
- Most of the patients do not feel comfortable leaving the blockages alone and do demand stents. Most of the physicians are not comfortable practicing paternalistic medicine.
- This study, while sending a clear message does leave a loophole. It says stents are justified if patient continues to have angina. In real practice, angina does not always come in the textbook form of typical chest pressure on exertion. Patients can have ‘twinges’, ‘sharp pains’ or ‘some breathing problems’ that are typically not thought to be due to the heart problem. However, in a patient who is being treated with medicines for blockages, these non-specific symptoms may make the patients as well as doctor nervous- ultimately leading to stent procedure.

Many people have asked me about the utility of stents ever since media discussed COURAGE trial. This is a good start. This study makes a great point. The real changes in practice however, will only come when patients start asking more about medicines as treatment for blockages. The patients’ awareness in turn will make physicians more comfortable not fixing every diagnosed blockage with stents or bypass. The COURAGE trial has brought along a great message. Lest we forget…
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Information Overload: PUTS to the Rescue

Many of us- health professionals or not- hear or read about medical research. TV, radio, papers, magazines and internet are some of the sources of medical information. Numerous sources of information competing for our attention have lead to the problems of mal-information and information overload. Mal-information can be due to some vested interests monopolizing our attention. Information overload has the potential of leaving us confused about some important basic concepts.

Some research that we read or hear about may impact the way healthcare is delivered, and some may have no significant impact. New kid on the block- blogosphere- has given several of us a unique opportunity to write on research and other topics. This helps readers get views from different angles. This however, also contributes to information overload.

Whenever a new research is presented, people wonder if they should rush to talk to their doctor about that ‘groundbreaking’ research. I think those who write or talk about the health research can help the public by providing a ranking to the research they write or talk about. Let us call it Pro-Per™ utility test score (PUTS). The scoring is on a scale of one to five. Higher the score, more the scorer thinks that the research topic will impact the way health care is provided.

Pro-Per™ Utility Test Score (PUTS)
0 PUTS. The research will not change the way health care is provided.
1 PUTS. The research will not make significant impact on healthcare delivery. Or it may say something that is already well known.
2 to 4 PUTS. The research may change the practice of medicine significantly. How significantly? It depends on what the scorer thinks. Same research may get different score from different scorers.
5 PUTS. The research will revolutionize practice of medicine.

Examples:
- High C-reactive protein (CRP) is thought to be associated with higher chance of heart problem. No study has shown that a measure that will cause pure CRP decrease (apart from treatment of already known risk factors) will translate into decreased chance of heart disease. So most CRP research will get a score of 0 to 1.
- A study suggested that non-specific EKG changes in women may mean higher chance of heart disease later. The physicians already routinely compare patients’ new EKGs with old EKGs for any fresh changes. Moreover, any additional steps in patients with non-specific EKG changes are unlikely to have significant impact on patient wellbeing. So this research will also get a score of 0 to 1.
- A study showed that a new antibiotic- Ketek- should not be used for simple bronchitis because of potential of serious side effects. Another study showed that frequent hand-washing will decrease the chance of infections. These two are likely to get a score of 2 to 4.
- Research showed that H. pylori- a bug- and not excessive acid is responsible for stomach ulcers. The discovery of a vaccine had the potential to eradicate a horrible disease like small pox. These two will likely get a score of 5.

According to PUTS system, most of the basic research will get zero Pro-Per™ utility test score (PUTS). This does not in any way diminish the importance of basic research. Moreover, a research that gets zero PUTS today may form the basis for a research with 5 PUTS in the future. PUTS will however, give us a good idea about the present utility of a research.
Pro-Per™ utility test score (PUTS) will help us provide the benefit of our expertise to the laity. By ‘laity’, I do not just mean patients. A cardiologist could be ‘laity’ for a topic on bone tumors or health care business, for example.
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What Is The Reason Behind Pay-For-Performance (P4P) System?

The American Medical Association (AMA) president William G. Plested III, MD wrote an article published in AMA news titled- Pay-for-performance: It's about cost control, not quality.

Pay-for-performance or P4P is a system with a premise that hospitals and physicians will be incentivized for better performance. The article by AMA president got me thinking about the reason behind pay-for-performance (P4P) concept.

Is it to assure quality? If this is to assure quality, what are the parameters of quality? I understand that tens of quality criteria are being measured for the calculation of incentives as a part of P4P.
A customer subconsciously uses tens of quality criteria before choosing a store that he or she buys groceries from. These criteria include: location of the store, parking, attitude of the employees, prices, placement of the goods- and the list goes on. The health care quality will need to be measured based on hundreds of quality criteria- some measurable (death rate, stroke rate etc.) and some not so easily measurable (emotional well-being, physician’s respect for patient’s belief system, etc.). Will we be able to measure all the important criteria for the purpose of P4P? If not, will we run the risk of ignoring the quality criteria that we are not being graded on- to the detriment of patient care?

Is it to cut cost? A common argument against ‘universal health care’ is that it will kill the type of care that American health system provides. This suggests people's satisfaction with quality of care. Moreover, commonest complaint against health care system at this time is the cost. Because of these issues, people wonder if pay-for-performance is a cost-cutting measure in the garb of a quality-enhancing measure. Is it? While it is easy to support attempts to get best value for every healthcare dollar spent, it is hard to imagine that P4P will be an effective cost-cutting measure.
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Women and Heart Disease: A Pro-Per™ Approach

It is important to be aware of 'non-classical' symptoms of heart disease . It is also important that awareness of these ‘non-classical’ symptoms does not get you perpetually worried about heart disease- turning you into a nervous wreck. Many of these symptoms can be due to tens of reasons other than heart.
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A Call to the Medical Journals

Times, they are achangin’. Many of us- medical professionals or not- are getting our medical news through Associated Press or Reuters rather than our conventional medical journals. The popular journals like New England Journal of Medicine and the Journal of American Medical Association have long issued press releases (a few days prior to availability of hard copy) about the research articles that they thought will be of interest to the general public. This leads to articles published in newspapers, magazines and Internet sites.

Times, they are achangin’. The blogosphere is responsible for some of these changes. There are several physicians and other medical professionals- including yours truly- who write their opinions on the new medical research. Several of us like to peruse these articles and write about their strengths and weaknesses. We will like to offer our opinions on recent research to our readers at the same time that it is written about in the press.

Most of the time, I get the news about the research from the press. Sometimes I can get my hands on the full article through the journal’s website. Sometimes I wait for the hard copy to get to my mailbox. Many times, it is too late- it is old news.

I think it is important that everybody get the details of the articles released to the press at the same time. This can be done in several ways. One of the ways is for the popular journals like the Journal of American Medical Association and New England Journal of Medicine to offer sign-up for the ‘press release’ through their websites. (Most of the journals already offer sign-up for table of contents.) That way, the subscribers to the press release alerts can get the full text article at the same time that the press does. It will help several writers give their viewpoint to their readers in a timely fashion.
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Heart Disease: Why Are We Not Talking Enough About Non-surgical Treatments?

A Feb 25, 2007 The New York Times article discusses two treatment options for blocked heart arteries- stents and bypass surgery (CABG). Some of the points made are:
- The number of bypass surgeries has gone down while the number of stent procedures has gone up over the years.
- One of the possible reasons cited for lower number of bypass surgeries is cardiologists not consulting surgeons before treating blockages with stents.
- The recognition of previously unknown complication of new stents-late stent thrombosis- may make bypass surgery an attractive option for more patients.
- The cardiologists say that some surgeons refuse to operate on sicker patients for the fear of adverse effect on their performance statistics. The performance statistics for individual surgeons are made public in some states.

In this article, Barnaby J. Feder writes about an issue that is commonly discussed- and argued about- among cardiothoracic surgeons and cardiologists. There are heart blockages that are clearly suitable for stent placement (performed by a cardiologist), and there are those clearly suitable for bypass surgery (performed by a surgeon). In addition, there is a gray area that is source of discussion between cardiologists and cardiothoracic surgeons. Of late, the cardiologists have taken over more of this gray territory.
At times, the argument between bypass surgery and stents can relegate non-surgical treatment measures to the background.

Pro-Per™ Points

A. Whenever blockage of heart arteries is diagnosed, some patients feel let down if they are told that their blockage will not and should not be fixed with stents or bypass surgery. The physicians at times also feel nervous about not fixing the blockage that they see. This happens despite the fact that research supports non-surgical management in many of these cases. This happens because we do not talk enough about the following:

- Whenever we notice any heart artery blockages, we are afraid that these blockages may cause heart attack. We used to think that blockages turn form 50 to 60 to 70%...eventually turning into 100%- causing a heart attack. The studies now suggest that majority of heart attacks happen at locations in the heart arteries that have less than 50% blockage- the extent of blockage that can easily be missed or deemed unimportant on a stress test or an angiogram. So while the tighter blockages may scare us more, the minor blockages are the ones that make us more vulnerable to dreaded heart attacks. This brings us to the next point.
- The heart artery blockage is the presenting symptom of body’s diseased plumbing system. It needs to be seen and treated as a systemic disease. Not all blockages need to be fixed surgically. Without regards to how these blockages are tackled (with or without surgery), attention to whole plumbing system of the body is most important aspect of the management. This includes medications and management of risk factors. These measures decrease the chances of various diseases of plumbing system: stroke, heart attack, peripheral arterial disease (P.A.D.). A person with heart attack is at a high risk for stroke and vice versa.

B. Anytime we discuss the treatment of heart artery blockages, non-surgical treatment methods including medicines, exercise etc. need to be given well-deserved place of pride along with other treatments.
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Blood-Letting or Phlebotomy: A New Use for a Medieval Technique?

Some studies have suggested the role of increased body iron stores in development of cardio-vascular disease. Blood- letting or phlebotomy is a procedure involving removal of a part of person’s blood- decreasing body iron stores. What about effect of blood-letting on heart attacks and strokes- two vascular diseases?
An article published in Feb14, 2007 issue of the Journal of American Medical Association (JAMA) studied the effects of blood-letting on death rate, heart attacks and strokes. All the study volunteers had peripheral arterial disease (P.A.D.).This study did not show any particular benefit of phlebotomy. However, the patients aged between 43 and 61 fared better after phlebotomy.

Pro-Per™ points:
- There is no indication so far that blood-letting will help patients with heart or vascular diseases.
- We are concerned that high iron stores may be responsible for cardiovascular disease. As a simple measure- especially for males- it may be helpful to make sure your daily vitamin does not contain iron.
- Research has shown that weight reduction and exercise help decrease iron stores- another reason for losing weight and exercising.

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The question is: how do you measure performance?

The government wanted to issue some guidelines on how to quit smoking, and corporate interests seem to have influenced what it said, an article published in Feb 8, 2007 Wall Street Journal (WSJ) says. The guidelines are seen as gospel by many. It is an open secret that vested interests work hard on influencing the guidelines. Many well-respected medical organizations issue guidelines on important health issues from time to time. Some have raised concern that many people responsible for issue of guidelines also work closely with big companies.
Pay for performance (P4P) is a simple and attractive idea: the health provider (hospital or physician) that performs better should be compensated better. Who can argue with that? The problem is that it is hard to find good yardsticks for measuring health care quality. Many of these yardsticks are created based on guidelines. If the guidelines are going to be flawed as the WSJ report suggests, how can we expect pay for performance measures to be fare? We need to work hard on the right criteria for measuring performance before we go too far with P4P. Otherwise, we run the risk of penalizing some genuine performers and rewarding those that are simply good exam-takers.
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What is the chance that you will have a heart problem over next 10 years?

Can we predict what an individual's odds of having blockage of heart arteries are? I think most of us will like to know. To help calculate the odds, a formula was created based on Framingham data.

This formula is available under 'self-help tools' on left bottom of DrChander.com

Can We Psyche Ourselves Into Feeling Better?

Vasovagal syncope is one of the causes of sudden episodes of loss of consciousness. One of the mechanisms of passing out is sudden drop in heart rate. In some cases, it can be demonstrated on a test called tilt table test. It was thought- because this problem is caused by low heart rate- why not put pacemakers in these patients so that pacemaker does not let the heart rate drop? This idea looked good on a study called VPS I. Subsequent studies did not show similar benefits.
A recent article in The American Journal of Medicine reviews all the studies that studied the role of pacemaker in case of vasovagal syncope. In some studies, all the study subjects were given pacemakers. The pacemakers were turned on in one group while were turned off in the other group. The research volunteers in both groups felt better. That made the researchers reach a conclusion that pacemaker is likely not of much use in people with vasovagal syncope (passing out episodes).
Why did people who had the pacemaker turned off (hence being same as not having any pacemaker) feel better? The study calls it an ‘expectation’ response. It means, “Patients who have undergone surgical pacemaker implantation might expect to have fewer syncopal recurrences.”
Mind body connection?
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Pro-Per Herald(TM) : Cheap Medicines

I talked about Walmart and Target's decision to sell cheap generics a while ago. A few days back, I called Walmart and Target pharmacies. They faxed me the list of medicines that are available for $4 for a month's supply. Walmart's list is available on the web while Target's is not. I read these lists. It looks like they cover most of the commonly used medications. Not knowing about this can cost us dearly. Please share this important information with your friends and health providers. You can get the details by clicking here.
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Pro-Per™ Way to Stay Healthy: Age and Gender Appropriate Screening Tests

A proactive approach to staying healthy includes undergoing certain screening tests from time to time. These screening tests have been shown to save lives and improve quality of life in a given population.

Screening tests are the tests devised to detect a disease in the early stage. For a test to be offered widely to persons of certain age and gender, it should meet some criteria including:

- The test should look for the disease that is a common problem in a certain population. For example, life time cumulative risk for breast cancer for women is 10% and life time cumulative risk for colon cancer is 6%. These numbers justify screening for these two diseases.
- The screening test should be easily doable.
- An effective treatment should be available for the disease we screen for.
- An early detection by screening should make appreciable impact on survival or quality of life.

Before we go any further, it is very important to understand following points regarding screening tests:
- These recommendations are for people who are at average risk for common diseases. A person at high risk may need to be screened more often or at an age younger than that recommended.
- Effective screening tests exist for certain uncommon diseases. These may not be offered to general population. However, they save precious lives when used in selective cases.
- The screening test recommendations can change from time to time. Different agencies may even have differing views on the same screening test at a given time.
- For the reasons given above, these important screening tests have to be carried out under the guidance of a health care professional.

The recommendations given here in tabulated form are based on information from agency for healthcare research and quality (AHRQ) website and US preventive services task force
Want to know what screening tests you should undergo? Click here

Please: Ask For a Time-Out

Pro-Per Herald™*010607-time-out
While driving to the hospital, I recently caught a part of Laura Ingraham show on radio. She was sharing her surgery experience. She said that she marked the part of her body to be operated on with a marker. She said this in a jocular way while making a very important point.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued recommendations with a self-explanatory title: ‘Guidelines for Implementation of the Universal Protocol for the Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery’. An important part of those guidelines is that entire operative team should go through a check-list (before surgery) including: correct patient identity, correct side and site, agreement on the procedure to be done, correct patient position, availability of correct implants and any special equipment or special requirements.
These guidelines are in response to reports of avoidable medical mistakes. Some of the dramatic ones are those where a wrong leg is operated on, a wrong toe is removed, etc.
I propose a time-out requested by the patient. If you ever go to the hospital for a procedure, and staff comes to get you for the surgery, you should request for a time-out. One of the ways to do it could be: hey guys, let me introduce myself. I am John Doe. I am allergic to XYZ. I am here for repair of hernia in my left groin area. Is this what your records say?
When you go to a hospital, you are looking for the best care for you or your loved one. The best way to do that is by communicating a lot, and doing it well in a pleasant manner. And no, I do not see any problem with doing what Laura Ingraham did. Do you?
* Pro-Per™, pronounced as the word ‘proper’ is DrChander.com’s trademark for different services. Pro-Per™ is a combination of two words- Proactive and Person.

Uses and Shortcomings of Stress Tests for the Diagnosis of Heart Disease

The blood flow through the blocked heart arteries- while adequate at rest- may not be able to keep up with the demands of a stressed heart. This can show up on the pictures of the heart taken after stress. This is the principle behind all the stress tests.
There are different kinds of stress tests. Which stress test is the best for you? It depends on several different factors. I have explained different stress tests here:
- Exercise treadmill test or stress test
- Exercise nuclear scan or nuclear stress test or Cardiolyte stress test
- Adenosine nuclear stress test
- Dobutamine nuclear stress test
- Exercise stress echo or echocardiogram
- Dobutamine stress echo

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How to Diagnose Heart Artery Blockage/ Coronary Artery Disease?

What does blockage of heart arteries or coronary artery disease mean?
How can I find out if my heart arteries are blocked?
Which is better at diagnosing coronary artery disease- stress tests or coronary angiogram?
Isn’t coronary angiogram a gold standard?
If coronary angiogram has all these shortcomings and is invasive, why do it?
If I have a normal stress test today, does that mean that I can be rest assured that I will not have heart attack next 5, 10 or 15 years?
What is the importance of tests for diagnosis of coronary artery disease?
What are different types of tests used to diagnose coronary artery disease or blockage of heart arteries?

Your Questions on Heart Stents Including Those on Problems With New Stents Answered

What is a stent?
What is the difference between 'new' and 'old' stent?
Why was there a need for drug-eluting stent?
I am hearing a lot about problems with new stents. What exactly is wrong with new stents?
If new stents can cause fatal problems, why not take them off the market?
What about a moratorium on the new stents till the problem is better studied?
Does that mean that public safety does not matter? Are we going to let all those people die from this compication?
What are your thoughts?

Can 10 Cents Be Equal To 15,000 Dollars? A Case Against Open-Artery Hypothesis? Lest We Forget: Message From OAT Trial

Many acute heart attacks are caused by complete shut down of blood supply (due to blockage of a heart artery) to a part of the heart. The heart muscle without blood supply for more than a few minutes can be damaged permanently. Because of this, earliest possible reestablishment of blood flow by opening the closed heart artery is the centerpiece of management of heart attack victims. The time is of the essence in these cases. The prevailing literature seems to be quite clear thus far. It tends to get murky from here on.

What about a patient who does not really come with a heart attack but is found to have a closed artery that might have closed days, weeks, months or years back? There have been some non-randomized trials that suggest that a closed artery should be opened regardless of how long it has been closed. This is the basis for open-artery hypothesis. Simply put, open-artery hypothesis presumes that an open heart artery is better than a closed artery regardless of consideration for most other factors. In addition to some research supporting this hypothesis, it also appeals to our psyche. Broken glass needs fixing; a broken plane engine needs fixing; a broken door knob needs replacing, and a closed artery needs opening. The human body is a complex interplay of several dynamic intangibles (hormones, chemical reactions not visible to the naked eye and so hard to grasp sometime) that a glass, plane or door knob is not. So inductive reasoning may not apply to opening any closed artery.

A study published in December 7, 2006 issue of New England Journal of Medicine (NEJM) studied the benefits of opening a closed artery 3 to 28 days after a heart attack. This randomized study is named occluded artery trial (OAT).This study included the patients who had a heart attack due to a blocked artery, but that artery could not be opened within a few hours for some reason. This study showed that opening the closed artery more than several hours after heart attack not only did not help, but showed a trend toward hurting the patients. This study seems to question the open-artery hypothesis. Hillis and Lange, the authors of an accompanying editorial say that giving beta blockers could be as good as or better than opening a closed artery late after heart attack. Having researched this issue themselves, these authors speak from a position of authority. Increased risk of complications from an invasive stent procedure not withstanding, can a 10 cent beta blocker pill be as good as or better than a 15,000 dollar stent procedure?

After reading this article, I could not help but think of hormonal replacement for post- menopausal females. We had observed that risk of blockages of heart arteries in case of females was much higher after menopause. The obvious difference between pre and post-menopausal women is lack of hormones in post-menopausal women. So replacing those hormones should decrease chances of heart disease in post-menopausal women. It appealed to our psyche. It all made sense! The observational studies seemed to show what we expected. Then came a well-designed trial called HERS (Heart and Estrogen-Progestin Replacement Study) that studied the impact of hormones on heart disease in case of post-menopausal females. It showed that hormone replacement therapy might actually have harmful effects.

Could there be a parallel between hormone replacement therapy and open-artery hypothesis there?

OAT trial discussed above has sent an important message. From here on, we need to do more to test open-artery hypothesis aggressively. Proving it will validate our present position. Disproving it will not only save our patients numerous potentially harmful procedures, but will also save us much needed health care dollars.
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How to Increase Good Cholesterol (HDL)? Unfortunate Demise of the Pfizer Drug

HDL is an acronym for high density lipoprotein. It is also called good cholesterol. It can be measured by doing a fasting blood test called lipid profile. HDL acts as a friendly scavenger, so higher HDL is protective against blockage of heart arteries. Low HDL is a strong predictor of blockages of heart arteries. The desirable level for HDL is 40 or above. One of the reasons that we tend not to be very aggressive about increasing HDL is that we do not have many easy and good options to deal with this problem.
Few years ago, a study published in the Journal of American Medical Association talked about Apo A-1 Milano that had caused regression of coronary artery disease (blockages in the heart arteries). This was great news. Short of curing the problem of blockages in the heart arteries, having something like a Drano for the heart arteries will be the most important development in the field of cardiology. Around the time of publication of that study, I had Dr. P. K. Shah, an authority on Apo A-1 Milano on my radio show.
Pfizer came pretty close to filling the need for an HDL enhancing drug. Unfortunately, their drug Torcetrapib recently had to be taken out of contention due to excessive deaths among research volunteers taking this medicine.
So what are the measures that can increase HDL?
1. Aerobic exercises like walking, swimming, bike riding and jogging.
2. Weight loss.
3. Smoking cessation.
4. Cutting ingestion of trans fats can increase HDL. Trans fats are found in abundance in fats that are solid at room temperature. The fats described as “hydrogenated oils” on the food packages have lots of harmful trans fats. New York City recently took the lead in banning use of trans fats in the city restaurants.
5. One or two drinks of alcohol daily can increase HDL. There is however, a down side to prescribing alcohol as an HDL enhancing measure. One of the possible problems is alcohol’s addiction potential.
6. There are good fats and there are bad fats. The good kind monounsaturated fats such as canola oil, avocado oil, olive oil and those found in peanut butter can help increase HDL. A word of caution: very low fat diets are known to lower HDL and too much of any fat increases calorie content which can lead to weight gain. The later in turn can decrease HDL.
7. Fibers found in oats, fruits, vegetables and legumes can help increase HDL.
8. The statins like Pravastatin, Simvastatin, Lovastatin, Crestor and Lipitor as a general rule are not good HDL enhancers. High doses of a B group vitamin called Niacin can help increase HDL. The patient acceptance however continues to be a challenge due to side effects like flushing and itching after taking this drug. Some tips on decreasing the chance of side effects from niacin are: taking an aspirin 30-60 minutes before taking niacin, taking niacin at night and avoiding high fat diet at night. Some long-acting niacin manufacturers claim fewer side effects as compared to short-acting niacin.
I am discouraged by the news of unfortunate demise of a promising HDL enhancing drug from Pfizer. But I am very happy to see oversight of research trials (that should assure safety of research volunteers) at work. I think a good, effective and well tolerated HDL enhancing drug will lead to a new phase of aggressive management of low HDL. Short of that, we should focus hard on HDL enhancing measures stated above. All these measures are not only good for increasing good cholesterol, but are also good for our overall wellbeing.
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On Door-to-Balloon Time: The Other Side

If a person is having an acute heart attack, we need to try to open the artery causing the heart attack as soon as possible. This can be done either by giving a clot-buster medicine or doing angioplasty and stenting. A recent article in the New England Journal of Medicine has drawn attention to a very important subject. This studied various factors that could cut the time it takes for a heart attack victim to get earliest possible angioplasty. I think most of these strategies other than that suggesting having a cardiologist in the hospital all the time can be put in practice. That will mean interventional cardiologists staying in the hospital on the day (and night) they are on call like they did during their training. It will be hard, as this practice will have the potential of dissuading the best talent from choosing interventional cardiology as a line of choice. But I think we can achieve time goals by smoothing the process at several other levels that were looked into.
There is a need to pay attention to another aspect of the issue. We are aware that some people, when they are being watched, are consumed by the thought of committing any mistakes. No, I do not think I will call it Hawthorne effect. The study published in NEJM has got a lot of well deserved ‘air time’. I think the following points also need to get attention:
- For an algorithmic approach to work well, clarity from point A to Z is very important. It should be made clear that this approach is for clear-cut heart attack with clear-cut ST elevation on electrocardiogram (EKG).
- The pressure to meet time goals can lead to over diagnosis of ST elevation heart attack, hence leading to unnecessary, expensive and sometime harmful procedures.
- Despite the need to make time goals, a diligent effort should be made to make the right diagnosis. We should follow World Health Organization (WHO) guidelines for the diagnosis of an acute heart attack. Out of the three features including typical chest pain suggestive of angina, typical EKG changes suggestive of an acute heart attack (MI), and blood test suggestive of an acute MI, two should be present to make diagnosis of an acute MI. Of course, there are odd presentations of an acute MI. But algorithmic approach to treating a disease does not work well for ‘Zebras’ of medicine.
- We should not feel pressured into over diagnosing heart attacks for the fear of missing a rare one with odd presentation.
- A careful, even if quick history and physical examination before heart cathetrization should remain an integral part of management. According to the prevailing wisdom, an early visit to the catheterization lab is the best option for heart attack victims with ST elevation on EKG. But this may not be the best option for an occasional patient on account of his or her wishes, significant co- morbidities etc. A diligent history and examination will help us unearth these issues.
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Mitral Valve Prolapse (MVP) F.A.Q.

I have tried to answers some of the questions on mitral valve prolapse like:
What is mitral valve prolapse?
How common is mitral valve prolapse (MVP)?
Can mitral valve prolapse (MVP) run in families?
What are the common symptoms of mitral valve prolapse (MVP)?
Can mitral valve prolapse (MVP) cause panic attacks?
What are some of the problems a person with mitral valve prolapse (MVP) can have?
I am really concerned that I might have mitral valve prolapse (MVP). What should I do?
Years ago, I was told that I had mitral valve prolapse (MVP). A doctor recently told me that I do not have mitral valve prolapse (MVP). How can that be possible?
I have mitral valve prolapse (MVP). What could I expect?
Click here for answers
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Questions on high blood pressure (Hypertension) answered

Over the years, I have been asked several questions on high blood pressure like:

What is the right blood pressure?
Which is more important, upper (systolic) blood pressure or the lower (diastolic) blood pressure?
I am 67 years old. What is the normal blood pressure for me?
What are the symptoms of high blood pressure?
Why treat high blood pressure if it does not cause any symptoms?
How do I know that I have high blood pressure?
What kind of blood pressure measuring machine should I buy?
Is measuring blood pressure at a store like Wal-Mart okay?
Are digital machines as good as those in a doctor’s office?
How frequently should I check my blood pressure?
How do you treat blood pressure?
What causes high blood pressure?
What is white coat hypertension?
When should I get worried about high blood pressure?
Why is my blood pressure so hard to control?
I have always had perfect blood pressure. Now my provider says I have high blood pressure. How can that be possible?
When is blood pressure considered too low?
For the answers, click here

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My Uncle Pete

I grew up watching my uncle work long hour in his store. He has never gone to school, but is able to do complex number calculations without the help of a calculator. He owned a general store. He had an uncanny ability to make every customer feel special. Every customer would walk out of his store thinking that he got the best deal. My respect for his business acumen has only grown over the years.
During the late 90s, I was enticed by the trend that later came to be known as dot-com bubble. I wanted to be part of that gold rush. I had a casual conversation with uncle Pete about different companies making tons of money by selling their projects to other companies. I talked to him about this despite thinking that it would be hard for uncle Pete to understand the intricacies of a new technology. He summed up his thoughts on dot-coms somewhat like this, “I don’t really understand much about the computers and internet. To my simple mind, for a successful business, you have to make more money than you spend. It looks like a lot of companies are getting capital and buying expensive projects without having figured out a way to make their money back.”
I did not lose a single penny during the dot-com bubble. This was not because I listened to the uncle, but because I did not have any money to invest.
Few days back, I had a conversation with uncle Pete on the health care system. I talked about the rising cost of health care, and how everybody is at a loss to figure out a way to make health care more affordable. To this he said, “ I am sure the best brains of the world are working on this problem. I do not really understand the details. I see any business as a transaction between the seller and the buyer. When these two parties get to make the main decisions, the seller does his best to woo the buyer and buyer shops for the best value for his money. I see health care as a transaction between a health provider and a patient. But it looks like neither of these parties is an important decision-maker. That can make it all hard to work well.”
Just like I thought about his answer to the dot-com question, I am wondering if the basis for such a humongous problem can be described in such a simple way.
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Potential Overuse or Misuse of Diagnosis of Heart Failure

A study in the Journal of American Medical Association draws our attention to heart failure in patients with normal left ventricular systolic function. The symptoms of heart failure can be due to weak heart muscles or inability of the heart muscles to relax. The former is called systolic heart failure while the later is called diastolic heart failure. Various studies have shown prevalence of diastolic heart failure (in the absence of weak heart muscles) to be up to 50%. The recognition of an entity called diastolic heart failure some years back was a good development. Prior to that, the medical community would not think of a diagnosis of heart failure in patients that had normal heart function on echocardiogram. The recognition of diastolic heart failure however brings following challenges with it:
It is easy to start treating for heart failure once weak heart function is recognized. Moreover, it is important to recognize systolic heart failure because we have definitive treatment available for this disease. Diagnosing systolic heart failure is also easy. Very simple procedures like echocardiogram can do it. On the other hand, diagnosing diastolic heart failure is difficult. Several diagnostic methods have been devised. Several of them are in the process of being validated.
The diagnosis of heart failure itself is not always easy. A shortness of breath or edema of the legs can be due to several causes including heart failure. The diagnosis of diastolic heart failure involves two steps; the diagnosis of heart failure and that of diastolic dysfunction. In the absence of foolproof criteria for the diagnosis of heart failure and diastolic dysfunction, some people can be wrongly given this diagnosis. If we are not careful, it has the potential of being the convenient diagnosis for a lot of symptoms. We saw this kind of overuse of the diagnoses mitral valve prolapse (MVP) and MVP syndrome some years ago.
The effective treatment of diastolic heart failure is the treatment of its causes including diabetes, high blood pressure and disease of heart arteries. Should we not be treating them aggressively any way?

Pragmatic action points:
- It is important to be aware of diastolic heart failure as a clinical entity. But it is important not to use it as an easy explanation for most of our patients’ symptoms. Other more easily treatable causes of the symptoms that can be confused with diastolic heart failure should be sought.
- We should focus on optimal treatment of the diseases that cause diastolic heart failure regardless of the presence of diastolic heart failure.
- It is very important to keep seeking better treatment measures for this disease. However, we need to be aware of potential misuse of this diagnosis.
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Outsourcing Medical Care

Kevin, MD and Dr. Wes recently talked about healthcare outsourcing. They talk about Americans going to other countries to seek medical care. The responses to their posts are a good gauge of emotions that this issue stirs.
Two or three days back, I heard an advertisement on the radio about some kind of heart procedure that is not approved in the US. The advertisement was offering that procedure in Singapore or Thailand. Things like this make people like me practicing medicine in the US nervous for our patients.
I have talked with several people about getting prescription drugs from other countries. Appeal to citizens’ nationalism and plea to support research in the US are some of the tactics that have been tried to prevent people from buying drugs from abroad. More than a few people told me that when it is a choice between eating and buying medicines, supporting pharmaceutical research is the last thing on their mind.
In a market place, Bloomingdale’s can be as proud of its quality as it wants. However, if most of the buyers choose to go to Wal-Mart, that is where they go. In this day and age, the world is turning into a big mall. If there is a product being sold at 40% off on the east end of the mall, that is where people will go. The customers do need to know more about this new concept of medical care abroad, so that they can be good judges of quality. Posts on Kevin, MD and Dr. Wes bring up challenges that come with seeking medical care abroad.
As health care providers, we work hard to give our patients the best possible care, and it is hard for us to fathom why some people would choose to seek medical care that seemingly is held to no standards. This is far beyond losing business to foreign competitors. It is personal, as we give far more than 100% to our profession. But if some of our patients are forced to choose between health care and financial health, they may decide to have both. And going abroad may seem like a great option to them.
The question is what can we do? How we can we stem this tide?
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Outsourcing Research?

A Wall Street Journal article reports that many drug companies are going to Finland for drug research. It is thought that study subjects there are more compliant, with low drop out rates. We have heard of similar interest in India and China.
Most of the research is done by changing a single variable. For example, half the patients given a study medicine are compared to the half that are not given that medicine. We try to measure the effect of a medicine in real life scenarios; that is an interaction of medicine with how study subjects live, what they eat, how active they are, the air they breathe, their ethnic background, and much more.
We have now recognized that people can have unique response to disease and treatment based on their gender, ethnicity etc. Against that background, should we apply the research data obtained on a different population to the patients in the US? Should FDA approve the drugs for use in the US based on research done on subjects on another continent?
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Six Things You Must Know About Heart Disease

1. No, you are never too young to be thinking of your heart.
2. We talk about heart disease, and heart attack comes to mind. In addition to blockage of heart arteries, several other problems can affect this organ . There can be problem with wiring of the heart causing heart to go too fast or slow or erratic. There can be problem with heart muscles leading to heart failure. There can be shrinkage or leakage of the heart valves or other structural abnormalities.
3. A concern for heart attacks makes us think of heart disease in local terms. We just tend to think of blockages that need fixing. The heart arteries are part of body’s plumbing system that runs from head to foot. Persons who have heart attack tend to be at a higher risk for stroke and vice versa. This makes a strong case for thinking of heart disease in systemic rather than local terms. Systemic approach should involve controlling the risk factors for heart disease aggressively.
4. Not too long ago, we used to think that heart artery blockages progress over time (progressing from 50 to 60 to 70 percent and so on), and eventually cause heart attack. Later studies suggested that most of the heart attacks are caused by the arteries that are less than 50% blocked. These are the blockages that are hard to detect through commonly used tests. I am saying this to make a case for effective proactive approach and not to convey a defeatist attitude. A proactive approach involves controlling risk factors for heart disease like high blood pressure, diabetes, high cholesterol, smoking, physical inactivity etc.
5. Cardiology (study of heart) is a rapidly evolving field. There was a time when people used to think that high blood pressure is an essential part of growing old. There was a time when swollen heart failure patients were treated by bloodletting mistakenly thinking that it will help them. The concept of intensive care unit treatment of heart attack patients has, and continues to save numerous lives.
6. And most important, it is possible to have perfectly normal life after heart problem. Quite often my patients have told me, “This heart attack was a wake up call for me. Now I eat right and exercise daily. I am feeling better than I have felt in a long time”.
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A Life Saver for Lung Cancer Victims

Lung cancer continues to be a disease with dismal prognosis. Currently in the US, 95% of people diagnosed with lung cancer die within five years. In most of the cases, by the time a diagnosis is made, it is too late. This has prompted constant search for a screening test that will impact survival in patients with lung cancer. We want to be able to do what we have done with mammogram for breast cancer and colonoscopy for colon cancer. For a screening test to be effective, it should have certain characteristics including the following:
1. Be easily doable in every day medical practice.
2. Be able to detect disease early enough to impact survival.
3. There should be good treatment options available for the disease we are screening for.
4. For it to be offered widely, this test should be cost-effective (a technical term for ‘bang for the buck’)
As a part of recently published study, nearly 30,000 smokers, ex-smokers and those exposed to second hand smoke (groups at high risk for lung cancer) were screened for lung cancer with yearly CT scans. This New England Journal of Medicine study shows that 412 study subjects that were found to have stage I lung cancer during surveillance had a 10-year survival rate of 88%. This is far better than survival without surveillance.
Based on this study, all but condition number 4 above for a screening test seem to be met. There is a need for some good cost-effectiveness studies utilizing CT scan for lung cancer screening.
There is a concern that CT scan surveillance gives false positives leading to unnecessary tests. I do not see it as a big point against surveillance. We do expect some false positives with any screening test.
It might be a little while before this test is widely offered, and third party payers agree to pay for it. Till then, if I had a loved one who smokes despite my threats, cajoling and nagging, will I want him or her to have a yearly CT scan? I think, I will.
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When the Gold Standard Comes Under Fire

A recent article questioned the research that was the basis for guidelines suggesting target bad cholesterol (LDL) of less than 70. It refers to the National Cholesterol Education Program (NCEP) guidelines on desirable cholesterol level that were revised in 2004. The guidelines are seen by some as a gold standard.
When they came out, these guidelines prompted some physicians to shoot for LDL cholesterol level of less than 70 for most of the patients. A perusal of the guidelines clarified that LDL cholesterol level of less than 70 is desirable only in certain special circumstances.

Ever since the cholesterol lowering medicines called statins have gone generic, we have seen direct to consumer marketing prompting people to take cholesterol-lowering medicines other than statins. One of the reasons given is that new medicines are different (just like wearing Versace is different?).

Here is my take:
- A case for aggressive lowering of cholesterol has partly been based on the data that effect of statins goes beyond just lowering cholesterol. Statins should be our first line of therapy for lowering cholesterol.
- More aggressive cholesterol goals prompt us to use higher doses of statins, and higher statin doses are more likely to cause side effects. These in turn affect patient compliance.
- There is a need for making the guidelines easier to follow, and less prone to spin by vested interests. We got some confusing signals from JNC 7 guidelines on high blood pressure as well.
- There is a growing group of people saying that standardized patient care saves money and life. The detractors think that the cookie-cutter version of medicine takes away flexibility from the treating doctors, and promotes mediocrity. The questioning of these guidelines has brought up another issue. They say that standardized care can sometimes be based on faulty guidelines. Based on that, they invoke a term from the computer world, GIGO. Advantage detractors?
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The BiDil Saga: Much Ado About Nothing

BiDil is trade name of a drug that is a combination of two medicines, Isosorbide dinitrate and Hydrallazine. Studies revealed that this combination is particularly useful in African-American patients with heart failure. This study stimulated a welcome discussion about custom-made medicine for patients based on age, gender, ethnicity etc.
A recent Wall Street Journal article talks about the tension between insurance companies and the maker of BiDil. The maker says that the nitrate and Hydrallazine combination contained in BiDil is a unique one. They claim that the unique dosage combination has an effect that the combination of generic and much cheaper Isosorbide dinitrate and Hydrallazine does not have. Moreover, based on the study data, FDA approved this combination for heart failure in African-Americans.
The insurance companies have so far refused to cover BiDil contending that the benefits from BiDil could be obtained from the much cheaper generic Isosorbide dinitrate and Hydrallazine.

Here is my take on it
1. I do not see any magic in the dosing of BiDil. Moreover, in every day practice of medicine, many times we are not able to keep patients on the doses that are used in research protocols. This is for several reasons including side effects
2. The cardiologists have used the combination of these two medicines for decades in patients who had heart failure but could not tolerate ACE inhibitors. ACE inhibitors as a group are considered first line drugs.
3. Each tablet of BiDil includes 20 mgm of Isosorbide dinitrate and 37.5 mgm. of Hydrallazine. The generic forms of these medicines are available in strengths that make achieving this dose very easy.

Action points:
1. Based on the research, there may be a case for starting African-American patients with heart failure on Hydrallazine and Isosorbide dinitrate as first line of treatment
2. A physician’s job, first and foremost is to provide best possible care to his or her patients at best possible price. I do not see any reason for the combination of generic drugs to be inferior to the combination marketed as BiDil
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Six Reasons Why Patients Stop Taking Medicines

Several patients stop taking life saving medicines within a month of having a heart attack, says a study published in Archives of Internal Medicine. This study did not examine why people stop taking medicines. As for why people stop taking medicines, here is what my sources tell me.

1. Most of the medicines are very expensive. Health is precious, but there are situations where our bills take precedence over health.
2. People look to conventional (allopathic) medicine for acute problems. But they do not seem to have as much trust in allopathic medicine for health maintenance or chronic conditions.
3. We are unable to give concrete reasons for taking the medicines that we prescribe. Many proponents of natural products are able to make a stronger case for their products. It is not uncommon to see patients using their limited dollars to buy natural medicines instead of allopathic medicines.
4. There are several patients who take up a vigorous and healthy life style after a medical event like heart attack. They work very hard on leaving a feeling of vulnerability behind. Taking a fist-full of medicines is a daily reminder that they are still very sick. Ignoring to take medicines is a declaration that they are not sick any more.
5. Side effects are an important reason for stopping medicines. The side effects like “not feeling well”, “feeling fatigued”, “feeling nauseous” may have a completely different significance for the person experiencing them as compared to the prescriber
6. And last but not the least, patients have a life too. They can forget taking medicines just because…

Munch on this while I work on the steps to prevent patients from stopping medicines.
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Preventing Death in Heart Patients

Rhythm problems and congestive heart failure are two of the main end results of all heart problems. The congestive heart failure in the advanced stages carries a long term prognosis worse than that of cancer. The rhythm problems involving the lower chamber like ventricular tachycardia and ventricular fibrillation can lead to sudden death.

A study called MADIT-II involved patients who had very low ejection fraction (ejection fraction is a measure of pumping power of the heart muscles) due to blockages of heart arteries. The study showed that a defibrillator (also called ICD) can help prevent sudden death in these patients. The defibrillator is sometimes called shock box in every day lingo. A defibrillator is like a pacemaker that is usually implanted under the collar bone. The computer in this machine can detect and try to treat any serious heart rhythm problems that could potentially lead to death.

Another study called SCDHeFT {pronounced as scud-heft (as in theft)} involved persons who had weak heart muscles regardless of the cause. In MADIT-II study above, the heart muscle damage had to be from blocked heart arteries. The study showed that these patients will benefit from ICD as long as they got short of breath on every day ordinary or less than ordinary activities (said to be belonging to NYHA class 2 to 3 in scientific lingo).
These two studies have made millions of patients eligible for defibrillators. Because of logistical as well as financial constraints, there is a need for prioritization. A recent study published in the journal Circulation (Circulation. 2006; 114:135-142*) has studied the cost-effectiveness of defibrillators in patients in SCDHeFT study detailed above. If you care, SCDHeFT stands for Sudden Cardiac Death in Heart Failure Trial.

The study shows that ICD is cost-effective in patients that meet all of the following criteria:
Have weak heart muscles (ejection fraction down to ≤35%)
Get short of breath on ordinary activities
Get defibrillator with single chamber pacemaker
Be expected to live more than 8 years

My take on the study:
It is hard to try to put a dollar figure on human life. When it comes to our own loved ones, rationing the medical care can make us angry. However, the limited numbers of dollars available demand prioritization. According to this study:

The ICDs are not cost-effective in the patients that become short of breath on less than ordinary activity or at rest.
We do know that patients that have very weak heart muscles may also have other problems that may seriously impair their life span. According to this study, the ICD is cost-effective if a person is expected to live more than 8 years.
The cost-effectiveness was measured based on the cost associated with single wire pacemaker. The trend lately has been to implant two or even three wire pacemakers with defibrillator. The calculation based on much more expensive two or three lead pacemakers will make these ICDs look much less cost-effective

The development of sophisticated ICDs is one of the major developments in the field of cardiology. Offering an ICD based purely on the basis of weakness of heart muscles is a relatively new field. There is a need for identifying the patients that ICDs may help the most, so that we do not squander our resources by the time we get to them.

*In case you are wondering, this information with all the numbers can be used to get to the original Circulation article.

A Not So Great Test?

Wall Street Journal talks about a urine test used to assure abstinence from alcohol. The report talks about a nurse and a pharmacist having lost their jobs after failing this test. The nurse has passed a polygraph test stating that she hasn’t drunk. The studies now show that this test that so many important decision may have been based on is not 100% reliable.
I wonder how many lives might have been adversely affected by blind faith in this test.

Mental Illness Awareness Week

October 1-6, 2006 is mental illness awareness week. I will be talking to representatives of National Alliance on Mental Illness on my live radio show today. You can join the discussion by calling toll free 1-888-7CHANDER between 4 and 4.30 PM mountain time today, October 4,2006.

Can a Heart Murmur Kill Me?

Heart Murmur F.A.Q.

Can a heart murmur kill me?
That depends. What if someone asked us if fever could kill you? If your fever is due to a minor viral infection, it may not mean anything. On the other hand, this fever can be due to a potentially fatal illness like cancer.

What is a heart murmur?
A murmur itself is not a disease. It could be sign of a disease. Heart murmur is simply an abnormal sound that is heard when your doctor listens over your chest with a stethoscope. Normal heart beat sounds somewhat like lub-DUB. Click here to listen to a murmur on a UCLA website.
The heart is a pump with four chambers and four valves. The chambers are separated from each other by valves or walls (septum). If there is a hole in the heart or shrinkage or leakage of a heart valve, the abnormal flow may cause a murmur. Some times simple blood flow through the heart chambers may cause a murmur. Later are called flow murmurs or innocent murmurs.

So can a heart murmur kill me or not?
The significance of a murmur varies. Some murmur-causing conditions need immediate treatment. Some heart murmurs are due to issues that will likely never cause trouble for you. Some heart murmurs are due to abnormalities that need to be watched closely over time.

How do I know whether my heart murmur is due to a serious problem or not? My grandfather who is 72 has had one all his life?
In most cases, the significance of heart murmur can easily be determined on the basis of a non-invasive test called echocardiogram. Before the echo days, people would carry the diagnosis of a “murmur” through their life. In this day and age, nobody should carry a diagnosis of “murmur” without knowing its significance. As I said before, not all murmurs mean serious heart trouble.

What do I do if I have a heart murmur?
Based on the tests including an echocardiogram, your doctor should be able to tell you what to expect in the future. Should you restrict your activities? Do you need follow up echocardiograms as a part of wait and watch strategy? Should you tell all your doctors including dentists that you have a heart murmur? These are the questions that your doctor will be able to answer for you.
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Can We Revive the Damaged Heart?

The heart muscles do not have the ability to regenerate. Recent research explores the possibilty of reviving dead muscles of the heart.
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$4 Menu: A Eureka Moment?

Wal-Mart and Target recently announced that they will sell a month’s supply of several generics for four dollars.
I recently saw an un-insured patient who was very excited about this news. He said, “Now I can see a doctor, buy cheap medicines and may be buy some kind of catastrophic health insurance for any emergencies, and I am all set. This is a history-making moment for our health care system”.
Do you think Wal-Mart and Target’s decision will make a significant impact on the problems that face health care system today?
If you want to talk about it on my radio show, call me toll free 1-888-7CHANDER between 4 and 4.30 PM mountain time, Wednesday, 9/27/06.
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