But this one particular week seemed to tip the scale in terms of grossly abnormal lab results needing immediate attention, bizarre medical complaints and truly distressing/worrying mental health issues.

Like the 96 year old woman who looked astonishingly 25 years younger with the confidence and assurance of a woman in her prime whose blood work had me scrambling to set her up with a specialist asap…or the frantic 87 year old I agreed to see spur of the moment who had pulled off multiple ticks from her chest. I’m not 100% sure, but I think she had been using tweezers to pull off skin tags and moles.

But somehow, it’s the mental health cases that are so distressing like the angry, young bipolar patient who was so upset and ashamed by this diagnosis years earlier that  we didn’t even know about that part of the history until the patient presented to me on this particular day – in crisis.  This patient was standing at the precipice of disaster scared by the thick, black, violent rage within. By the time I was able to speak to other family members, the ED,  the crisis intervention people, and of course the patient, I was running almost an hour behind….

Someone recently asked how I debriefed from that session. I was a little startled because of course, I didn’t – I was too backed up. I simply had to see the next patient until gradually, I became caught up in the next story, the next illness. Some days, I struggle to remember all the cases I had that day.

What I do is not unusual – all my colleagues have days like this. Juxtaposed against these sometimes intense days and the constant reminders of  human frailty is the phone call asking me to pick up milk on the way home or the empty bird feeder that is waiting to be filled or the ride Jacob needs from his friend’s house. It’s these reminders of my outside-of-work life that nourish me in a different way from the work that I do – and for that I am grateful.

I have a number of patients who are either overweight or obese and although this is always of concern to me because of the  potential for diabetes, hypertension and dyslipidemia, I am most concerned about my obese younger patients.

We note the BMI (body mass index) on all our patients. This is a very simple chart that has the height in inches along the vertical axis and the weight along the horizontal. By simply measuring the person’s height and weight, it’s a simple step to finding the BMI.

A BMI between 25 and 29 is considered overweight and a BMI 30 or more is obese. Furthermore, there is a distinction between obese and extreme obesity which is a BMI of 40 or more.

So it was with particular sadness that I met a teenager whose BMI was greater than the chart measures (a BMI over 54). He was already showing signs of diseases we would expect to see in middle-aged adults: hypertension and elevated cholesterol.  Needless to say, he suffered from depression.

He has a long psychological road ahead of  him and almost certainly a medically complicated future. At this stage, simply eating less is not likely to produce the desired outcome because of the complex metabolic reactions that conspire to keep him from losing weight.

Research in the causes and treatment of obesity is compelling but still a long way from practical application. Given the enormous financial burden this puts on our health care, (let alone the psychological burden endured by individual), we need to develop public policy that promotes nutritional education in high-risk groups, brings back physical education in schools, bans the sale of fast-foods and soft drinks in schools and supports a tax on the sale of foods that we know contribute to this epidemic.

I believe we can reverse this epidemic in the same way that we have decreased the number of people who smoke cigarettes by banning television advertisements and the sale of cigarettes to minors as well as a well orchestrated educational media blitz.

We can’t afford to let this epidemic go unchecked.

Generally speaking treating insomnia involves treating the underlying cause if possible. If insomnia is due to psychiatric causes such as depression or anxiety, the individual may be put on anti-depressants or anti-anxiety medications.

If insomnia is due to an underlying medical condition such as fibromyalgia, gastroesphophageal reflux, restless leg syndrome, sleep apnea etc, then treating the cause often leads to successful outcomes.

For those whose insomnia doesn’t fit the above, I consider several drug categories that have been used in the past as sleep aids. These include:

• antihistamines (older, first generation ones)
• benzodiazepines
• antidepressants or
• sedatives

Antihistamines

Older antihistamines such as Benadryl (diphenhydramine)  are noted for their sedating side effects. These medications are sold over-the-counter and are often used for transient episodes of insomnia. Many people who first take the medication report a “hangover” effect the next day meaning that they feel groggy hours later.

This is a transient side-effect that generally dissipates the longer one takes the medication. In the event that fatigue continues, taking 1/2 a tablet (12.5 mg) often solves the problem.

By the way, Tylenol P.M. is used as a sleep aid and is a combination of Tylenol and diphenhydramine. If all you’re looking for is something to help you sleep, you can skip the Tylenol component and buy diphenhydramine. It’s cheaper.

Benzodiazepines

Benzodiazepines are generally referred to as sedative/hypnotics and are used to induce calmness in the awake patient thereby to induce sleep. They are mainly used to treat anxiety but are often used as sleep aides. The drawback to this class of meds is their potential for abuse and withdrawal symptoms if stopped abruptly. I am not an advocate of keeping patients on this and use it only for the short term because of the strong likelihood of dependence.

Antidepressants

Some antidepressants such as Trazadone are noted for their sedating side effects and are therefore given in low doses which would not be therapeutic for treating depresssion. Seroquel, a medication used to treat schizophrenia, is also prescribed in small doses to treat insomnia. In patients struggling with depression, this can be a good alternative.

Sedatives

Health insurance companies put a limit on the number of sedatives that can be prescribed in a month usually limiting the number of pills to around 12. Why? Again, it is very easy to grow dependent on medications to induce sleep and given that many Americans look to medications to solve their problems, it’s easy to understand why there is a limit.

The NYTimes published a list of its most viewed stories for 2009 and this was on it. Written by Tara Parker-Pope, I’m including it in its entirety if you haven’t read it. Given that weight loss is the most popular New Year’s Eve resolution, I think you’ll find it helpful.

The 11 Best Foods You Aren’t Eating

Nutritionist and author Jonny Bowden has created several lists of healthful foods people should be eating but aren’t. But some of his favorites, like purslane, guava and goji berries, aren’t always available at regular grocery stores. I asked Dr. Bowden, author of “The 150 Healthiest Foods on Earth,” to update his list with some favorite foods that are easy to find but don’t always find their way into our shopping carts. Here’s his advice.

1. Beets: Think of beets as red spinach, Dr. Bowden said, because they are a rich source of folate as well as natural red pigments that may be cancer fighters.
   How to eat: Fresh, raw and grated to make a salad. Heating decreases the antioxidant power.
2. Cabbage: Loaded with nutrients like sulforaphane, a chemical said to boost cancer-fighting enzymes.
   How to eat: Asian-style slaw or as a crunchy topping on burgers and sandwiches.
3. Swiss chard: A leafy green vegetable packed with carotenoids that protect aging eyes.
   How to eat it: Chop and saute in olive oil.
4. Cinnamon: May help control blood sugar and cholesterol.
   How to eat it: Sprinkle on coffee or oatmeal.
5. Pomegranate juice: Appears to lower blood pressure and loaded withantioxidants.
   How to eat: Just drink it.
6. Dried plums: Okay, so they are really prunes, but they are packed with antioxidants.
   How to eat: Wrapped in prosciutto and baked.
7. Pumpkin seeds: The most nutritious part of the pumpkin and packed with magnesium; high levels of the mineral are associated with lower risk for early death.
   How to eat: Roasted as a snack, or sprinkled on salad.
8. Sardines: Dr. Bowden calls them “health food in a can.” They are high in omega-3’s, contain virtually no mercury and are loaded with calcium. They also contain iron, magnesium, phosphorus, potassium, zinc, copper and manganese as well as a full complement of B vitamins.
   How to eat: Choose sardines packed in olive or sardine oil. Eat plain, mixed with salad, on toast, or mashed with dijon mustard and onions as a spread.
9. Turmeric: The “superstar of spices,” it may have anti-inflammatory and anti-cancer properties.
   How to eat: Mix with scrambled eggs or in any vegetable dish.
10. Frozen blueberries: Even though freezing can degrade some of the nutrients in fruits and vegetables, frozen blueberries are available year-round and don’t spoil; associated with better memory in animal studies.
    How to eat: Blended with yogurt or chocolate soy milk and sprinkled with crushed almonds.
11. Canned pumpkin: A low-calorie vegetable that is high in fiber and immune-stimulating vitamin A; fills you up on very few calories.
    How to eat: Mix with a little butter, cinnamon and nutmeg.

You can find more details and recipes on the Men’s Health Web site, which published the original version of the list last year.

In my own house, I only have two of these items — pumpkin seeds, which I often roast and put on salads, and frozen blueberries, which I mix with milk, yogurt and other fruits for morning smoothies. How about you? Have any of these foods found their way into your shopping cart?

At issue is the fact that the addition of caffeine leads the consumer to believe s/he is less intoxicated than if strictly alcohol was  consumed, despite performing just as badly on sobriety tests .

Because it gives (young) people a false sense of sobriety, the consumption of these drinks is worrisome. In addition, caffeine is regulated to no more than 200 parts/million in soft drinks but is unregulated in alcohol. To date, the article reports that 27 companies have removed their combo drinks from the market.

Follow this link to read more about the effects of caffeine on alcohol intake.

Common causes of post-menopausal uterine bleed include atrophy of the vaginal mucosa and in fact is the cause of 59% of bleeding. Polyps account for another 12% with endometrial cancer accounting for 10%. Cervical cancer accounts for less than 1%.

Atrophy is caused by the lack of estrogen which explains why post menopausal women often have vaginal dryness. This dryness leads to micro tears that cause spotting. Treatment, depending on severity is by estrogen replacement, either topical or oral.

Endometrial cancer is the leading cause of genital cancer in post-menopausal women and is highly treatable when caught early with 96% of women with localized (non-metastatic) endometrial cancer surviving after 5 years.

UpToDate publishes a great patient handout that I highly recommend: Endometrial Cancer Treatment. 

Treatment involves dilatation of the constricted area with a large caliber balloon, but this treatment is not permanent and recurrence is common after 5 years.

The chief symptom is a feeling of food getting stuck in the throat. Once treated with dilatation, it is generally recommended that medications to suppress acid be given as this may help to decrease the frequency of recurrence.

What is not known is whether XMRV, which is also linked to prostate cancer, actually causes Chronic Fatigue Syndrome or if it is an opportunistic virus which appears as a result of Chronic Fatigue Syndrome.

There has been a great deal of debate surrounding the definition of Chronic Fatigue Syndrome. In 1994, a group of international medical experts drafted a definition of CFS. Essentially, CFS is characterized by a profound fatigue, unexplained by other medical causes, that lasts 6 months or longer and involves swollen lymph glands, painful joints and/or muscle pain, sore throat, sleep that is not restful, and several other symptoms. The Centers for Disease Control (CDC) has useful information on Chronic Fatigue Syndrome.

The XMRV virus, known as xenotropic murine leukemia virus-related virus, has been linked to prostate cancer and is known to cause leukemia and tumors in animals. It is not unusual for viruses to be linked to specific diseases (think of HIV, hepatitis B & C, Epstein-Barr virus etc).

For more information about the link between viruses and cancer, the Proceedings for the National Academy of Sciences has a web site that has published an in-depth article about the link between XMRV and prostate cancer.

Gout is a painful arthritis

Standard pharmacological therapy works in 2 ways: 

• reducing uric acid production OR
• increasing uric acid excretion

Urate develops as a byproduct of purine metabolism and in fact is thought to be beneficial due to its antioxidant properties that rival the benefits of Vitamin C. However, too much urate leads to hyperuricemia, a condition defined as high serum uric acid levels that exceed 7 mg/dL. At this level, the urate crystals become supersaturated in plasma. Not all people who have hyperuricemia develop gout but in those that do, the crystals become lodged in the tissue and joints causing pain and inflammation. 

 Whether urate levels become problematic depends on striking a balance in three areas: the body’s rate of production, rate of excretion and intake of dietary sources. Treatment therefore is aimed at these three areas with medication working to either reduce the formation of uric acid or increase the body’s ability to excrete the crystals.

Uricosuric Agents

Uricosuric agents work by enhancing excretion of uric acid by the kidneys. People who suffer from kidney stones are generally not candidates for these medications because of the increased risk of stone formation.

These agents are generally reserved for people for whom it has been shown actually under-excrete uric acid.

There are several uricosuric agents on the market in the U.S.: probenecid and benzobromarone of which the former is the most widely known and used. Starting doses are low and are gradually increased over a period of several weeks.

The major side effects of uricosuric agents are:

• rash
• GI disturbances
• recurrence of acute gouty attack
• kidney stones

Strokes otherwise known as cerebrovascular accident (CVA) or brain attack occur when blood flow is obstructed to the brain causing permanent brain tissue death. The difference between a “mini stroke” or TIA (transient ischemic attack) is that no permanent brain damage occurs.

Strokes are caused by either a blood clot or a hemorrhage. Of the two, a blood clot is more common than a bleed (80%). In order to distinguish between the two types of stroke, the first diagnostic test your doctors will order will be a CT scan of the brain to see what damage, if any, has been caused and where that occurred.

If the CT scan is due to a bleed, this will show up very quickly. However it can take up to 48 hours for changes on the CT scan to show if the cause is due to a clot. This is why a CT scan is repeated especially if symptoms do not resolve. An MRI may be done to clarify the situation.

Other diagnostic tests to help determine the cause, as well as to assess further risks, include a carotid ultrasound, and an echocardiogram and an EKG. 

The carotid ultrasound is done to see if the arteries that supply blood to your brain are blocked. Depending on the degree of blockage, doctors will determine if a carotid endarterectomy would be appropriate for you. This is a fairly straight-forward procedure in which the plaque is removed from the carotid arteries.

The purpose of the echocardiogram is to take a look at the blood flow through the heart to see if there are any abnormalities that may be causing blood clots. An echocardiogram is really just an ultrasound of the heart. For the same reason, an EKG is done to see if there are conduction abnormalities such as atrial fibrillation or bradycardia (a decreased heart rate) that my have caused a stroke/TIA.

These are the most common diagnostic tests to expect once you have symptoms of a TIA/stroke. Remember, if you have any signs, it is important to call 911 even if your symptoms quickly resolve because there are treatments that will help minimize the risk of further TIAs or stroke.