‘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.

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>

So Your Doctor Says You Have High Cholesterol: How To Read Your Cholesterol Report

December 22nd, 2018

By Natan Schleider, M.D.

Dr. Schleider Cholesterol Report

So you had a physical and your doctor told you you have ‘high cholesterol’ but what does this really mean?

Historically, labs could only test ‘Total Cholesterol’ so alevel above 200 was considered high and below 200 was considered normal. This is a vast oversimplification to the point that in the 21st Century, Total Cholesterol tells doctors very little as it includes both Good (HDL) and Bad (LDL) cholesterol. So, for example, if your LDL cholesterol in 90 (which is quite low) and your HDL cholesterol is 120 (which is quite high but that’s good, the higher the better) your Total Cholesterol would be above 200 and you would have enviable cholesterol.

I included my own cholesterol test results above. This is a fancier panel which some insurance companies will not cover but it is detailed and a good teaching tool.

The common cholesterol test (aka lipid test panel) your doctor performs includes the following which I will help you to interpret (so you can decide whether to skip the bacon cheeseburger and/or exercise more and/or add a medicine for cholesterol.

Cholesterol Tests:

  1. LDL (Low Densiy Lipoprotein)–If you remeber anything, the LDL is THE MOST IMPORTANT NUMBER ON YOUR CHOLESTEROL TESTING. Commonly called bad cholesterol, LDL is the stuff that sticks to and clogs arteries anywhere in the body cauisng heart attacks and strokes and peripheral vascular disease. [Note different sub-types of cholesterol are sometimes called ‘particles’ and the smaller the particle the more likely it is to clog arteries. You will note my test has a ‘Lipoprotein Particle Evaluation’ which for our purposes is too complex to review and not that relevant for most patients]. As a general rule, if your LDL is above 160 treatment is immediately indicated, generally with a medicine. This does not mean you are committed to Lipitor for life but if your cannot keep you cholesterol below 160 you may need medicine indefinitely. Note I take Lipitor 40 mg daily for prevention reasons as current USPTF guidelines show that artifically lowering your cholesterol from normal to low reduces risk of artery clogging, heart attack, and stroke. If LDL is below 100 you are in the clear (unless you have high risk factors for artery clogging like diabetes, tobacco smoking, or perosnal history of heart attack or stroke) in which case LDL should be below 70. If your LDL is between 100 and 160 there is some debate but as a general rule, if you have zero risk factors for artery clogging try to get LDL to 130 or less without medicine. If you have some risk factors for artery clogging like obesity or high blood pressure try to get LDL to 100 or lower.
  2. HDL or Good Cholesterol–This should be above 40 ideally but the higher the better. While some new injectable medicines can raise HDL, as of 2018 these are not commonly used in primary care. Only regular exercise brings up good cholesterol although statin medicines like Lipitor may help a bit.
  3. Triglycerides–These are a type of fat that do not stick to arteris very well so I won’t say they are not important but will say try to keep levels below 150 with diet and exercise and consider a medicine if they run above 150.
  4. Total Cholesterol–As mentioned before, no real information here, the devil is in the details of the other tests.

So that covers the basics on cholesterol. I know I am seeing an educated intelligent patient when they say “Tell me about my LDL and HDL, the total cholesterol doesn’t matter much.’

Thanks for reading,

Natan Schleider, M.D.

Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Medical Secrets (Shhh Don’t Tell)

ARE YOU TOO FAT. Vintage weight loss advertisement circa 1900

By Natan Schleider, M.D.

December 12th, 2018

Gone are the days where I could simply skip desert and stay rather lean and toned. Having just turned 43, I literally feel my metabolism slowing and all I need to do is look at carbs and they go straight to my gut by osmosis. 

I weighed about 175 pounds (standing 5’9″) into my late 30s but after a recent physical I weighed in at 220 pounds and have shrunk to 5’8″. At this rate I’d be a walking doughnut with a head so I left my doctors office determined to get lean using every bit of advice I could find in the world of medicine, science, and technology.

Its been two weeks and I am down to 205 pounds. I could say I feel great but I’d be lying. My internal barometer seems to want me obese which I qualify for using a Body Mass Index Calculator. I’m tired as I don’t sleep well when I’m hungry. I’m cranky but fortunately I get a lot of telemarketing calls which allow me to toy with people trying to sign me up for ‘limited time offers’ on credit cards, business loans, and Nigerian Gold Mines.

I presume my mood and body will get used to my goal weight which is 180 to 190 pounds if I can get there. 

So here is what has been working to get the weight off…

  1. I go to the gym at least 5 days a week and workout with a trainer. This is my life one big luxury but I am so lazy if I didn’t pay the trainer I would barely work out. The trainer doesn’t let me skimp on those last few squats that leave me dizzy and gets a good laugh when I fall on my face doing box jumps. Bottom line: if you can afford a trainer or have a motivated work out partner that really helps. That said, weight loss is about 80 percent diet so if you cannot afford a trainer and hate the gym most of success lies in meticulous eating.
  2. I started using a My Fitness Pal app which is a real pain because it takes about 5 minutes to enter calories for every meal depending on the number of ingredients. The simpler the meal the faster I can enter and count calories. I’m aiming for 1500 calories daily, a few hundred more if the workout has been strenuous. Some of the things I snacked on like a slice of American Cheese or Prosuciutto have way more calories than I thought so the app has been educational. Even cucumbers have calories and if you are going to lose weight, you need to be rather meticulous in your calculations
  3. I’ve stopped eating out or ordering take out as I cannot count these calories–plus I like to cook so not a biggie for me.
  4. I have prepared healthy meals ready to be cooked or simply heated. I have a great healthy tomato bisque recipe–if anyone is interested let me know.
  5. I have my ‘skinny jeans’ front and center in my closet and try to put them on every few days. They obviously don’t fit (yet) and this negative reinforcement pisses me off, re-motivating me to stick to the diet exercise plan.
  6. Studies show drinking diet beverages can actually cause weight gain and other issues but when I have a sweet craving, I’ll go for a Diet Cherry Coke which is better than Cherry Garcia.
  7. I bough a food scale for about 10 dollars and while I think anyone weighing their tomato wedges is nuts, it is the only way for me to know exactly how many calories I am eating (because the common advice ‘just portion control’ means instead of eating an entire pizza pie, I eat half for dinner and half for dessert).

Some of the above I am sure you’ve read while other may seem somewhere between fanatical and disciplined but if I am serious about weight loss, this is a discipline which takes time and I just hope I can stick with it to the point it becomes routine.

Anyway, thanks for reading!

Natan Schleider, M.D.

Humorism: Why Modern Medicine is Still an Infant or Maybe a Young Toddler

December 11th, 2018

By Natan Schleider, M.D.

‘The Four Humors’ by Granger Drawing Circa 1574

So its the 21st century, you had a physical, and the doctor collected body fluids like blood and urine for ‘sophisticated’ testing. Ah the marvels of modern medicine.

But wait, doctors have been doing this for thousands of years. I would have been one impressed Gladiator in Ancient Rome if my doctor tasted my urine and explained I was feeling weak and urinating a lot because I had too much sugar in my blood. And doctors did just that. No glucose strips or little battery powered devices. Diabetes mellitus was diagnosed with a simple taste test, not blood test. 

Perhaps that doctor sends me to a specialist in Gladiators (who had the status and value of today’s NBA and NFL stars when Rome ruled the world) who likely would do a blood test. Sounds perfectly reasonable. Who wouldn’t want to know if their four humors (black bile, yellow bile, phlegm, and blood) were out of whack.

Today, we honor those four humors and their inventor, a physician known as Hippocrates (460-370 BC):

  1. Doctors take the Hippocratic Oath
  2. We take humors like phlegm and blood of out peoples bodies to test (IE for infection or anemia) and treat them (IE for Polycythemia)
  3. Doctors keep their patients humors in balance by reducing phlegm if they have too much of it so they can breathe

Around the 1500s doctors realized that there may be more to medicine than the four humors but that didn’t stop doctors from bleeding patients therapeutically for virtually any ailments into the early 1900s. Did you know George Washington died of being bled by his doctors for a throat infection. Seriously!

The greatest advances in medicine in the last few centuries include soap (probably saved more lives than all the antibiotics ever created), antiseptic surgical technique, and Viagra (not necessarily written in order of importance).

Sure we have fancy breathing machines, pictures that let us see inside our bodies, and robotic surgery. 

I’m no surgeon but I have to wonder about the bedside manner of robots, I mean, after fixing my heart valve will they reassuringly rest their arm on my shoulder and take a sip of my urine to confirm my diabetes is under control?

Thanks for reading!

Natan Schleider M.D.