Vitamin D and Cancer

In a previous post from January 27, 2016  (http://blog1.smopinions.com/2016/01/7-interesting-facts-about-vitamin-d.html), it was mentioned that there are associations between vitamin D deficiency and certain types of cancer. This post will explain a little bit more about them.

Regarding colorectal cancer, it was noticed about 2 decades ago, that there is more mortality from colorectal cancer in the northern and northeastern parts of the United States, the ones which receive less sunlight. This in itself is not enough to establish a meaningful association, however, it gave a starting point for research. Then, 2 studies showed that having levels above 30 ng/dL in the blood may reduce the incidence of colorectal cancer by half^1,2.

With respect to breast cancer, a recent study found that postmenopausal women may get a benefit from having adequate vitamin D levels in the blood. The risk of developing breast cancer in this particular group of women was lower than in the same group of women with lower vitamin D in their blood³.

Finally, in regards to prostate cancer, it has been found that this cancer is also more common in regions with less sun exposure. In addition, lower vitamin D levels in the blood are related to more aggressive forms of prostate cancer. Last but not least, adequate levels of vitamin D may aid in the slowing of the progression of this type of cancer⁴.

More research is needed in order to confirm and strengthen these associations. In the mean time, it does not hurt to have adequate levels of vitamin D in the blood, particularly for people living north of the 30th parallel.

References

1. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Lancet. 1989;2(8673):1176-8.

2. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Alim Pharm Therap. 2009 30(2):113-25

3. Plasma vitamin D levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies. Bauer SR, Hankinson SE, Bertone-Johnson ER, Ding EL. Medicine (Baltimore). 2013;92(3):123-31

4. Association between serum 25(OH)D and death from prostate cancer. Tretli S, Hernes E, Berg JP, Hestvik UE, Robsahm TE. Br. J. Cancer 2009;100(3):450-4.

Marco A. Ramos MD

MTHFR mutation. One in 6 people have it. What to do if you have it?

MTHFR mutations are one of the commonly found mutations in genetic testing. If someone is homozygous (carrying one mutation from your father and one from your mother) for the C677T mutation, it may be associated with increased cardiovascular events (heart attacks, strokes), malignancies and birth defects (spina bifida). This does not mean that if someone has the homozygous mutation that person will have a problem. It means that there may be an increased risk.

MTHFR stands for methylenetetrahydrofolate reductase, an enzyme in the metabolic of folic acid. It is also the name of the gene that codes for that enzyme. People with the homozygous mutation have a defective enzyme and  may have some difficulty with the metabolism of folic acid. At the same time, there may be increased levels of homocysteine in the blood, an amino acid associated with thrombotic problems. 

What to do if someone is homozygous for the C677T mutation? Many people find this after testing in commercially available genetic testing. If this mutation is found, a physician or genetic counselor should be contacted. The most likely next step would be an evaluation of homocysteine levels in blood. If normal, the person should be reassured that its risk for cardiovascular events and other problems is probably similar as the rest of the population. If the levels of homocysteine are high, it does not hurt to try to reduce it by having folate supplements and increased vegetables with the diet.

Marco A. Ramos MD

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

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

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

How to Obtain a Second Medical Opinion?

Obtaining a second medical opinion is very important, specially when the medical problem that a person is dealing with is complicated, chronic or needs aggressive and expensive medical care. The primary care provider and the specialist who sees you or your relative may be very good, but ultimately, the body belongs to you and not only you must be seeking  care, but also making sure it is good care.

Here are some steps that may be followed:

1. If you are thinking about obtaining a second medical opinion, you must make up your mind first. If the last medical visit was left with more questions than answers, or you need reassurance, it is always a good habit to give the physician who saw you a call in order to clarify things. Keep in mind that time is not a luxury of doctors these days, so they might just need more time to talk to you. If after talking to the doctor again, questions remain unanswered, then, there is a good case to look for a second opinion.

2. Once the decision is made, you should contact your insurance company in order to see if second medical opinions are covered by your plan and in case they are, to see what physicians can provide it. 

3. When the options are provided, the physicians’ credentials must be verified. You can look into the specific Specialty Board’s website to check the physician’s background and experience.

4. If the choices do not satisfy you, there can be other physicians available. Look into medical schools, hospitals and friends and family recommendations. Do a thorough internet search and verify credentials. Be prepared to pay out of pocket money in these cases.

5. Once the second opinion is obtained, request a written report. This is important because it will give you a document to refer to and will help you when going back to your original physicians. It can contain valuable information and it can help you and your doctor in the developing of the plan of care.

Although requesting a second medical opinion is a right, some physicians may be offended by the fact that you are doing it. Reassure your physician by saying that this is meant for you to be further educated about your condition and its treatment options.

Marco A. Ramos MD

Take a look at www.smopinions.com

The Importance of Organ Donation

Organ donation is extremely important. Many people are currently in waiting lists for kidney, liver, heart, lung, pancreas and intestine transplants. A significant percentage of these patients, pass away before receiving the transplant.

The situation for every organ is different. While people in need for a kidney transplant or a liver transplant can receive an organ (or part of it) from a living donor (provided that the donor is immunologically compatible with the recipient), the other organs need the donor to be a deceased person. Also, while people with kidney insufficiency can undergo dialysis treatments while waiting for a kidney transplant, the situation is different for the other organs because besides medical treatment, there is no effective way of replacing the organ functions. 

How to become an organ donor? There are a couple of ways. Any person, at the time of registering for an state ID or (renewing it) can register as an organ donor. In addition, there are state organ donation registries, accessible through the internet. It is important to carry a card that can provide consent for a donation of organs in the event of sudden death. Living donation is also possible in the event of a friend or relative needing an organ. There are also “paired donation programs” by which, in the event the donor is not compatible with the intended recipient, there could be a “cross donation” by which an organ will be given to a compatible recipient provided that this recipient has a donor compatible with the first recipient.

There are medical conditions that a living donor must not have in order to qualify to donate an organ . These are HIV disease, diabetes mellitus, malignancies or any chronic infectious problem. Also, the donor must not have any condition that may be worsened by organ donation like, for example, chronic kidney disease.

Finally, it is important to say that for the transplant recipient, the problems are not over after receiving the donated organ. They have to continue with lifelong immunosuppressive therapy which has risks of their own. However, overall, it is a second chance for enjoying life.

For further information visit: www.organdonor.gov

Marco A. Ramos MD

The Importance of Individualized Medical Care

In our days, due to the pressures of the health insurance companies (private and public), the legal system, the physician shortage and academia there is a push towards standardizing the medical care at all levels. This would work well if everyone of us were genetically and culturally equal, with the same responses to infectious agents, dietary habits  and the stresses of life in general. However, as you probably already concluded, this is not the case.

Health insurance companies base their profit models in statistics. They use averages, standard deviations and trends in order to make decisions. An individual with a unique problem, who does not fit in the pattern usually creates some degree of stress in the system that needs time to be solved. In many occasions, neither the physician nor the bureaucrats have the time to actually solve the issues.

The legal system uses the “standard of care” as the standard to compare the practicing behaviors of physicians with at the time of malpractice litigation. Because of this, the practicing patterns of physicians tend to be similar regardless of the patients’ uniqueness. This is one of the characteristics of “defensive” medical practice, which increases the cost of care without necessarily increasing its effectiveness.

The physician shortage has created a situation by which physicians do not have enough time to analyze the situation of a particular patient, specially if the problem is complex. This is one of the reasons, why diagnoses of rare conditions can take longer than they would if the physicians had the necessary time to study the rare and complex cases.

Academia has pushed for the practice of “evidence-based medicine”. While this is a great concept specially at the time of gathering knowledge, it can become a problem if the practitioner applies the conclusions of research to patients who do not fit the inclusion criteria of the same research.

There is no simple fix for the healthcare system as a whole. Individuals have to take responsibility of their own healthcare and use the available resources in order to solve their problems, specially if they are complex. for example,there are the private-pay “concierge” practices. These physicians can offer more time to patients and they would definitely make the patient understand his or her own issues. There are also several second medical opinion services, which can provide access to specialists who can dedicate their time to analyze the patient’s case in detail. These services, I believe, understand better the need for individualized medical care.

Marco A. Ramos MD

Why a Second Medical Opinion?

The doctor-patient encounter has traditionally been a strict relationship between a physician and the patient requesting the services. However, there were always concerns regarding the cost of the services and how accessible the services were. Starting some decades ago, insurance companies (private and government owned) started to participate in the relationship in an effort to make it more efficient. This had the consequence of spreading the risk and making healthcare more available to people. 

As time passed, healthcare became more dependent on the wellbeing of the insurance programs or companies. In order to be able to provide for all enrollees, the reimbursements to the providers started to decrease and, as a consequence of that, the time that the providers give to the patients also started to decrease (because they had to see more patients in less time so as to pay for overheads and remain profitable.) 

The natural result of this is that people remain with more unanswered questions and more doubts regarding their conditions or diseases. In this current world of gigantic leaps in the development of pharmaceuticals, surgical techniques, gene therapy, amongst others, the explanations that professionals (primary care providers and specialists) need to give their patients are complex. Many patients try to enhance their knowledge by using the internet. This is risky. The internet is filled with unreviewed information posted by un-credentialed people who might confuse or even misguide the patient who needs more answers.

A second medical opinion is a tool that will enable patients to be better informed, to be more reassured regarding their conditions and to bring up the possibility of more educated and effective communication with their doctors. For complex problems, two minds are better than one.

Marco A. Ramos MD