3 Reasons Why “Weight Loss Challenges” May Be Unsafe

Weight loss challenges have become a popular way to lose weight. People who consider themselves to be overweight sometimes gather as a group and engage in them in order to lose the extra pounds they consider they have. On some occasions, these activities are promoted by gyms and “fitness” centers. They may consist on exercise routines that may be extreme and in dietary regimens that may be unhealthy. Here are 3 risks that any person participating in these challenges may be exposed to.

1. Risk of muscle injury. Muscle injury (rhabdomyolysis) is a condition that may happen if muscles which have not been subject to exercise regularly are suddenly exposed to it. The main problem with muscle breakdown (besides the pain) is the release of muscle enzymes into the bloodstream. These enzymes are known to be toxic to the kidneys and are known to cause kidney failure.

2. Risk of low sodium concentration. Low sodium in the blood (hyponatremia) can occur in people when they lose body salts through sweat from exercise and drink pure water or low salt-containing fluids. The body, when dehydrated, tries to retain fluid and when a dehydrated person drinks water most of it stays in the body, diluting the remaining sodium concentration. If sodium becomes too low, it can precipitate seizures .

3. Risk of low potassium concentration. Low potassium in the blood (hypokalemia) is known to happen when someone has a prolonged decreased food intake. The main risk of hypokalemia is the development of cardiac arrhythmias that can cause a person to collapse and even to have a cardiac arrest. 

There are other risks of performing unusual physical activity coupled with severe restrictions of food intake. The ones presented in this post are ones that are known to happen and that may pose a risk to a person’s health. Whenever there is a health related issue that needs to be addressed, the primary physician is the best suited professional that can guide a person through the process. He or she should be able to create the best approach for losing weight

Marco A. Ramos MD

3 Common Ways Kidneys Get Damaged Acutely

The kidneys are very delicate organs. As it can be seen in a previous post, they are in charge of many different functions and need to have a good supply of blood at all times in order to perform appropriately. 

1. The most common reason the kidneys get damaged is when the blood supply decreases. This happens when an individual loses fluids through diarrhea, vomiting and does not replenish its fluids with salt-containing fluids. 

2. Certain pain medications, can affect the internal blood flow of the kidneys. If these medications are taken and the body is not adequately hydrated the blood flow to the kidney cells can severely decrease and cause kidney damage. The type of pain medications belong to a category called non-steroidal anti-inflammatory drugs. Common examples of them are ibuprofen, naproxen and ketorolac. Other medications, taken when the body is not well hydrated can also damage the kidneys these include diuretics and blood pressure medications called ACE-inhibitors (examples: captopril, lisinopril, enalapril) and angiotensin receptor blockers (examples losartan, valsartan, irbesartan).

3. Finally, the kidneys can get damaged by a substance that is necessary for certain diagnostic procedures. The use of radiocontrast for coronary angiograpahies or CT scans can damage the kidneys if they are already chronically damaged or if the patient is not adequately hydrated.

There are other causes for acute kidney damage. The post concentrates in the common ones.

All these causes are usually temporary and the faster they are corrected, the better the chances of avoiding longer damage. Whenever there is a change in the level of fluids a body, the balance has to be restored. Do not hesitate to talk to your doctor or go the the closest Emergency Department if you feel at risk.

Marco A. Ramos MD

Is Moderate Alcohol Drinking Good for your Cardiovascular Health?

The answer, of course, is more complicated that everyone thinks. For many years, we have been told, (and as a physician I have told people) that drinking alcohol in moderate amounts is good for the cardiovascular health. This is based on  studies that indeed show a decrease in cardiovascular events (heart attacks, strokes and death) in people who drink alcohol moderately compared to non-drinkers or to heavy drinkers. The basis seemed to be an increase in the HDL “good” cholesterol.

Today, with the availability of genetic testing, scientists have been able to identify a subset of people (15-20% of the population) that may get a huge cardiovascular benefit from drinking alcohol moderately. According to one study, they can reduce the risk up to 80%. What this means is that if someone does not belong to this group, drinking alcohol in moderate amounts probably does nothing to the cardiovascular risk.

What are the potential lessons from this information? The first lesson is that Medicine is an evolving science. As knowledge increases, we physicians will be able to practice better and serve patients better. The second lesson is that individualized care is extremely important. Nowadays we tend to look for “fit-for-all” solutions. The reality is that we are all built differently. 

Marco A. Ramos MD

3 Reasons to Obtain a Second Medical Opinion

Healthcare is complicated. Specially if we are talking about complex situations like chemotherapy, dialysis, surgery or advanced procedures. The decisions made between the doctors and the patient will always involve the body of the patient. 

First, a second medical opinion is a way to reassure the patient regarding the course of action its healthcare is taking. There might be many doubts concerning a proposed surgery, for example. A second medical opinion would provide the patient the peace of mind necessary to minimize anxiety associated to the procedure.

Second, a new opinion rendered by a specialized physician would complement and supplement the information that the patient already has. A problem with the current healthcare system is the lack of time physicians have to provide the necessary data that patients need to make informed decisions

Third, a second medical opinion may broaden the options a patient can have. Specialized physicians looking specifically into the patient’s case can provide new insights withe respect to the case and when doing this, alternative therapies can emerge as possibilities when they were not considered initially.

A second medical opinion is a tool that all patients should consider, specially when the the proposed treatment strategies are complex and involve a certain level of risk for the life or wellbeing of the patient.

Marco A. Ramos MD

3 Pieces of Advise if You or Your Relative are Hospitalized

Hospitalization is a reality. It will happen to most of us, for one reason or another. It gets more common as age increases. The hospitalization process can be risky. There are specialized medications being given and invasive procedures performed. Regardless of the training and capabilities of the physicians and the watchful eyes and caring hands of nurses there will be side effects that might threaten the life or well being of a patient.

The first piece of advise is never to be confrontational with the hospital staff. In many occasions healthcare workers are working at the limit of their capabilities. Adding more stress to an already stressful situation by nature (which the hospitalization is) will only create negative feelings towards the patients and families. Healthcare workers are human beings and although they have been trained to be non-judgmental and to treat everyone equally, they are also human beings and have emotions of their own.

A second piece of advise is to make sure that all information about the hospitalization process is understood and that decisions are made together with the doctor. Patients and families sometimes fail to answer the questions because “the doctor already rounded and we missed him or her”.  It is the physician’s duty as the one ordering the treatments to inform the progress to the patient’s and/or families. Nurses know how to locate physicians and they will do it upon patient’s or family’s request.

Last, but not least, what do you do in case, in spite of multiple efforts to comprehend what is going on in the hospitalization process, things are not understood? At this point, what is needed is the intervention of the primary care provider (or even a third party physician patient advocate). Nowadays, there are more and more hospitalist services and the primary providers are staying away from the hospital scene. The primary provider or a private physician patient advocate would be able to interact with the hospital personnel and explain the issues to the patient and family afterwards.

The hospitalization process is complicated, but communication is key to a successful outcome. Barriers to effective communication can convert an already difficult situation into a worse one.

Marco A. Ramos MD

3 Reasons to be Careful with Genetic Testing

Nowadays, it is possible to obtain access to one’s genome data easily and relatively cheap. There are several companies offering this information and together with interesting information regarding ancestry they provide medically relevant data.

The first reason to be careful with is the meaning of the data by itself. The majority of diseases are multifactorial in origin, meaning that not one, but many genes could be involved in their genesis. In addition, the environment is also important, meaning that if even if the “defective genes” are present, a healthy diet and physical fitness can ameliorate the effects. An adequate interpretation of the data has to be performed by a physician and if further questions arise this should be followed by a second medical opinion of a physician with training in genetic counseling.

A second reason to be cautious is the abundance of information in the internet about certain conditions and the recommendations provided by well intentioned, non-medically trained people. We always have to keep in mind that we are unique and that the combinations in our genetic material probably do not repeat in another person. Therefore, the recommendations have to personalized. Again, as in the previous paragraph, your physician has to be in charge of starting a necessary treatment or reassuring the patient if necessary.

Finally, what would happen if an insurance company obtains someone’s personal information? Would they use to raise premiums if they know that you are at risk for a certain condition? Would a person become uninsurable? Privacy of course has to be a key factor here. Even if you disclose information to your personal doctor and he or he makes it part of the medical record, the insurance company might have access to it.

Genetic testing, now widely available and cheap can provide medically relevant information. However, there are risks associated with obtaining it. The primary physician should be in charge of guiding the interpretation and possible therapies associated with it and also has to be instrumental helping you keep the privacy of the information. Also, we cannot underestimate the importance of a second medical opinion.

Marco A. Ramos MD

3 Situations to be Careful if Taking Diuretics

Taking diuretics has become one of the cornerstones of the treatment of hypertension and heart failure. Although it has benefits, it has risks too. Here are 3 situations that any person taking diuretics has to be watchful for.

People usually follow the doctor’s recommendations and take the diuretics faithfully once, twice or thrice a day. However, if the person taking the diuretics develops, diarrhea, vomiting or loses its appetite, he or she runs the risk of developing low blood pressure for volume loss in the vascular system. This can cause dizziness, syncope (passing out) or kidney failure.

Diuretics always carry the side effect of losing potassium and/or magnesium though the increased urine production. The best way to avoid this is to have a balanced diet or to take supplements. Low potassium or magnesium can cause dangerous cardiac arrhythmias or muscle weakness.

A low sodium concentration in the blood is also a potential consequence of the use of diuretics. This can happen if the person taking this type of medication drinks too much water while replacing the losses through the urine. Low sodium concentration in the blood can cause headaches, loss of balance, and if severe, lethargy, seizures and death. All diuretics can be associated with low sodium concentrations, however, the thiazide type of  diuretics are more commonly  related to this problem.

All medications cause side effects. Always talk with your doctor regarding these when starting a new one.

Marco A. Ramos MD

The Three Most Common Causes of Kidney Failure

The kidneys are very important organs in the human body. They perform many functions other than just make urine (see my blog post published on October 23, 2014). The kidneys can lose 80-90% of their total function and there could not be any symptom, however, if more than that is lost, dialysis or kidney transplantation are needed in order to survive. So, what causes kidney failure? The list is long, however, the three most important causes are as follows:

The number one reason for people requiring dialysis is diabetes mellitus. 38-45% of all cases of kidney failure are caused by this condition.

The second cause for kidney failure is hypertension (elevated blood pressure). 25-28% of the people who require renal replacement therapy have hypertension as its main mechanism. We have to keep in mind that many diabetics are hypertensives too.

The third cause for kidney failure is glomerular diseases in general. Many of these conditions are autoimmune and have long and complicated names and can only be diagnosed accurately by a kidney biopsy. 10-15% of dialysis cases are from these conditions.

These three causes account for about 85% of all reasons for going into dialysis. There are other situations like genetic conditions,
medication reactions or toxicity from herbal “remedies” that can also cause the kidneys to fail. Since kidney dysfunction rarely produces symptoms until it is too late, it is important to undergo yearly physical examinations that include basic laboratory workup that would detect that the kidney is failing. 

Marco A. Ramos MD

How to Correctly Rehydrate a Person

How to Correctly Rehydrate a Person

Dehydration can occur due to many reasons. The most common reasons to become dehydrated are vomiting, diarrhea and lack of oral intake. Doctors prefer to use the term “intravascular volume depletion”, however, it sounds too long and complicated. For the sake of simplicity I will consider “dehydration” and “intravascular volume depletion” equivalent terms.

Many people believe that drinking water or beverages like juices or tea are good to rehydrate a dehydrated person. The problem is that when someone becomes dehydrated he or she loses salts together with water. The content of salts in the above mentioned solutions is minimal. As a consequence of that, the body loses salts and water and gets back water. The sodium (the main electrolyte in the extracellular fluid) becomes diluted. Too much sodium dilution can cause problems like headaches and lack of balance. Severe sodium dilution can cause seizures and death.

In addition to what I have just mentioned, when the body is dehydrated, there is a hormone called anti-diuretic hormone (ADH) which is secreted. This hormone does not allow water to leave the body. This can have the effect of diluting further the sodium in the body. This is why, we need the right amount of salts when rehydrating.

There are over the counter solutions available can can help with the rehydration process. A good salty broth can also do the trick. However, if the dehydration is severe and vomiting does not allow proper oral rehydration, you might need to go to the closest emergency department before there is kidney failure or before you collapse

Marco A. Ramos MD

Three Reasons for Electing Private Pay Over Insurance for Outpatient Health Care

Being insured in order to to see your primary doctor or specialty physician has become the norm. Many traditional physician practices will only accept you as a patient if you are enrolled in an insurance plan, either government funded or non-government funded. This has created a change in the relationship between a physician and the patients. In this post, I will show three reasons why patients should seek private pay arrangements with the physicians of their choice. 

1. To keep the decision-making between the doctor and the patient. The moment a doctor is allowed by an insurance company to see  patients who pay premiums to it, that doctor is accepting that there is a third entity that will monitor, question and in many changes change the decisions made by the doctor and the patient in the office encounter. 

2. To assure privacy. Once a patient participates in an insurance plan, the patient is surrendering its private health information to a third party. There will be other individuals, employed or contracted by the insurance company, that will review the medical record for different purposes including quality of care, financial analysis and approval or denial of specific treatments.

3. To not be subject to restrictions and limits in insurance plans. Insurance companies can change their plans. Benefits that were part of the plan might not be present in the amended plan. Most of benefits are partially paid and the remainder has to be paid “out-of pocket” by the patient.

The concept of insurance is to spread the risk amongst a pool of people. The greater the pool, the better spread the risk is and the premiums may be lower. This is necessary when we take into account that hospitalizations, surgeries and prolonged treatments like, for example, dialysis or chemotherapy can be extremely costly. However, for outpatient care, when we deal with preventive medicine or with specialist consultations, it would be probably better to seek models that keep the relationship between a doctor and patient strictly between them.

Marco A. Ramos MD

The Importance of Knowing your Disease Process and its Treatment Options

Health issues can be complicated. Not only the diagnoses can be complex and difficult to understand, but the treatment options can also be overwhelming. This is why an encounter with a physician is extremely important. It can have the effect of making the patient understand fully the condition he or she is going through or, it can have the opposite effect if the encounter is too short or the communication skills are just not there.

The first thing that needs to be understood fully by the patient is the disease process that leads to the situation the patient is on. If the case is cancer, renal failure, or heart failure, there is a unique set of circumstances that led to that situation. What needs to be always remembered is that every person is unique. Everyone of us carries a distinct genetic background and have lived different lives with different nutrition and exercise habits. Unless a person is victim of an accident, the causes for any condition are usually multiple. This is  what doctors mean when they use the term “multifactorial”.

In this information era, many people resort to the internet as their source of information. This is the consequence of the internet being readily available, as opposed to a physician, who is usually difficult to find and when found, the encounter might be short and not yielding the expected answers. The internet can be a good source of information, however, there is so much out there that the wrong conclusions can be drawn easily. The other consequence is to make the patient more confused.

The same happens for the treatment options. A long term therapy such as chemotherapy or dialysis should be a process that the doctor and the patient go in (or not go) together, with the doctor providing guidance, not orders. When the patient lacks the right set of information, the decisions made at a given point in time, can lead to expectations that might seem unrealistic in the eyes of the doctor. 

For a patient, knowing the disease process and its treatment options are crucial elements for good healthcare outcomes and a good physician-patient relationship. When the point in which either or these elements are not achieved, a second medical opinion can be what is needed to achieve the elements and ensure good healer outcomes and solidify the relationship between the patient and his or her doctor.

Marco A. Ramos MD

Can a Doctor be Offended if We Request a Second Medical Opinion?

Unfortunately the answer to that question is yes. Physicians are usually highly driven individuals who dedicate most of their time to their patients. They have studied at least 13 years between medical school (doctorate), residency (post doctorate) and fellowship (post post doctorate). Some of them have 2 or more fellowships or are employed by a famous university. Others are the owners of their own successful practices. For a lot of doctors, the prospect of a second medical opinion is a challenge to their knowledge, a challenge to the “loyalty” that a patient should have. 

What we have to do is always keep things in perspective. The human body that the physician is treating belongs to us, the patients. The patient is the one who would suffer if a mistake is made an the one who would miss the opportunity of a better treatment if the treating physician fails to offer it. The other thing that needs to be kept in perspective is the degree of autonomy that we should have. A physician does not order a treatment. A physician recommends a treatment. The decision to follow the physician’s recommendation belongs to the patient and to follow a recommendation is a measure of trust.

What to do in the event that doubt arises? What happens if we need reassurance about a new treatment or a new diagnosis? What if the treatment or diagnosis is complicated? This is the territory of the second medical opinion. The treating physician would be the one releasing the records to the second medical opinion physician. The best approach, as always is to be transparent and upfront, but always respectful. The second medical opinion is a tool which should strengthen the relationship between the treating physician and the patient. 

The way that healthcare is evolving means that there might be less and less time for physicians to spend with us. This means that there will be less time to explain complicated issues and more second medical opinion consultations. Treating physicians can be offended, but they should not be offended, specially if the process is respectful. Two brains always think better than one.

Marco A. Ramos MD