‘You’re at risk for artery clogging like a heart attack, stroke, kidney disease. See the plumber.’ Says my General Practitioner.

HEART / ARTERY HEALTH, & ATHEROSCLEROSIS FOR DUMMIES PART I: HISTORY AND CULTURE AND THE SCARY STATISTICS OF ARTERY CLOGGING (AKA ATHEROSCLEROSIS)

By Natan Schleider, M.D.

July 11th, 2019

Vintage Anatomical Print of The Heart

6:00 AM: Opened my weekly pill organizer taking an aspirin, a statin (IE atorvastatin generic for Lipitor), blood pressure medicines, and quickly drank my coffee through a straw (which supposedly prevents teeth staining)

6:15 AM: My 6 year old daughter Ellie wakes up, rubs her eyes, and says ‘Daddy, cereal?’ I pour a bowl of ‘CAN HELP lower CHOLESTEROL‘ Cheerios with Silk Almond milk at 30 calories per serving.

Cardiovascular disease (CVD) which includes clogging of arteries to the heart, brain and kidneys namely accounts for approximately 800,000 deaths in the United States (US), or one out of every three deaths. On an average day in America of 2192 die from CVD. Note these number does not include people that just have non fatal events like heart attacks, angina, and strokes that leave you weak or paralyzed.

To keep things in reference 2,977 people were killed on 9/11 while last year 192 Americans died from opiod overdoses during our media frenzied nationwide opiod epidemic.

As far as I’m concerned, every newspaper headline every day should read “Another 2000 Americans Die From Preventable Illness” and no, it was not a zombie invasion!

I love America, greasy fries, a quality cheeseburger, stagnating in my chair playing chess vs a computer that always wins, and salt be it kosher, seasoned, Tajin, or any of the number of gourmet salts celebrity chefs tout on about.

The causes of our nation’s greatest killer are so woven into the fabric of American culture and history that we not only take it for granted but celebrate it. Tobacco was America’s number one economic export before there was a USA and central to George Washington’s wealth and the Revolutionary war. Which American president didn’t pose biting into a McDonalds or Burger King burger?

So I wanted to give you a smorgasbord of background and education before digging into our nationwide epidemic: atherosclerotic disease.

Part II of this article blog will focus on signs, symptoms, and other things most of us do daily (or neglect to do) that causes the clogging.

Thanks for reading!

Natan Schleider, M.D.

Screening Options for Colon Cancer

THE BEST COLON CANCER SCREENING TEST IS THE ONE THAT GETS DONE!

By Natan Schleider, M.D.

July 9th, 2019

Source: American Family Physician Vol. 100 No,1 July 1st, 2019 p.10-11

As I approach 50 years old, I am thinking about which colon cancer screening test is right for me.

I will likely go with the gold standard, screening colonoscopy. If you don’t know what this is, the patient is put to sleep under mild anesthesia which is quite safe and a fiberoptic tube is placed up the anus all the way through the large intestine to look for colon cancers or precancers which appear as polyps. Pros of screening colonoscopy: you need it only every 10 years (5 if you are high risk or more often if you have colon cancer or have been treated for colon cancer); the procedure only takes about 20 minutes and you are home same day. Cons or the biggest complaint I hear is being up all night with diarrhea as patients are given a strong laxative to flush out their colon (aka large intestine) which allows the doctors to see the lining of the intestine without stool being stuck to the walls.

Screening colonoscopy is my choice because while there are many of good noninvasive tests which I will review below, if they are negative, reassuring; but if positive, you will need a colonoscopy anyway to confirm whether it is a true or false positive.

Other screening tests for colon cancer:

  1. Stool testing for blood also called Fecal Immunotherapy Testing (catches about 58% to 72 % of colon cancers). This is a cheap easy option an with a 97 percent specificity (meaning if the test is negative, you probably do not have colon cancer) this is a nice easy choice.
  2. mSEPT9 Blood Test (Epipro Colon) detects 73 percent of colon cancers with a specificity of 82 percent. This may be a nice option if you are not inclined to sending your poop to a lab, understandable.
  3. Cologuard is a stool DNA test where you ship your poop to a lab where the examine it for colon cancer risk. This can be done every 3 years and I like this alternative option.
  4. Computed tomography colonography means no invasive testing but you will still need to have your intestines cleaned meaning you’re up all night with diarrhea but at least this is not invasive.
  5. Flexible sigmoidoscopy is like a mini colonoscopy which while still approved, is hardly done anymore as it only looks at the first part of the colon potentially missing cancers in the middle or distal colon.

If you opt against colonoscopy, you can do some or all of the noninvasive tests. Any testing is better than no testing and unlike most cancers in the 21st Century, colon cancer is one we can catch and treat early. Go get tested!

Thanks for reading!

Natan Schleider, M.D.

Lofexidine (Lucemyra) for Treatment of Some Opiod Withdrawal Symptoms

By Natan Schleider, M.D.

Source: American Family Physician V.99 No.6 March 15th, 2019

While I am pleased that a new medicine recently FDA approved for mitigating some symptoms of opiod withdrawal (IE sweating, increased heart rate, some of the physical symptoms of anxiety) I am cautiously optimistic at best that this medicine will see much

The pros of lofexidine:

  1. Most importantly it demonstrates that someone / the pharmaceutical industry realizes a need for more medicines to address the current opiod epidemic. This is extremely important given the few resources available for treating opiod dependence so kudos to all who did the work to get this medicine approved seriously.
  2. See point 1

The cons of lofexidine:

  1. It costs about $1,776 dollars for a seven day supply whereas there is an older virtually identical medicine (also commonly used to mitigate withdrawal symptoms) clonidine which costs nine dollars for a 30 day supply.
  2. Dosing is 4 times a day (presuming a patient in acute withdrawal isn’t vomiting everything they try to swallow which is often the case).

I don’t mean to ‘poo-poo’ this medicine and I will certainly prescribed it when indicated. I will be astonished if an insurance company covers it but at least there is one more weapon in the arsenal.

Thanks for reading.

Natan Schleider, M.D.

Aspirin: Good or Bad for Preventing Heart Attacks?

BY NATAN SCHLEIDER, M.D.

JUNE 24, 2019

Image result for vintage aspirin

As a physician in private practice for 15 years, the specialty I once viewed as rigorous in the scientific method and always backed by strong data in powerful studies has been disappointing me. When paying half a million dollars for medical school, the professors tend to omit the fact that 50 percent of what they are teaching as the latest important clinical findings will be completely wrong.

For example, in medical school I was taught that hormone replacement for women after menopause would reduce risk of heart attack and osteoporosis. Hormone replacement not only helped hot flashes but was good for you, right?

Wrong. In 2002 The Women’s Health Initiative (a large study dwarfing the studies that had provided the info I learned in medical school) found that hormone replacement significantly increased breast and uterine cancer risk. Suddenly, prescriptions for menopausal symptoms went the way of the dodo.

I was also taught that Oxycontin was not addictive, ha!

For years aspirin has been considered an excellent choice for reducing risk of heart attack, stroke, and even colon cancer. Suddenly this month’s editorial in American Family Physician says with need to ‘rethink’ aspirin’s role in primary prevention. Really! Aspirin is the oldest pain medicine around since the mid to late 1800s. And we still are unclear about it’s efficacy?

In medicine’s defense, new large studies are constantly done (as the cornerstone of science is ability to repeat results given the same questions and data but often the second study does not jive with the first. So medical students are left knowing less then when they started [but at least the tuition bills are consistently on the up and up].

Simply put, for patients with risk factors for artery clogging/heart attacks (but with little or no risk for aspirin inducted gastrointestinal bleeding) aspirin 81 mg daily is recommended, especially age 50 to 70.

I am 43, have high cholesterol (addressed with Lipitor) and high blood pressure (addressed with medicines). Rather than perfoming certain convoluted risk calculations to determine my need for aspirin, I just take it daily.

Do I won’t to over-medicate you dear reader? No. But you can take comfort in the fact that if the ‘experts’ praise the results of a study this year, 10 years from now they will likely praise a newer study which discredits the first one.

As objective as medicine presents itself, the good doctor knows the art and science of good medical practice.

A Succinct Review of the Top Medical Research Studies of 2018 for Family Physicians

By Natan Schleider, M.D.

May 19th 2019

SOURCE: AMERICAN FAMILY PHYSICIAN V.99 # 9 MAY 2019 P.565-573

Every year I try to some up the most important easy to understand studies for my patients, doing my best in eliminating fancy medical mumbo jumbo.

Here are the important points for 2018:

  1. Home blood pressures are more accurate than doctor’s office blood pressures. Sooo, if your blood pressure is high at the hospital or doctor’s office (which it should be unless you are super zen), check your blood pressure at home with any machine that measures above the elbow OR ask a friend who knows how to check blood pressure. If you find yourself surrounded by machines as in the above photo, you are doing something wrong…that photo is actually an old ECG machine.
  2. Lower blood pressures are almost always better EXCEPT in elderly patients 85 or older.
  3. Shorter courses of antibiotics are almost always as effective and have fewer side effects than longer courses. So, for example, if a Zpack usually helps your bronchitis or ear infection or sore throat, opt for the 3 day Zpack rather than the 5 day.
  4. For women who suffer from 3 or more UTIs annually, drinking an additional 1.5 liters of water daily reduces risk of future UTI by 50%.
  5. Several studies show that non-opiod pain medicines are as effective for relieving acute injury of arm or leg pain in the emergency room compared to opiods.
  6. Patients who exercise (at least 150 hours per week or more) have lower risk of depression.
  7. For patients being medically treated with anxiety who then stop their medicines, 1/3rd will have a relapse and require medication again. 1/6th of all patients with anxiety will have worsening anxiety despite treatment.
  8. Stool testing for colon cancer screening using DNA found in stool (called Fecal Immunochemical Tests or FIT) is better than standard stool testing for blood and an optional substitute for colon cancer screening other than colonoscopy.
  9. Type II diabetics should shoot for a HbA1c of 7-8 percent (and not lower as previously advised).
  10. If you are 60 or older, a blood pressure of 150/90 or lower is ok presuming you do not have other serious medical issues. Below 60 lower than 140/90 is ok.

Please contact me with any questions or comments.

Thx,

Natan Schleider, M.D.

Is Breakfast Really the Most Important Meal of the Day?

By Natan Schleider M.D.

SOURCE AND QUOTES FROM:
JAMA. Published online May 1, 2019. doi:10.1001/jama.2019.2927

‘Back in 1917, the same year that she cofounded the American Dietetic Association (now the Academy of Nutrition and Dietetics), Lenna Frances Cooper authored an article in Good Health magazine that noted “in many ways the breakfast is the most important meal of the day, because it is the meal that gets the day started.” Good Health was published by the Battle Creek Sanitarium, a Michigan health resort run by Cooper’s mentor, John Harvey Kellogg, MD, the coinventor of corn flakes (his brother started the cereal business that would become the Kellogg Company).’

Recent studies indicate that eating breakfast may NOT improve weight loss and nutrition, speaking to how the public’s medical knowledge that ‘everybody knows’ has no scientific support. Other fallacies that our parents told us include sitting too close to the TV will cause eye damage, for example–it will not.

One Meal A Day (commonly called OMAD) has been a recent diet trend where a person consumes all calories within an 8 hour window or fewer.

Bottom line for the patient with a normal metabolic system is that total calories consumed per 24 hours will best reflect weight loss outcomes, regardless when calories are eaten. That said, plenty of serious body builders and models eat no carbs after 12 noon .

If breakfast is integral to your nutrition, diet and lifestyle, great, don’t change a thing. I personally am not big on breakfast eating usually some egg whites sauteed with some onion and tomato and chipotle tabasco sauce (about 200-300 calories). If you have been forcing down breakfast and not particularly hungry, recent data shows this may kickstart metabolism and hunger later in the day leading to weight gain.

Thanks for reading,

Dr. Natan Schleider

Turning 50? Get ready for a battery of tests…here is what is recommended.

‘Some men just can’t seem to grow old gracefully.’

By Natan Schleider, M.D.

January 14th 2019

I’ll be turning 50 soon and I can tell. I wake up 4 times nightly to pee )so my prostate is growing.’ My hair is thinning. Joints hurt. I shrunk from 5’9″ to 5’8″ based on my last physical. While I am researching anti-aging medicine, I am preparing for the slew of tests indicated at age 50.

In no particular order if you are 50 or older you should have these tests:

  • Screening colonoscopy for colon cancer every 10 years for those at normal risk of colon cancer. Alternate options which I am considering is Cologuard which is a stool based DNA non invasive test with 95% accuracy done every 3 years instead of colonoscopy (unless of course the test is positive in which case you need colonoscopy).
  • Screening Chset CT Scan (age 55 to 77) if you have ever smoked 30 packs of cigarettes in your life or have smoked any cigarettes in last 15 years.
  • Prostate testing in men annually–debatable, talk to your doctor.
  • Checking your weight, cholesterol, and blood sugar annually
  • Pap smear every 5 years in women
  • Mammogram annually for women
  • Annual skin exam by skin doctor
  • Make sure vaccines are up to date–these get confusing and probably warrant another blog/article–most common is tetanus booster with pertussis every 10 years

If anyone knows a good anti-aging doctor, let me know!

Natan Schleider, M.D.

‘Dear Blue Cross Blue Shield, Thanks for raising my fees because I know the 1+Billion Profit You Made in 2018 Will Go Straight to the Sick and Infirm!’

By Natan Schleider, M.D.

January 12th, 2019

First let me say if you are reading this blog and comment or follow me on social media and are a new patient with no health insurance, I’ll provide you free medical care for 3-6 months within the scope of my specialty. Why? Quite simply if I can afford to run a medical practice with zero income from some new patients, perhaps large insurance companies can do the same?

Anthem made 1.1 Billion Dollars in 2018 while dropping 888 thousand clients. Way to trim the fat.

If health care providers provide medical care and patients receive medical care why do the middle men–health insurance companies–make all the money? This complex question which seemed innocent in 1917 has snowballed to the point I pay over $2000 dollars a month for health insurance for me and my daughter which we sometimes use. But not $2000 a month! We are healthy fortunately.

So my proposal to Empire Blue Cross Blue Shield, the biggest insurance company in New York City: For every free patient I treat, you treat a free patient like a 9/11 victim, a pregnant mom, anyone warranting care.

If we both lose a 100 million dollars monthly then we regroup but if everything goes smoothly, become a nonprofit that gives out smoothies!

Hope to see some new patients soon as well as people commenting on my blog.

Natan Schleider, M.D>

Going for a routine physical exam? New guidelines suggest less is more.

January 4th, 2019

By Natan Schleider, M.D.

Early Electrocardiogram called a String Galvinometer Circa 1911

My primary care physician is a very bright internist in his early 70s who I saw recently for a routine physical exam. He examined my head, neck, chest, and abdomen and then, putting on gloves and grabbing some KY jelly, told me to bend over for a prostate exam.

‘Prostate exam!’ I said, ‘Why? I have no prostate or urinary issues, no personal or family history of prostate cancer, and don’t see the need.’

‘Just being thorough,’ he replied.

While I like my doctor, there is thorough and then there is ‘too thorough.’ Moreover, I reminded him, routine prostate exams are no longer indicated [Source: US Preventive Task Force].

‘We’ll skip the prostate exam.’ I said. He shrugged as if to say he wasn’t doing his job properly. He then checked my legs and the exam was over.

While some of you may like the comprehensive check every nook and cranny exam, I personally don’t nor do I recommend or perform them. I stick to what the data supports. Why some patients seem disappointed that I haven’t probed every orifice is beyond me but to each their own.

Next time you’re in for an adult physical, here are tests which are no longer considered routine or necessary unless, of course, the doctor feels they are needed based on your medical history, symptoms, or other risk factors.

  • Digital Rectal Exam (meaning sticking a finger into your anus and rectum)
  • Pelvic Exams in Women
  • Testicular exams are up in the air but consensus is that male patients, especially those age 20-35 (when testicular cancer is most common) can perform their own monthly self-examination and/or have the doctor do the exam. The US Preventive Task Force recommends against testicular exams during a normal physical [Source: https://www.ncbi.nlm.nih.gov/books/NBK82767/table/vaphysical.t1/?report=objectonly]
  • Thyroid exam for thyroid cancer
  • Abdominal exam for pancreatic cancer, liver enlargement, or spleen enlargement
  • Lymph node palpation
  • Back exam for determining mobility
  • Checking reflexes in arms and legs
  • Breast exams need not be done if more sophisticated tests like mammograms are available

Some testing on routine physical exam are still being reviewed but as I peruse the medical literature, it seems that, to my old school doctor’s chagrin, much of the physical exam in adults is probably not helpful and may even lead to false positives.

Certainly some patients will swear that their doctor caught a disease by poking around or hammering on the knees with a reflex hammer and all I can say is: God bless those doctors. I’m interested in the facts here, just the facts.

Thx for reading,

Natan Schleider, M.D.

Source: https://www.ncbi.nlm.nih.gov/books/NBK82767/

Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult

Hanna E Bloomfield, MD, MPH and Timothy J Wilt, MD, MPH.

Created: October 2011

‘I don’t need the flu vaccine, it always makes me sick plus I can count on ‘herd immunity.’

January 4th, 2019

By Natan Schleider, M.D.

Poster by Board of Health Advising People wear mask in 1918 to protect against Spanish Flu


‘I don’t need the flu vaccine,’ said a mid 30s healthy female patient to me yesterday, ‘it always makes me sick plus I can count on herd immunity.’

My patients are well read, opinionated, and know plenty of medical jargon to make their point. Herd immunity, if you’re wondering, means that if everyone else around you is vaccinated and immune to a disease, the chances of them giving it to you is very low.

Let me also add the influenza vaccines do not give live virus, just the proteins of the virus to illicit an antibody and immune response if you are exposed to the virus. The immune response caused by the vaccine results in some cold symptoms like fever, sore throat, runny nose, cough, aches/pains, but DOES NOT cause the flu.

So why all the hype about the flu vaccine?

There are several answers:

  1. The media often has nothing really news worthy so given the mantra’ if it bleeds it reads’ they can always turn to the dangers of the latest deadly flu virus bound to land you on a ventilator before you can change the channel. Remember all the media hype about Avian Flu (H5N1) about 5-10 years ago. Turned out to be nothing. And the dreaded Swine Flu of a few years ago infected the airwaves aggressively (and fortunately did not infect many people). If you really want information about influenza ask your doctor, check the CDC and WHO websites, and ignore the publish or perish journalists.
  2. Historically, certain strain of influenza were actually quite deadly. the most infamous in Spanish flu, an aggressive form of H1NI influenza virus that spread quickly and was unusual in that it killed more young health adults (ages 20-40) than the young or elderly. Over 100 years later, this pandemic killed more people than those that died in WWI.
  3. If another aggressive flu virus rears its head, the flu vaccine does a nice job at keeping you alive–presuming the CDC and WHO have guesstimated the right 3 or 4 viruses to put into the vaccine that season.

I recommend all my patients get the flu vaccine. I get it annually and have never had the flu (which let me remind you results in days of miserable fever and chills and 2-4 weeks to recover…this isa cold on steroids).

My flu vaccine of choice is the quadrivalent vaccine (meaning it has four flu virus proteins in it) while the classical influenza vaccine has three. If you are worried about mercury (thimerosal) get the preservative free vaccine. If you are worried about autism note there is little if any data to support vaccines causing autism but it is up to you. If you are worried the shot will hurt, make sure the doctor injects with a brand new needle (that is, not the same needle used to draw up the vaccine from the vial as this will blunt the end of the needle and cause more pain).

After the flu vaccine, you can take Tylenol or Advil or Alleve and can expect your arm to be sore for a day or three.

Take home message: get the flu vaccine yearly and stop wasting your time and losing sleep over the myriad of journalists that have nothing better to do than scare you about so they can make a living.

Thx for reading,

Natan Schleider, M.D.