Bisher AKIL, MD

Archive for April, 2009|Monthly archive page


Do I have to?

In General Health on April 28, 2009 at 7:43 pm

As the media coverage of this infection spreads, I have been asked more questions. Here are some of them:

1. Should I cancel my trip to Mexico? The CDC is recommending against unnecessary travel to Mexico. Similarly, many countries have done the same. I recommend canceling all unnecessary travel for the time being to any destination. 

2. Are airplanes safe? Not clear. This was reported earlier today in the NYTimes: “Most of Boeing’s airplanes have air filtration systems with “similar performance to those used to keep the air clean in hospitals, operating rooms and industrial clean rooms,” according to Jim Proulx, a Boeing spokesman. “These filters are very effective at trapping microscopic particles as small as bacteria and viruses,” Mr. Proulx continued. “All Boeing production airplanes have HEPA filters, which are effective at capturing greater than 99 percent of the airborne microbes in the filter air.”- However, if you are sitting next to someone with Swine Flu (or within 6 feet from that person) then filters will not be of much use to you.

3. Should I wear a mask?: Face masks and respirators (see below) are most useful for people who are in crowded settings, such as classrooms, subway or airplanes, where they will protect the mouth and nose from germs and reduce the likelihood of coughing or sneezing on other people.

4. Would any mask do? No! Don’t count on those disposable masks to completely protect you against the swine flu. These are loose-fitting and designed largely to help stop droplets from spreading from the person wearing the mask. They also protect the wearer’s mouth and nose from splashes. They are not created to protect the wearer from breathing in very small particles. Respirators, on the other hand, are made for just that. They are similar in appearance to the relatively inexpensive face masks but are designed specifically to protect the wearer from breathing in such particles. These masks, known as N95 for its filtering ability, fit more snugly on the face than face masks so that most air is breathed through the filter material. They work best if they are fitted specifically to the person wearing the mask. so wear the correct mask (N95) and fit them snugly on your face.

5. Is this it? Am I now protected? No.  Face masks and respirators should be used along with other precautions, such as frequent hand-washing, covering coughs, staying at home if ill and avoiding crowds.

6. Should I panic now? No absolutely not. This is preventable and treatable illness. If you protect yourself and others, use common sense and do not ignore symptoms, then we will all be better.


Do I have the Swine flu?

In General Health on April 28, 2009 at 6:18 pm

Many of us are concerned about the Swine flu. As a physician in Medical practice, I received a lot of call from my patients about this. So here I will try to answer some:

1. What is Swine Flu? :Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs.

2. Is it contagious? Do I have to go to Mexico to get it? CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it is not known how easily the virus spreads between people. People who have it can pass it on to others.

3. If I have it what do I feel? The symptoms of swine flu are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu.  Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

4. How can I tell if it is Swine Flu from regular flu?: probably the most telling symptom is fever. Swine flu usually brings on fever above 100.5F, which is not common with regular flu.

5. How can I get infected with Swine flu? Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

6. How soon can one infect other? Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

7. How long would the flu virus stay infectious if it is on a door knob or handle or other hard surfaces? In addition to the droplets from coughing or sneezing, germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. the virus will remain contageous probably for 24- hours after dropping on a surface.

8. How can I protect myself  from the flu? First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.There is no vaccine available right now to protect against swine flu. 

9. What can I do to protect myself from getting sick? There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:

   * Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

    * Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.

    * Avoid touching your eyes, nose or mouth. Germs spread this way.

    * Try to avoid close contact with sick people.

    * If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

10. Is there any good news? Swine Flu responds to treatment, and we have two medications that can treat it (Tamiflu, Relenza). These medications must be started within the first 48 hours of symptoms. These medication do not prevent the infection, but rather treat it. Do not take thee medications unless there is high level of suspicion for Swine flu.


PSA, should we check it?

In Cancer on April 28, 2009 at 4:37 pm

Prostate cancer is the most common noncutaneous cancer in men in the United States. Despite its prevalence, the natural history of this disease is remarkably heterogeneous. In many patients, the cancer progresses slowly, resulting in tumors that remain localized to the prostate gland. Although potentially life-threatening, such cancers are most often curable.  Many patients with low grade and volume cancers may be candidates for active surveillance. In other patients, however, tumor growth may be more rapid, resulting in cancer spreading beyond the confines of the prostate. In such cases, long-term survival may be considerably diminished compared to survival associated with organ-confined cancers. Strategies for managing prostate cancer have therefore been aimed at early detection, with selective, tailored treatment.  Prostate-specific antigen (PSA) is a tumor marker currently used for early detection of prostate cancer. The American Urological Association has recommended that baseline prostate-specific antigen testing (and digital rectal exam) be offered to men as young as age 40 — with life expectancies of 10 years or more — after a discussion of testing’s benefits and risks. The recommendation appears in the group’s updated “Best Practice Statement” on PSA testing and contrasts with guidelines issued by other groups, including the U.S. Preventive Services Task Force. In August 2008, the USPSTF concluded that “the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75”; the group also recommended against screening those aged 75 or older. Ref: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf. Comments: Two reports came out recently against routine testing for PSA. The reports created a lot of stir and made front page for may newspapers. The definitive study is yet to be done; in the meantime, testing for younger men, along with proper counseling, digital exam and common medical sense is the way to go for now_BA


New Human Illness from Swine Flu Virus _ Do we have an epidemic?

In General Health on April 27, 2009 at 8:20 pm

In the past several weeks, there has been an outbreak of illness in Mexico and the U.S. caused by a new strain of influenza virus that contains a combination of swine, avian, and human influenza virus genes. The illness has killed many patients, and the outbreak has features that suggest it could become a global pandemic. Federal officials have responded by declaring a public health emergency in the U.S., freeing up new resources for the prevention, diagnosis, and treatment of the disease.

Pigs, birds, and humans are each susceptible to lots of influenza viruses. Typically, these viruses infect only one species. However, sometimes the viruses swap genes, creating new viruses that have the capacity to infect more than one species. Even then, new viruses capable of infecting two species typically are very hard to transmit from human to human. Sometimes, however, further recombinations or mutations of genes create a virus that can spread rapidly among humans — creating a global pandemic. The worst global pandemic in modern times was the pandemic of 1918–19. It affected about a third of the human race, and killed at least 40 million people in roughly a year — more than have been killed by AIDS in three decades.

The World Health Organization and the CDC have confirmed that the new swine flu virus is transmitted between humans. It is not clear yet how transmissible it is, nor how it is transmitted. Almost surely, like other flu viruses, it can be transmitted by aerosol and by skin-to-skin contact with an infected person.

As of this writing, about 100 deaths have been attributed to the virus — all in Mexico. The 20 confirmed cases in the U.S. have all recovered (with only 1 case requiring hospitalization). Ominously, many of the deaths in Mexico seem to have occurred in healthy young adults, a pattern seen in past pandemics — not young children and the frail elderly, as is most often seen with the flu. It remains uncertain what the mortality rate is in Mexico and why the illness appears to be milder so far in the U.S.

The new virus is resistant to amantadine and rimantadine, but sensitive to oseltamivir (Tamiflu) and zanamivir (Relenza). Based on experience with other flu viruses, treatment would be most effective if given within two days of the onset of symptoms. Obviously, there is no vaccine yet for the new virus, and the CDC has expressed doubt that the current flu vaccine will offer protection.

The initial symptoms with this swine flu virus are like those with the annual flu viruses: fever, myalgias, rhinorrhea, and sore throat. Nausea, vomiting, and diarrhea may be more common with this flu than with regular flu. The usual precautions for patients apply:

 

  • Sneeze and cough into tissues and throw the tissues in the trash.
  • Wash your hands or use alcohol-based hand cleaners frequently.
  • On greeting people, don’t shake hands or exchange kisses.

 

People should be considered contagious until at least 7 days after the start of symptoms; with children, it may be 10–14 days. Patients can be reassured that they cannot get swine flu from eating pork.If a global pandemic ensues, governments may well close schools and public places, require as many people as possible to work from home, warn any people who develop symptoms to isolate themselves at home, and warn those with symptoms indicating more severe disease (particularly breathlessness) to seek medical attention immediately. Journal Watch will update you regularly as new information is available.Updated information from the CDC is available at   http://www.cdc.gov/swineflu/.Published in Journal Watch General Medicine April 27, 2009.

Comment: This is an excellent summary of where we stand today. Unfortunately we maybe at the brisk of an epidemic_BA


It is never too late to start.

In General Health on April 13, 2009 at 2:46 pm

Does increasing physical activity in middle age lead to longer life?
In this prospective population-based study, Swedish investigators examined the effects of changes in physical activity and of smoking cessation among 2205 men (age, 50 at study enrollment in 1970–1973).
After 35 years of follow-up, absolute mortality rates for men with low (sedentary), medium, and high (3 hours of active recreational sports or heavy gardening weekly) levels of physical activity were 27.1, 23.6, and 18.4 per 1000 person-years, respectively. During the first 10 years of follow-up, men who boosted their physical activity from low or medium levels to high levels exhibited significantly higher mortality than did men who sustained high baseline levels of physical activity (hazard ratio, 1.70). However, after 10 years of follow-up, men who increased their physical activity to high levels showed the same mortality rate as men who sustained high levels of activity. Furthermore, mortality was halved in sedentary men who increased their physical activity to high levels compared with rates in men who remained sedentary (HR, 0.51). Similar results were found for men who increased their physical activity from medium to high levels. These rate reductions were comparable to those observed with smoking cessation (HR, 0.64). Ref: Byberg L et al. Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort. BMJ 2009 Mar 5; 338:b688. FROM JOURNAL WATCH. Comments: Smoking remains the most crucial modifier of longevity, but exercise is up there _ BA


How much Aleve is safe?

In General Health on April 13, 2009 at 2:37 pm

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed but carry both gastrointestinal (GI) and cardiovascular (CV) risks. Multiple guidelines offer recommendations for mitigating the GI risks associated with NSAIDs (e.g., bleeding), but strategies for simultaneously dealing with the GI and CV risks of these drugs have not been published. To bridge this gap, the Canadian Association of Gastroenterology convened a panel of 21 physician-experts to develop evidence-based recommendations for long-term (>4 weeks) NSAID use.
After considering the strength of relevant evidence in the literature, the panel voted on a series of questions regarding NSAID use. Their answers were used to develop an algorithm to guide the use of NSAIDs in different GI and CV risks. Patients with high CV risk were assumed to be taking low-dose aspirin. The panel’s consensus document included the following recommendations:
1. Patients with low GI and low CV risks should receive a traditional NSAID.
2. Patients with low GI and high CV risks should receive naproxen (Aleve).
3. Patients with high GI and low CV risks should receive a cyclooxygenase-2 inhibitor (Celebrex) plus a proton-pump inhibitor (such as Prilosec, Prevacid, or Protonix).
4. Patients with high GI and high CV risks should receive a careful assessment to prioritize risks.
NSAIDs should be prescribed at the lowest effective dose and for the shortest possible duration. Ref:Rostom A et al. Canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: Benefits versus risks. Aliment Pharmacol Ther 2009 Mar 1; 29:481. FROM JOURNAL WATCH.
Comments: Studies are still needed to validate these guidelines that are mainly based on personal experience more than clinical data; but this is a start _BA


Enhance the Immune Response to HIV

In Immune System on April 1, 2009 at 12:53 am

When a viral infection cannot be eradicated and becomes chronic, the immune system gets exhausted. Human studies have shown that lymphocytes that are exhausted by chronic HIV infection display greater numbers of a receptor called programmed death 1 (PD-1). In an in vitro study, researchers found that an antibody that blocked the ability of PD-1 to activate its suicidal signals allowed lymphocytes to fight HIV more effectively (JW Gen Med Oct 10 2006).
Nine monkeys were treated with partially humanized PD-1 antibodies at 10 weeks or at 90 weeks after they were infected with simian immunodeficiency virus (SIV; a cousin of HIV). Five SIV-infected control monkeys were treated with an antibody against another receptor. The active treatment greatly increased the numbers and the function of both virus-specific CD8+ T cells and memory B cells. Treatment also greatly reduced viral load and led to a remarkable difference in mortality: 150 days after treatment, no treated monkeys, but four controls (80%), had died. Safety studies revealed no abnormalities in liver, kidney, or marrow in treated animals.


Aspirin and Heart Disease

In Heart on April 1, 2009 at 12:38 am

The U.S. Preventive Services Task Force now recommends that aspirin be used in men to prevent MIs (Myocardial Infarction) — and in women to prevent ischemic strokes — when these benefits outweigh the risks for gastrointestinal bleeding.

The task force considers older age and male sex as the major risk factors for gastrointestinal bleeding, followed by upper GI pain, ulcers, and NSAID use.

The recommendations, published in Annals of Internal Medicine, update the USPSTF’s previous statement, released in 2002. The current statement factors in evidence from the Women’s Health Study that “aspirin may have differential benefits and harms in men and women.” The task force also concludes that evidence is “insufficient” to weigh the benefits and harms of aspirin prophylaxis among people over age 79 — and that use among men under 45 or women under 55 should not be encouraged. An editorialist writes: “Aspirin continues to be underused, and the routine incorporation of the USPSTF’s recommendations … [will] prevent many thousands of cardiovascular events every year.”
Here is a summary of the recommendations to physicians:
1. Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions (heart attack) outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation)
2. Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation)
3. Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I statement)
4. Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. (D recommendation).


HIV Related High Lipids is Difficult to Treat

In Heart on April 1, 2009 at 12:30 am

Dyslipidemia (abnormal lipids in blood) is common in HIV-infected patients, but treatment outcomes are often unsatisfactory. In this study from Kaiser Permanente in California, investigators compared responses to lipid-lowering therapy between 829 HIV-infected patients and 6941 uninfected controls, all with laboratory evidence of dyslipidemia. The HIV-infected patients had significantly smaller LDL (low density lipoprotein) declines in response to statin therapy than their HIV-negative counterparts (reduction, 25.6% vs. 28.3%); within the HIV population, pravastatin (Pravachol®) was less effective than other agents (simvastatin – Zocor®, lovastatin – Mevacor®, or atorvastatin- Lipitor®). Response to fibrate therapy (gemfibrozil – Lopid®) was also worse among HIV-infected patients, particularly those receiving PIs. Three cases of rhabdomyolysis occurred in the HIV-infected group versus one in the control group; laboratory abnormalities occurred in fewer than 5% of those with HIV infection.


Too Much Red & Processed Meats Can Kill You

In General Health on April 1, 2009 at 12:12 am

High intake of red and processed meats is associated with increased risk for death in older adults, while white meat may have a protective effect, reports Archives of Internal Medicine.http://archinte.ama-assn.org/cgi/content/full/169/6/562
More than a half million adults aged 50 to 71 completed food-frequency questionnaires and then were followed for 10 years; during that time, some 48,000 men and 23,000 women died.
After adjustment for confounders including BMI and smoking status, men and women in the highest quintile of red meat intake had significantly increased risks for overall mortality, cancer-related deaths, and cardiovascular-disease–related deaths, relative to those in the lowest quintile. High intake of processed meat was also associated with increased mortality risks.
Conversely, consumption of white meat (poultry and fish) was associated with significantly decreased risks for total and cancer-related mortality.
Comments: Although the results are intuitively not surprising, this study gives evidence to what we know. One possible explanation for increased cardiovascular disease is elevated blood pressure has been shown to be positively associated with higher intakes of red and processed meat, even though the mechanism is unclear, except that possibly meat may substitute for other beneficial foods such as grains, fruits, or vegetables.BA