Smarter Medical Care

Smoking

admin — Tue, 28 Feb 2012 01:07:37 +0000

Smoking harms almost every organ and accounts for nearly 20% of all deaths in the USA. Almost all cancers of the lung and many other cancers are caused by smoking. Heart disease and stroke are increased and death from chronic lung disease—emphysema and bronchitis — is more than 10 fold higher in smokers. But equally if not more important, smoking is associated with chronic illness before death with severe symptoms that diminish activity. The illnesses and deaths associated with smoking are chronic, not reversible and often not adequately treated by medical care. Stop smoking; even better, don’t start.

Before You Leave the Hospital

admin — Fri, 10 Feb 2012 20:00:15 +0000

When you leave the hospital, you will need instructions to maintain the gains made in the hospital. Despite all the efforts made, misunderstandings can occur about the level of activity involved, foods that are best, wound care, how to take medicines and avoid side effects, and so much more. Ideally, family members should be around in the hospital during care. The investment in time then promotes the best exposure to what should be done at home. Family involvement is so helpful.

The challenge these days is to make sure care continues into the home. The transitions probably will require discharge nursing and social services , but also directions about when to call for help, when to see their physician next, and when blood tests may be needed. The expectation of the medical care systems today are that you’re leaving the hospital occurs during a time of transition, and that ongoing care in the house or nursing home will be necessary to promote further healing. One other important item: as you leave, be sure someone is aware you want a copy of the discharge summary. That will give you, in typed form, your medical records, your diagnoses, the medicines they have been given and the tests done.

Alcohol and Cancer

admin — Thu, 17 Nov 2011 01:14:49 +0000

There is a strong relationship between alcohol and specific cancers such as esophageal cancer and head and neck cancer. At least three quarters of people who have a mouth and throat cancer consume alcohol frequently. People who both drink alcohol and smoke have a much higher risk of developing head and neck cancer than people who use only tobacco alone . Alcohol may be the more important of the two habits that cause head and neck cancers. Half of all those with esophageal cancer consume excessive alcohol. People who drink alcohol frequently are 6 times more likely to develop one of these cancers. Drinking “large” amounts of alcohol (more than one drink a day for women and two drinks a day for men) clearly increases the risk of cancer of the mouth, throat, esophagus, and larynx. “Large” means different things to health care professionals such as doctors and nurses than it does to the average person. Alcohol use is less strongly associated with other cancers but there is little doubt it contributes to the risk to get some other cancers. For example, for breast cancer and for cancers that start in the liver, alcohol is part of the cause of these cancers in some people. For breast cancer which accounts for 38% of all cancers in women, even a small increase in breast cancer associated with alcohol is very important. More than ¼ of a million women were studied by one group and even one drink/day was associated with a 10% increased risk. At 3 drinks per day, the risk appears to be 20% higher than non-drinking women. Researchers reported in April 2011 that as many as 10% of all cancers in the United States are related to drinking this much or more. There is some material that suggests one drink a day may be helpful for your heart and even that it may decrease the risk of being senile. No studies exist to say more alcohol increases these effects and even these effects need more study. Some experts say there is no safe level of alcohol.

Surgery for Epilepsy

admin — Wed, 05 Oct 2011 23:29:44 +0000

Surgery has a definite role in the therapy of some people with epilepsy. Of the three million people with epilepsy, medications are almost always the first line of therapy. One third of those with epilepsy will take medicine but not be controlled. One third of those or about 10% will potentially benefit from surgery. To identify who may benefit, people with epilepsy will need special MRI and other tests. Operations can be done on the very young and even on those more than 70. Each situation needs to be individualized. There are a variety of surgical operations from removal of one small part of brain (the temporal lobe) where the seizure appears to begin to placing different types of devices into or on the surface of the brain in order to find the point where the seizures begin. You need to have the right procedure for the right person. Perhaps unexpectedly, the brain itself does not feel pain; the only parts of the surgery that can potentially cause pain after the surgery are the skin and the outermost very thin covering of the brain – the dura. As a guide, the surgery may take 4-5 hours, pain medicines may be needed for a few days and people are usually home within a few days. Anti-seizure medicines may be continued for up to a year. If we can eliminate the seizures or even markedly reduce them in frequency, we as neurosurgeons and our patients will commonly consider that “a success”.

Navigating the System

admin — Wed, 28 Sep 2011 17:10:36 +0000

Before illness strikes, people should know about the medical care systems so they can work within it most effectively. Choose your system of care: —an HMO system like Kaiser, private practice that can be an HMO, or PPO or a variation of one of these types of insurance, or Medicare or as needed Medicaid. Then, choose and then know your insurance policy. Eventually, when care is needed, people are in one of three groups. One group consist of those getting routine follow up after having had an illness; they have little or no new anxieties (except the night before follow up for a serious illness). A second group are those in whom the doctor or patient have a new and real concern for serious illness. A third group consists of those in the middle of a workup or therapy for a serious illness such as cancer. Your PCP, especially if you have had a long-standing relationship, can help you get the best workup, the proper consultants for you to determine the workup and care, and handle other medical problems and psychosocial issues as they arise. You serve yourself best by understanding what’s going on. But have others help you if possible. For example, have others with you especially for important meetings. If you have cancer, develop relationships with other health care professionals such as the nurses or radiation therapists who are involved should you be getting chemotherapy or radiation. Develop a relationship with the social workers or navigators who should be available through the hospital or the system you’re in. Some individuals are readily available as part of the team that is caring for you. If more help is needed to understand your insurance coverage and your share of cost, ask for that help from the physicians, nurses or personnel at the infusion center. Medical systems offer lots of help from qualified professionals but you will need to ask. You may want another opinion to confirm a diagnosis or suggest other possible therapies. Don’t be afraid to ask for help for fear you’ll offend or in some way push your physicians away. Your PCP or RNs on your team can help get other physicians identified for a second opinion, hear your concerns, be a good listener and offer advice and in other ways help you. You can also ask that your problem be discussed at Tumor Board. Hospitals have periodic meetings among experts in cancer care with different expertise to discuss individual problems. Such discussions can either validate the present course of care being pursued or suggest alternatives or both. These meetings are free to you and can be very helpful.

Head & Neck Melanoma

admin — Tue, 20 Sep 2011 00:04:54 +0000

Melanoma is the most serious form of skin cancer. It begins in the pigmented cells of the skin but, for head and neck melanomas, it can also start in the sinuses in the head or the mouth. It behaves very differently from other cancers of the head and neck. Some of the other cancers of the head and neck begin in the skin, but many begin inside the mouth see such as the tongue, the back of the throat, the tonsils or the larynx. Many are associated with alcohol and smoking whereas melanoma is often associated with sun exposure. The other cancers frequently spread to the neck glands first; melanomas may do that but they also can skip these areas and go elsewhere— the skin, the liver, the lungs, the bone, the brain or other organs. The surgery needed to produce cure is very different than when a melanoma is in a different location. But some of the information needed to give people the best care are the same for all melanomas: be sure the tumor is melanoma under the microscope and know what type it is, know how deep the tumor is in the skin where the first or primary lesion occurred, know how may cells appear to be dividing and if the body’s immune cells are in the tumor, and and know if the top layer of the primary lesion is not present. This information guides us to know what kind of surgery is best and what our ability to produce a cure is. For melanomas on the skin, repeated exposure to the sun, especially if there are bad sunburns or no sunburn at all, increase your risk of sunburn. Melanomas can occur anywhere on the exposed skin. For these exposed areas, a hat and frequent application of sun screen is helpful to avoid the problem of melanoma later in life. Sometimes, the surgery needed to prevent local recurrence or to produce a cure requires a plastic surgeon to cover areas where the skin needs to be removed. At times, radiation is an important part of the therapy. Prior to this last year (2010), when disease had spread, these physicians had very few tools to help people, but in the last year there have been some very promising drugs now available to give people a better quality of life.

Each of the members of a melanoma tumor board can contribute their opinions about what is going on in an individual. There are many doctors in tumor boards and the combined opinions, discussed openly, will create a better opinion for how care is best than the opinions of any single individual physician. The drugs just being made available are more targeted drugs than the previous chemotherapy agents. Some, like ipilumumab, can produce significant problems for the patient but when they work, the responses are well worth it. There are also other new drugs, such as a drug that works against a material, B-raf, that your body is making to drive the cells to grow. The first drug of this type to reach the market is Vemurafenib. It will be some time before we know how to use these drugs properly but the promise is there. Remember though that the best way to prevent melanomas that begin on the skin of the head of the neck is to cover up with clothes, sun screen or both and avoid serious sun burns.

Action Plan for Deep Medicine

admin — Sun, 03 Jul 2011 03:24:49 +0000

Everything we do in life is either health-supporting or health-negating, down to each of our activities of daily living. How do we create action from this concept? We each have within us a wealth of positive experiences that can be the basis of reaching our goals. There are several “A’s” in these concepts. One is assessment: What am I thinking, what am I doing and is it working? Once the concept of “mindful living” is accepted and some assessment made, actions should emerge from our assessments. We need to do these actions. Health is balance and healing is change to restore balance..

The tasks to do and the decisions for change we make can seem formidable. The decision to change needs you to believe that the decisions should, at the least, pass tests you create to believe they are right, sustainable, kind and intelligent. These principles will help us decide if the changes should be made and should they be made now. Usually health-enhancing behavior is just as easy to do as health-degrading behavior. Talk for a while helps to make a decision, but at some point, we need to take a step. If the action is wrong, it can be reversed. Without action, we may develop anxiety or other health-negating behaviors. The steps should be small enough that you will do them, but not so large as to be paralyzing or in some other way health-negating. For example, we may decide to lose weight. If we are too extreme in setting the goals for these changes, we may not achieve them. If we set the goals at one time, we can change them at any time if re-assessment says that is best. Any steps we take need to be repeated so that the steps become integrated into our behaviors and our lives. That’s how we can eliminate bad habits and foster good ones. Integral to this process is that assessments have to be re-visited.

Part of that assessment are observations which are essential after we take some steps. We need to both observe and be prepared to negotiate with ourselves. New plans can always be re-visited to see if they are correct for you.

We all can be energized by simply building on the pillars in our life: nutrition, physical exercise, stress management, meditative or contemplative study, and community and relationship. Such self-directed programs go beyond the management of disease. Properly assessed, modified and re-assessed, self-directed core behaviors will help us initiate and maintain change and through those changes—health enhancement. . Making sustainable change will help us make us better in all the areas of the pillars mentioned above. Self-directed change can be very successful in promoting change to change not only to diet, exercise, but also weight, exercise, interactions with others, behavior and many other aspects of our lives.

Our well being is life-long learning, and there is a place for guides, mentors and experts. Professional help can give us expert advice, and may require a detour from our maintenance activities to maintain our overall health. Re-assessments can lead us on the course to health enhancement as circumstances change and change again. We all know what we all would like to do to make us better in our own eyes; the next choice we make is the first step to promote the changes we want to achieve.

Deep Medicine

admin — Tue, 03 May 2011 17:35:07 +0000

Everything we do is either health-supporting or health-negating, down to each of our activities of daily living. Once that concept is accepted, each action should be the consequence of “mindful living”. The task can seem formidable, but usually health-enhancing behavior is just as easy to do as health-degrading behavior. We all can be energized by simply building on the pillars in our life: nutrition, physical exercise, stress management, meditative or contemplative study, and community and relationship. Such self-directed programs go beyond the management of disease. The core behaviors we need to do will help us initiate and maintain change and through those changes—health enhancement. Making sustainable change will help us make us better in all the areas of the pillars mentioned above. Self-directed change can be very successful in promoting change to change diet, exercise, weight, behavior and other parts of our lives. Our well being is life-long learning, and there is a place for guides, mentors and experts. We all know what we all would like to do to make us better in our own eyes; the next choice we make is the first step to promote the changes we want to achieve.

Guided Imagery

admin — Mon, 28 Mar 2011 22:25:34 +0000

Guided imagery is a way to take you to a place where you can understand your feelings and beliefs more completely. The technique can be used to handle many stresses, from day-to-day issues that may send you reeling, all the way to unresolved threats, such as persistent threatening illness. Specifically, many individuals diminish their psychological stresses and physical symptoms as they come to grips with a diagnosis such as cancer. Guided imagery begins by finding time for yourself to focus on breathing in and out, functions that allows your mind to track only your breathing, This simple move allows you to not focus on the stressful events. The next steps are to remember an environment that is completely relaxing and positive. Spend time enjoying that good feeling. Imagery is a natural process available to all that can be done by anyone, but it helps initially to have someone help you until you are comfortable on your own. The goal is to help you develop emotional resiliency and/or less symptoms from an illness like a cancer or its therapies.

Surgery and Weight Management

admin — Tue, 15 Mar 2011 22:58:21 +0000

Surgery for weight management may be appropriate for those who have tried and not been successful with a prior program. Surgery should not replace the three mainstays of weight management — behavioral or lifestyle changes, exercise and decreased caloric intake. For now, surgery is not usually considered as “front line’ by most weight management professionals. There are different surgeries that are classified into one of two types: surgeries that decrease the size of the stomach and surgeries that create an inability for the body to absorb calories (but also other potentially essential elements such as vitamins). Surgeries are becoming more common, but long term maintenance of decreased weight still requires behavioral changes in eating as well as exercise. Restrictive procedures to decrease the size of the stomach decreases your desire to eat and your ability to eat; a common surgery is a “sleeve” gastrectomy. There are risks from any of these surgeries including mortality (but that risk is probably less than 0.5% even with the more complicated procedures). Infection and leakage of fluid into the abdomen from within the stomach) are also risks of surgery. The risks go down dramatically among the surgeons who do a lot of these procedures. The least invasive procedures may work for those who are not extremely obese, and depending upon other illnesses, these procedures may be done without a hospital stay. That is a decision between patient and physician. For any of these surgeries, the need to walk before and after surgery is very valuable to help maintain good breathing and prevent clots in the legs. For information about the procedures, a good web site is www.obesityhelp.com. Internet sites can also help with lifestyle change programs; the National Institutes of Health’s web sites are a good place to start.

Weight Management

admin — Thu, 10 Feb 2011 22:55:52 +0000

Sustained significant weight loss requires medical, exercise, behavioral, and nutritional care. For best results, chronic commitment is essential. Obesity means there is too much fat when too many calories are eaten compared to the calories used. Obesity requires confronting the issues that have led to excess weight. Chronic commitment is essential to change foods consumed, increase exercise and understand how obesity occurred in you. Changing to foods with low calories such as more vegetables and fruits that contain water and fill the stomach are very effective foods to promote weight loss. You need protein found in the higher calorie foods, but not as much as many people eat. Three meals a day, even with snacks is fine, if it keeps caloric intake low. You need to plan what you eat, even if you’re eating out. In addition, several 10 minute walks contribute to weight loss. A small pedometer in your pocket counts the steps each day. Building to 10,000 steps/day is a good weight maintenance goal. People need to know why they want to lose weight because commitment is essential to maintain weight loss. One set of goals can be to maintain better health. Regular feedback about high blood pressure, cholesterol levels, Diabetes and sleep apnea help maintain motivation. Follow up visits are most often necessary to first take off weight and then keep it off.

Loss of Appetite

admin — Tue, 11 Jan 2011 22:22:12 +0000

Anorexia is the loss of appetite. There are several causes of anorexia in all people, but the most common cause in cancer patients, is the chemotherapy. Cancer appears to not only change your desire to eat but also how you perceive taste. Tastes change in many people with cancer. You can also get sores in your mouth referred to as ulcers from chemotherapy. When you lose your appetite, caloric intake is diminished, and that in itself can make people feel poorly. There are a number of medicines that can stimulate the appetite but each has risks as well as benefits. The drugs include steroids like decadron, amphetamines, Marinol, a derivative made from marijuana, and Megace. These drugs do have the potential to put you back into positive caloric balance. Don’t forget the dieticians; they often understand how to modify the diet to be tolerated better by cancer patients.

Nausea

admin — Fri, 10 Dec 2010 21:18:51 +0000

Nausea in people with cancer occurs but not in everyone, even when they get chemotherapy. The commonest cause is chemotherapy and therefore it is predictable for any chemotherapy when it might occur. Treatments are usually very effective. Cancers in the liver, cancers of the stomach or brain, or pain in a person with any cancer can be nauseating. Great progress has been made with drugs that prevent or treat nausea. The chemotherapy and expectation for when the nausea may occur determines which drugs may be best for you. Nausea or short periods of vomiting are not helpful. You should call your physician for persistent nausea. Prior discussions with your physician can determine for you when to call. If something unexpected occurs— fever with the nausea, a bad headache, you feel badly all over and its 3 to 5 days after you had chemotherapy —you should call your physician.

What is Cancer?

admin — Tue, 16 Nov 2010 22:30:36 +0000

Dr. Rodvien discusses what cancer is and what the causes of cancer are. Cancer is made up of cells that grow in an uncontrolled manner or that do not die on time. Usually although we may look like all of ourselves are living with us as we move from day to day, week to week, and month to month, all of our cells are being born, then living for a relatively short time, and then undergoing death to be replaced by other cells. It is only when cells accumulate within an area of our body, and then develop the capacity to spread to other organs such as our liver lung, brain or bone, that we are either living with cancer or being threatened by that cancer.
Cancers then, are a group of diseases that we name by the organ where they begin. When they spread elsewhere we still name them by the initial organ where they began but we now say that the cancer is metastatic to another area. An example would be: cancer that has spread or is metastatic to the liver. Pathologists also describe cancers by what they look like under the microscope and these words are added to the others to give a more complete description of the cancer.

Diarrhea in the Cancer Patient

admin — Tue, 12 Oct 2010 21:55:45 +0000

Multiple, loose bowel movements that are watery define of diarrhea. In the setting of cancer may not be self-limited and can be dangerous to the patient. Beyond the usual causes, there can be an overgrowth of bacteria or other infectious organisms in the bowel. The cause of diarrhea in the setting of cancer needs to be identified, especially those caused by these unusual infections. Calling the physician should occur if it’s a first episode, if the diarrhea was not expected, if a symptom beyond diarrhea is making you sicker than expected, or if the cancer physician had suggested that if diarrhea occurs then a call is necessary. Fever or weight loss also will often make it necessary to call. Diarrhea can be persistent and be dangerous. Over-the-counter treatments can be used early on but sometimes detailed evaluation and other treatments are needed.

Epilepsy in Women

admin — Fri, 24 Sep 2010 22:00:23 +0000

Women with epilepsy looking to get pregnant can be safely taken through pregnancy with a very high probability of a normal fetus, and no increase in problems to the Mom as well. To increase the chances of a normal baby, it may mean changing medicines to the newer, safer drugs for a period of at least 6 months before trying to get pregnant to make sure the new medicines prevent seizures. Women with epilepsy do have additional problems. Compared to other women, women with epilepsy can have endocrine problems such as higher rates of infertility, irregular cycles and sexual dysfunction. Should these problems exist, there are anti-seizure medicines that can minimize these problems.
When choosing to get pregnant, women must also consider the effects of the anti-seizure medicines on babies. Women with epilepsy can expect to have normal babies but there is a slightly higher risk of having certain problems in their baby. Many of these problems in the baby are mild but some can be quite severe. The risk from Mom’s epilepsy to have any of these problems is perhaps twice the non-epileptic pregnant women. The risk to the baby exists because the Mom has epilepsy and may be further increased by certain anti-seizure medicines. For this reason, some medicines –like valproate and barbiturates – are avoided completely. Women can also have a higher risk of migraines, mood problems and depression.

There are specialty clinics at hospitals where there are epilepsy specialists as well as groups who care for people with high risk pregnancies. The threat to the baby from Mom having a seizure is higher than the threat of birth defects so that the proper choice of anti-seizure medicines throughout the pregnancy is important. The first line drugs for women thinking of or in fact pregnant are Kepra, Tegretol and Lomictil. Pregnant women with seizures also need counseling about breast feeding. Most of the medicines are put into Mom’s milk if there is breast feeding and the newer ones do not make the baby sleepier. Mom’s may need Vitamin K, especially at the end of the pregnancy while on older anti-seizure medicines. All women need folate in pregnancy. During pregnancy, women will gain weight, retain fluids and have changes in hormones that can change the amount of anti-seizure medicines they need as the pregnancy progresses. Therefore, they need to have blood levels of the anti-seizure medicines during the pregnancy. When delivery is near, the anesthesiologist needs to know about the seizure problem and keep Mom well hydrated.
Epilepsy is almost always not inherited. It’s the same risk as the general population though one of the problems of any complicated delivery is seizures.

Epilepsy Medicines

admin — Tue, 14 Sep 2010 20:33:32 +0000

Women with epilepsy may need to change medicines to stop seizures, to enhance the quality of the life for the woman or to protect the baby of a pregnant woman. There are numerous drugs available at this time, and at least at this time, the dose in any pill in the generic drugs is unacceptably too high. Side effects can occur if the doses vary too much from pill to pill. Dr. King-Stephens discusses these issues in detail, using the example of Kepra.
For any individual, we don’t know which medicine is best without trying it. The concern is that these medicines will be needed for long periods of time and we don’t necessarily know the full battery of side effects –especially long-term side effects — associated with all these medicines. Anti-seizure medicines are affected by other medicines such as anti-depressants. For example, lomictil may need to be increased when birth control pills are added. Changing doses or not needing to change must be evaluated in the context of the whole person – age, sex, other medicines, other illnesses, etc. If there is a seizure, the best care is associated with getting a blood level of the anti-seizure level. Some of the drug interactions may take two to three months to develop before breakthrough occurs and by then, some people forget about the change. Genetic information is also becoming available that may help predict the potential for bad drug side effects, leading to even more personalized care.

Anemia

admin — Wed, 01 Sep 2010 19:40:51 +0000

Anemia is a diminished number of red cells in the blood. Red cell count, hemoglobin and hematocrit also measure anemia. Lowered blood levels means you can’t deliver oxygen as well to the tissues of your body. Anemia is quite common; the common causes are iron deficiency, thalassemia, infections and/or inflammation, blood loss, poor functioning of the bone marrow (myelodysplasia), sickle cell anemia and pregnancy. Blood loss can cause chronic or very acute anemia. Some of these problems — thalassemia and sickle cell disease which inherited forms of anemia. There are numerous other causes. The degree to which you feel poorly depends upon the rapidity that the anemia occurs and the extent of the anemia. People who are are sick from the anemia may have a high pulse rate, a lowered blood pressure, shortness of breath and anxiety among other problems. Each of the causes of anemia may also have special symptoms specific to that cause of anemia. If you lose blood fast, you can get sick quickly. If blood loss occurs slowly, symptoms can be quite subtle for a long period of time. Therapy depends upon what’s causing the anemia. For example, people can be iron deficient or folate or B12 deficient. Replacement with the specific vitamin is a first step, but each of these problems then need to be addressed at a second level: why are you lacking the vitamin? Erythropoietin is used when the marrow is not working as well as it should. The FDA is limiting the use of this drug for good reason. It should be used in an individual, understanding its potential benefits and what the risks are in you. Transfusion of red cells also has its proper uses and can be quite helpful if blood loss is significant. The reason to transfuse blood should be understood by you, including its risks and benefits, before it is given. For both blood transfusion and erythropoietin use, your physician or another appointed health care professional should give that explanation since it needs to address the issues in you.

Leaving the Hospital on Coumadin

admin — Tue, 20 Jul 2010 19:05:08 +0000

Leaving the hospital when taking Coumadin is a transition from one environment to another so Coumadin doses can change, sometimes markedly. Get a blood test, an INR (or PT), very soon after you leave. Knowing the INR within 36 hours of leaving the hospital may save you a trip to the emergency room if the INR is shifting away from the desired level for you. Your diet, your activity and other medicines can easily change your sensitivity to the Coumadin. The list of potentially interacting drugs is very long, but for most of the drugs, you may not be sensitive to a change in Coumadin on or off other drugs. Some drugs however are often modifiers of your need to change Coumadin doses; these drugs include antibiotics 9such as Septra for a UTI) and amiodarone, a heart medicine. Get your tests in one laboratory; the INR does vary between labs. If your physician uses a laboratory that does INR tests on blood taken from the elbow area, that test may take hours to get back. In that case, I would prefer to have early hour appointments with the doctor or at least an early visit to the laboratory, and I would avoid Fridays to decrease the chances of not being called with the INR and Coumadin adjustments over the weekend.

Whenever you leave the hospital, have the contact information for your physicians. Also, be responsible for yourself. Know what the next steps are in your care, and when your next visit to the doctor or doctors are. Get a discharge summary (which will include your hospital identification number and the hospital’s medical record number assigned to you as well as your diagnoses at discharge), have a list of all your medicines, know which ones may be interacting with the Coumadin, and what happens to the INR and Coumadin if one of the medicines is modified or stopped after discharge.

Pulmonary Emboli

admin — Wed, 07 Jul 2010 19:29:49 +0000

Clots, forming in the veins of the legs or pelvis, can migrate to the lungs and cause problems that range from no symptoms through mild problems to quite severe problems with pain, shortness of breath, changes in the heart’s capacity to support your blood pressure, coughing up blood, and in fact death. High risk times for anyone to get these pulmonary emboli exist when there have been prior clots in the legs, active cancer, prior surgeries or hospitalization in general. Often pulmonary emboli can be prevented using medications, cuffs on the thighs and calves, or filters. Beginning the medicines before surgery allows less drug to be used and creates some protection from having emboli. Treatment of established pulmonary emboli are variable; frequently physicians use heparin for 5-10 days followed by coumadin for months. Even then the clot may not break down but it is adherent to the inside of the vein wall that they will rarely embolize (migrate to the lungs) after that period of time. New clots may form however and they will need active therapy. Pulmonary emboli are one of the major causes of worsening medical problems that appear to occur more frequently once in the hospital.

Genetics of Coumadin

admin — Thu, 24 Jun 2010 22:02:13 +0000

Coumadin is usually completely absorbed when taken by mouth. Differences in doses from one to another person occur because Coumadin in the liver is altered by at least two different proteins that determine how long the Coumadin will remain as an active drug. VKOR and CYP2C9 are these proteins and they are genetically determined for each of us. Research is ongoing right now, funded by Medicare, to see If we can determine early Coumadin doses by measuring these proteins, and if this information gives us a safer dose range that translates into less bleeding, and less rethrombosis.

Vitamin K and Coumadin

admin — Mon, 07 Jun 2010 21:45:31 +0000

Vitamin K is a series of different chemicals, all of which allow your body to change four inactive proteins made in the liver into proteins that can protect you from bleeding excessively. (There are a few other proteins made in a similar fashion in the presence or absence of Vitamin K that affect other tissue such as the bone, but their clinical effects are minor in comparison. ) These same four proteins, when changed by Vitamin K, may create clots — thromboses – in places that can harm you. Of the different Vitamin Ks, One type is in the food you eat. Although there are foods with lots of this Vitamin K, it is not clear how much gets absorbed since the Vitamin K is contained within little microscopic capsules within the food. To absorb this Vitamin K, the capsule needs to be digested. Another type of Vitamin K is made in your colon; it is affected by some antibiotics which decrease the production of this Vitamin K. Then, less is absorbed to go to your liver. The third type of Vitamin K is stored in your liver. All the Vitamin Ks can make the same change in the four proteins made by the liver. Without Vitamin K, or in the presence of Coumadin, the change to a potentially active set of proteins cannot be made. It is NOT an all or none effect by the different Vitamin Ks on these proteins; the proteins that don’t get changed are a small per cent of the total made by your liver so that correct doses of Coumadin can slow down clotting but not eliminate it.

Off Coumadin, a healthy American diet gives you enough Vitamin K. On Coumadin, you still don’t need to measure total Vitamin K stores. You just monitor the blood level with an INR; but that implies you try to eat about the same amount of Vitamin K. Don’t take a Multivitamin with Vitamin K if you’re on Coumadin unless you’re specifically told to do that. (That shouldn’t be done unless you’re part of a clinical study.) The relationship of INR to Coumadin and Vitamin K is not an easy one to understand. The INR measures one of the four proteins, Factor VII, in the blood. Factor VII has a very short half-life compared to the other three proteins that are the main participants in clotting or allow bleeding. But the INR usually measures only that protein and physicians have learned how to use the INR to get your other Vitamin K-sensitive proteins made in the correct proportions. Because of the difference in how long these proteins stay in your blood (about 6 hours for Factor VII and more than 30 hours for the other three proteins), the INR is suggesting what may be happening in the next few days as you get a changing dose of Coumadin.

Stopping Coumadin

admin — Thu, 03 Jun 2010 20:20:41 +0000

Coumadin can be stopped electively or temporarily because of bleeding. There are many variables for your physician to consider, but if Coumadin is stopped but Vitamin K is not given, complete reversal may not occur for 3-7 days. It depends upon the dose of Coumadin you’re taking and the other medicines you are prescribed. Many people don’t need Coumadin indefinitely; for example, if you have developed a thrombus or clot in the leg. After many months, the drug may be stopped simply by letting the drug be broken down by your body. In other circumstances, you may need life-long Coumadin; the best example is a person with specific types of artificial heart valves. People with atrial fibrillation may need indefinite Coumadin. There are some patients in whom urgent reversal of Coumadin is needed. A physician then will stop the drug, often give Vitamin K and may even use plasma from the Blood Bank. This latter material is called FFP — fresh frozen plasma. Other plasma materials are being tested now for those who need urgent removal of the Coumadin effect. Mild elevations in INR do occur, often without bleeding, and one can lower the INR by different techniques — skipping one or more doses with or without taking some oral Vitamin K. These are judgments your physician will make should the INR be high with or without bleeding. Find out in advance how your physician wants you to act should your INR be high at some point. Also know what to do if bruising or other bleeding occurs. There are some steps you can take to try to prevent bruising, other bleeding or a high INR. One important step is to let anybody who prescribes or stops any medicine for you know then and there that you take Coumadin. Try to eat about the same type of diet, especially with regard to green, leafy vegetables. Also, remember that, although aspirin and Coumadin put you at greater risk to bleed than Coumadin alone, the INR will usually not reflect that increased risk.

Home Monitoring of Coumadin

admin — Mon, 19 Apr 2010 17:40:15 +0000

Home monitoring of the INR can be done measured on a drop of blood from a finger stick. Then, people have more freedom to travel on Coumadin and to get tests immediately should they be bleeding or hurt themselves. The machines have several other advantages including the fact that there is not variability in the INR result because of machine variation. Often people on Coumadin can call the result to their physician or clinic so that professionals can guide changes in Coumadin dose if the INR is outside desired limits. Insurance companies often defray the costs of these machines; the manufacturer’s can help you in this process.

Pain Management and Coumadin

admin — Mon, 19 Apr 2010 01:14:36 +0000

When taking Coumadin, management of pain with drugs needs to take into account that many of the medicines to control pain can make your sensitivity to bleed from Coumadin greater. Some pain meds like aspirin, Advil and naprosyn can alter the platelets we rely on to help us stop bleeding. These effects will not be measurable by the INR we use to measure the “Coumadin effect”. An occasional Advil, also called Motrin or ibuprofen, is safe for almost all people. Tylenol is also safe in small doses; higher doses in anyone can cause liver damage and these same doses may affect how you handle Coumadin. Narcotics such as codeine ( which is in Percoset which also has Tylenol) are also OK when on Coumadin. There is no simple answer; talk with your physician. When taking any drugs while on Coumadin, but especially pain meds, always be a good observer of your own response. Easier bruising, gum bleeding or nose bleeds should prompt you to call your physician. As always, on Coumadin, if you suspect your propensity to bleed has increased, get an INR which will rule out some but not all the ways in which Coumadin may interact with other pain meds in you

Starting Coumadin

admin — Sun, 18 Apr 2010 21:48:44 +0000

Coumadin is given to people who have an established thrombus or clot or who at risk to have a clot. An INR and history to include other medicines you take (including Chinese herbs and over-the-counter medicines), other illnesses and diet will determine how much Coumadin you get. Within each of these groups, there are factors that can affect your risk to bleed. In addition, certain genes control how Coumadin is broken down by the body and how Vitamin K is recycled. These two genes can vary from person to person. They can make us differently sensitive to Coumadin, a difference that may explain why some people have bleeding issues with Coumadin within the first month of receiving the drug. Many medicines interact with Coumadin and will alter what dose to start at. Usually, it is common to take 5 mg a day. The commonest response to Coumadin is nothing although there are rare people who will inappropriately have clots. You may feel a painful bruise over your breast or hip. Call your doctor. You need to be very systematically given Coumadin and get frequent blood tests — an INR — every other day to increase the safe use of this drug. The INR blood test result early on may reflect a higher risk to bleed a few days later; the INR in the beginning reflects “Coumadin” effects days later more than at the time you had the drug. Coumadin Clinics give you that systematic care with software that searches out the right dose very methodically. Still, it can often take 5 to 7 days to get you to the point where you are adequately anticoagulated.

Anticoagulation Clinics

admin — Fri, 02 Apr 2010 22:44:46 +0000

For patients who have experienced blood clots, there’s much to know about lifestyle changes, the proper use of Coumadin, and interactions of Coumadin with other medications. In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, discusses the relative merits of anti-coagulation clinics. Test results are immediately available when finger sticks to do INRs are done, and education of the patient discussing questions emerging from present circumstances are the best way to learn about this drug so that it works best for you as the patient.

Introduction to Coumadin part 2

admin — Fri, 02 Apr 2010 22:23:10 +0000

An increasing number of patients are being prescribed Coumadin, yet far too many are unclear about what the drug does, how it works, and why it’s critically important that dosing be properly monitored. For example, warfarin and Coumadin are equivalent. There are many potential ways that your dose of Coumadin may varyu, depending upon other medicines we take and the foods we ingest. Vitamin K is in many foods to different degrees but not everyone absorbs all the Vitamin we eat. In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, explains how Coumadin works, how blood tests can help you avoid episodes of bleeding or clotting and what else to anticipate when taking this medication.

Introduction to Coumadin part 1

admin — Fri, 02 Apr 2010 19:05:18 +0000

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

admin — Thu, 04 Mar 2010 19:05:02 +0000

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admin — Thu, 04 Mar 2010 19:04:40 +0000

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admin — Thu, 04 Mar 2010 19:04:11 +0000

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admin — Thu, 04 Mar 2010 18:05:55 +0000

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Approaches to Abdominal Surgery

admin — Tue, 08 Dec 2009 06:05:46 +0000

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

MRSA

admin — Fri, 04 Dec 2009 06:05:43 +0000

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

Colonoscopy

admin — Wed, 02 Dec 2009 05:04:56 +0000

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

Epilepsia Tres

admin — Thu, 26 Nov 2009 05:04:52 +0000

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

Managing your time

admin — Mon, 23 Nov 2009 21:29:51 +0000

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

Epilepsia Dos

admin — Thu, 19 Nov 2009 21:25:34 +0000

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

Epilepsia

admin — Mon, 16 Nov 2009 21:22:05 +0000

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

El medico puede llegar a un diagnostico correcto de la epilepsia a través de escuchar cuales son los síntomas y signos que el paciente manifiesta durante la crisis. El electroencefalograma (EEG), o el estudio de la actividad eléctrica del cerebro, ayuda a confirmar el diagnostico. La imagen por resonancia magnética (MRI) es el estudio que mejor ayuda a identificar la causa de la epilepsia. En aproximadamente el 20% de los pacientes con epilepsia, el EEG y/o el MRI pueden ser normales por lo que la historia clínica es lo que mejor ayuda al medico a diagnosticar esta enfermedad.

Causes of Cancer

admin — Thu, 12 Nov 2009 21:19:45 +0000

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

Information about HIV

admin — Thu, 05 Nov 2009 21:05:42 +0000

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

Introduction to HIV

admin — Mon, 02 Nov 2009 20:30:29 +0000

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

The Swine Flu

admin — Wed, 16 Sep 2009 20:23:05 +0000

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

The Flu

admin — Wed, 16 Sep 2009 20:15:52 +0000

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

Dementia

admin — Mon, 18 May 2009 17:14:12 +0000

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

Epilepsy

admin — Mon, 04 May 2009 17:31:44 +0000

Epilepsy is another name for recurrent unprovoked seizures. By unprovoked, neurologists mean there is no identifiable cause of the seizure such as a very low blood sugar, a stroke, meningitis, or alcohol withdrawal. Seizures occur because of the excessive discharge of the neurons in the brain. People then have self-limited abnormalities that can be observed by others such as staring into space or movement disorders. Epilepsy itself is more likely to occur in young children or people over the age of 65 years. Not all epilepsy syndromes are life long, and frequently epilepsy is controllable but not curable with medicines. For the 30% or so of people with epilepsy who do not have good seizure control even with the best available medications, surgery may be beneficial. The goal is control of the seizures with medicines or other techniques that produce minimal or no side effects.
When people have recurrent unprovoked seizures, they have epilepsy. It is not a single disease but very different symptoms can occur because of the common pathway of abnormal electrical activity in the brain. Seizures can be partial or they can be global and they can involve motor activity abnormalities such as flailing of arms and legs, or they can involve periods of time where the person with the seizure just appears to have “spaced out”.
For the 50 million people worldwide with epilepsy the vast majority are either young children or people over the age of 65 years. Not all epilepsy syndromes are lifelong. Epilepsy is usually controlled but not cured with medication but for the 30% of people with epilepsy who do not respond to seizure control medications, more aggressive treatments such as surgical intervention may be beneficial. This type of evaluation is best performed by neurologist and/or neurosurgeons who concentrate on taking care of people with refractory epilepsy.

Back Pain

admin — Mon, 27 Apr 2009 17:03:38 +0000

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

Reducing Coumadin Risk Through Genetic Testing

admin — Mon, 13 Apr 2009 17:10:16 +0000

Dr. Robert Rodvien, the founder of the Coumadin Clinic at California Pacific Medical Center in San Francisco, identifies some reasons why people need different doses of Coumadin. Certain genes control how Coumadin is broken down by the body and how Vitamin K is recycled. If either gene is different in one individual from the general population, then less Coumadin is needed to produce an anticoagulated state. Scientists call these families of genes CYP2C9 and VCOR. They can be analyzed in the blood or saliva. The genes are not related to each other but, because Coumadin and Vitamin K offset the action of each other, the two proteins produced by the genes can interact to alter the effectiveness of the Coumadin. The United States government in 2010 is testing whether differences in these measured genes can allow safer use of Coumadin. If the genetic material suggests Coumadin sensitivity, Taking less Vitamin K in your diet or avoiding multi-vitamins is neither necessary nor good. It is better to take less Coumadin. Taking these gene tests may allow physicians in the future to decrease the bleeding problems associated with Coumadin .

Vitamin K and Coumadin

admin — Mon, 06 Apr 2009 17:05:05 +0000

There are many variables in our lives—genetic material, illnesses, fever, drugs and foods — that affect how sensitive any individual is to Coumadin. Foods contain Vitamin K and it is this vitamin that can affect Coumadin’s ability to prevent clots or promote bleeding. Vitamin K is not one substance nor is it available to people from one source. Vitamin K exists in your diet, it is made by bacteria in your intestine and it is stored in the liver. The best method to ensure that Coumadin is used safely and effectively is to eat any food (like spinach) that is rich in Vitamin K with some regularity. Large variations in Vitamin K ingestion may affect how effective Coumadin is to prevent clotting. Avoid Vitamin K containing pills, even over-the-counter ones. Should you need antibiotics, be sure to remind the prescribing physician that you’re on Coumadin; otherwise antibiotics can kill the vitamin- producing bacteria in your bowel. If you have liver disease, storage of Vitamin K may be diminished. If you have doubts about whether or not Vitamin K sources have changed for you, you can always get a blood test —an INR— to test the effect of the Coumadin.

How Coumadin interacts with other medicines

admin — Mon, 30 Mar 2009 16:52:06 +0000

For any given person, any medicine can cause you to be more or less sensitive to Coumadin. Some of the drugs to remember are pain relievers (especially aspirin), antibiotics, and medicines to keep stents open (like Plavix). If you need one of these drugs, talk with your physician. If your physician prescribes a medicine, remind him or her you are taking Coumadin. If you intermittently take Chinese herbs, make sure you get frequent blood tests. (You probably should get blood tests every 4 weeks or more frequently, even if the INR is stable and no medicines have been started or stopped.) If there are concerns that the Coumadin effect may be changed, get an INR. Although the effect of most medicines is to increase your risk to bleed from Coumadin, some medicines can decrease the effect of Coumadin to slow clotting. That effect can also be estimated by doing the same blood test —the INR.

How Aspirin and Plavix Interact with Coumadin

admin — Mon, 23 Mar 2009 16:45:34 +0000

Coumadin’s main risk is that it can cause or exaggerate bleeding. The reasons are many, but one of the main reasons is the addition of drugs, like aspirin and Plavix, that interact with Coumadin directly, modify other defenses the body has to prevent bleeding or both. Coumadin, taken with either drug or both drugs, should never be taken without the advice of your physician. The pathways to help us stop bleeding after injury are so important to the maintenance of life that multiple interacting pathways exist to prevent blood loss. Coumadin affects one set of pathways that cause proteins that are soluble in the blood to become insoluble. Aspirin and Plavix affect a different pathway involving cells called platelets so that cannot be as effective in promoting the transformation of these proteins into a solid mass. Tests exist to look at some aspects of these pathways but the interactions are not able to be tested. The common way to handle this issue is for everyone to be aware that you are on Coumadin and or both of the other drugs so that the INR is not prolonged as much by Coumadin and so that the physicians can watch you more carefully.

Neuropathy

admin — Thu, 05 Mar 2009 21:58:55 +0000

Dr. Robert Miller defines what a neuropathy is (an abnormality in a nerve), why different neuropathies cause different symptoms, what the usual causes of neuropathy are, and what the relationship between cancers, cancer treatments and neuropathies are.

ALS

admin — Thu, 26 Feb 2009 21:44:20 +0000

Dr. Robert Miller is interviewed about how ALS (or Lou Gehrig’s disease) involves nerves controlling voluntary muscle movements. Weakness in one muscle group, speech changes and difficulty swallowing are some of the problems that initially affect people and cause them to seek medical attention. Care is complex, relying upon multiple therapists to give people the best quality of life. At this time, one medicine has been shown in trials to slow down but not halt the progression of disease. Maintaining hope, accepting symptoms to relieve symptoms, maintaining good nutrition, ensuring good lung function and involvement in a multi-disciplinary clinic have all been shown to improve people’s quality of life.

A Lump in the Neck

admin — Thu, 26 Feb 2009 00:52:11 +0000

Dr. Mark Singer, a noted head and neck surgeon in San Francisco, describes in straight-forward terms what to do when a lump is discovered in the neck. There are several possible causes —infection, inflammation, a remnant of a cyst from the time of birth as well as cancer. Depending upon where in the neck the lump is as well as the lump’s characteristics (size, location in the neck, hardness and tenderness), the person’s age, the possible history of a sore throat a few weeks earlier, a history of smoking and many other factors, physicians can prioritize which of the several causes are most likely. Often a trial of antibiotics is appropriate. There is also a simple, painless procedure to place a small needle into the lump that can identify the cause. Cells can be evaluated under the microscope and cultures can be taken as well through the needle. Tumor cells and often the type of tumor can also be identified, an important issue for some patients. The procedure is called an FNA for fine needle aspirate.

Voice Prostheses

admin — Tue, 16 Dec 2008 18:33:00 +0000

You needn’t live in silence even if your larynx is removed. Dr. Mark Singer, a head and neck surgeon, describes how people who need total removal of the larynx, the natural voice box, can regain speech.

The Value of Hospice

admin — Tue, 16 Dec 2008 17:43:31 +0000

Hospice is a Medicare benefit that offers care at home, the availability of several support services for those in need, and active cancer care if that is medically appropriate. Dr. Andrew Lasher is interviewed in order to understand and maximize … Continue reading →

Managing Pain

admin — Thu, 10 Jul 2008 23:18:09 +0000

Cancer patients understandably feel concern when new pain arises, yet their pain may not be the cancer itself. It might be coming from their treatment; it may be exacerbated by depression.In this episode, Dr. Robert Rodvien speaks about managing the … Continue reading →

Clotting and Anti-Coagulation Clinics

admin — Thu, 05 Jun 2008 23:58:38 +0000

For patients who have experienced blood clots, there’s much to know about lifestyle changes and proper medication. In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in … Continue reading →

Introduction to Coumadin

admin — Thu, 05 Jun 2008 23:55:44 +0000

An increasing number of patients are being prescribed Coumadin, yet far too many are unclear about what the drug does, how it works, and why it's critically important that dosing be properly monitored. In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, explains the basics about Coumadin (or Warfarin) and what to anticipate when taking this medication.

Clinical Trials

admin — Wed, 19 Mar 2008 23:56:35 +0000

Every cancer drug must go through a clinical trial and there are many reasons for cancer patients to participate. Your doctor may recommend applying for a trial, but that doesn’t mean you will be accepted. Clinical drug trials can provide hope, a proactive plan of action, and, ideally, some relief and perhaps even a shot at a cure. As Dr. Rodvien explains in this episode, participants are closely monitored and can opt out at any time, for any reason.

Genetic Testing

admin — Tue, 18 Sep 2007 23:52:13 +0000

Some day, we may be able to conduct genetic testing for most cancers. As of now, there are limited tests available for some cancers and, even then, there's no definitive course of action dictated by the results. In this episode of Smarter Cancer Care, Dr. Rodvien discusses genetic testing for breast and ovarian cancer, the pros and cons, genetic counseling, and how women with a significant incidence of these cancers in their families might proceed.

It’s the Patient’s Decision

admin — Wed, 29 Aug 2007 23:48:21 +0000

There are many instances, from diagnosis through late stage cancer, when a patient has to choose a course of treatment. While doctors often make recommendations, it is the patient who gets to decide. This can be challenging for family members who, in some cases, won’t understand or support a patient’s choice. In this episode of Smarter Cancer Care, Dr. Rodvien discusses the role of the doctor and those closest to the cancer patient when it comes to making treatment decisions.

Any Port in a Storm

admin — Tue, 21 Aug 2007 23:43:26 +0000

Cancer patients often feel that their turning their veins over to others. Blood must be drawn on a regular basis and, when necessary, drugs, fluid, and blood must be given intravenously. One good option for many patients is to have a permanent catheter implanted to provide safe and convenient access to a large vein. This can help avoid discomfort and protect your veins.

Coverage Denied

admin — Tue, 14 Aug 2007 23:38:46 +0000

Cancer patients and Oncologists experience frustration when coverage for a particular therapy is denied by medical insurance companies. In this episode of Smarter Cancer Care, learn about steps that you can take in such instances, when to appeal such decisions, … Continue reading →

How You Can Help

admin — Tue, 31 Jul 2007 23:36:15 +0000

The key, according to Dr. Robert Rodvien, is to listen to your friend or family member who has cancer. Often, that's the greatest gift you can offer. As well, you may be able to help with household chores, rides, or speaking to others. In this episode of Smarter Cancer Care, you'll learn ways to help and when to step back and provide the patient with privacy.

Coping with Fatigue

admin — Tue, 17 Jul 2007 23:22:47 +0000

Cancer can be exhausting. So can chemotherapy…and radiation…and depression. Anemia often causes fatigue in cancer patients and for that, there's immediate help. In this episode of Smarter Cancer Care, Dr. Robert Rodvien provides strategies for coping with fatigue and urges … Continue reading →

Lung Cancer Basics

admin — Wed, 04 Jul 2007 00:07:07 +0000

There are approximately 175,000 new cases of lung cancer diagnosed in the U.S. each year, with an 85% chance of mortality. In this episode of Smarter Cancer Care, Dr. Robert Rodvien explains the difference between cancer in the lung and … Continue reading →

How Cancer Drugs are Developed

admin — Tue, 12 Jun 2007 23:59:05 +0000

There are tight regulations on how drugs are developed in the United States and this happens in phased clinical trials. From preclinical trials in the laboratory, through animal models, and Phases III and IV, involving cancer patients, everything is heavily monitored. Criteria for acceptance into a clinical trial is strict and, even when results are fairly consistently positive, FDA approval takes time. Learn about the pros and cons of participation in clinical drug trials in this episode.

Consequences of Some Cancer Therapies

admin — Tue, 29 May 2007 23:42:41 +0000

When embarking on a cancer treatment plan, it helps to be able to anticipate both the physical and emotional reactions that might ensue. Dr. Rodvien explores some of consequences that one might experience as a result of cancer therapy and … Continue reading →

Legitimate Treatment Options

admin — Sun, 20 May 2007 23:37:33 +0000

In some cases, the evidence points to one particular cancer treatment plan. In others, a patient will have more than one legitimate option. In this episode, Dr. Rodvien explores the concepts of surgery, chemotherapy and radiation, and what factors are … Continue reading →

Oncology History and Medical Insurance 101

admin — Wed, 09 May 2007 23:32:23 +0000

When Dr. Rodvien graduated from medical school, hematologists treated cancer patients. In this episode he traces the evolution of oncology and the various sub-specialties that have arisen. Also, we continue our exploration of medical insurance for cancer patients and discuss … Continue reading →

Paying for Cancer

admin — Tue, 01 May 2007 23:27:15 +0000

Ideally, cancer patients should be able to focus on the quality and nature of their medical care, rather than its cost. Yet, paying for cancer care can be daunting. In this episode of Smarter Cancer Care, Dr. Rodvien discusses how much insurance is enough, HMO vs. PPO, why some physicians won't treat Medicare patients, how high out of pocket costs can run, and whether cost should be a factor when choosing medical care.

Getting Accurate Information

admin — Wed, 25 Apr 2007 05:03:32 +0000

There's a temptation to listen to well-meaning friends and/or to devour whatever information is available on Internet when searching for information about a newly diagnosed cancer. The problem is that you may end up with disinformation. In this episode of Smarter Cancer Care, Oncologist/hematologist Dr. Robert Rodvien provides sound advice on where to turn for accurate information about your cancer.

Negotiating the System

admin — Wed, 18 Apr 2007 05:00:50 +0000

Your best consultant for helping you navigate your way through the cancer world is your primary care physician. In this episode of Smarter Cancer Care, Dr. Robert Rodvien explores how to move through the system in the most efficient and effective way possible. It helps to understand that time delays are often necessary and that things will tend to take longer than you would like. A kind and patient attitude can go a long way toward minimizing anxiety and stress.

Emotional Impact of Diagnosis

admin — Wed, 11 Apr 2007 04:49:36 +0000

Shock, confusion and fear are some of the emotions that cancer patients often experience upon receiving a diagnosis. Close friends and family members often share these feelings and are uncertain of how to respond. In this episode, clinical Oncologist Dr. Robert Rodvien offers sound advice on how to help cancer patients with their initial psychological responses. Caring friends and relatives should always remember that the needs of the patient come first and that they do not have to respond to everything that is said.

Choosing a Cancer Team

admin — Fri, 06 Apr 2007 04:39:00 +0000

What is the difference between a a clinical Oncologist, a radiation Oncologist, and an Oncologist who specializes in a particular form of cancer? Is the mass the same as a tumor? In this episode, Dr. Robert Rodvien answers these questions and others to help cancer patients, their family members, and close friends have a command of the basic terminology of cancer. With compassion, Dr. Rodvien offers practical suggestions for selecting the best medical practitioners and touches on a number of subjects to be explored in depth in future episodes: the impact of medical insurance, managing the information flow, second opinions, and getting the most from your medical appointments.

Entering the World of Cancer

admin — Thu, 29 Mar 2007 04:26:28 +0000

You’ve just been diagnosed with cancer. What happens next? How do you deal with normal life while being completely pre-occupied? What do you do when you get home after being diagnosed? How quickly should you proceed, both medically and psychologically? … Continue reading →