What is COPD? Who has it?

COPD stands for Chronic Obstructive Pulmonary Disease. There are 2 main conditions that are associated with COPD. The first condition is emphysema (the most common) and the second condition is chronic bronchitis. Smoking tobacco is the most common cause for COPD, although there are relatively rare genetic conditions that lead to similar changes without the influence of smoking cigarettes.

The term “chronic” represents that the anatomical changes in the lungs become fixed and may not reverse, although stopping smoking will certainly slow down the progression towards oxygen dependency. The term “obstructive” refers to the loss in elastic recoil of the lung tissue that will prevent the airways to be sufficiently opened at the time of exhaling air. This causes functional obstruction and air to be trapped in the lungs.

COPD can be a seriously debilitating condition. In its more severe form, it leads to the need of oxygen supplementation for the patient. In addition, a person with COPD is more prone to lung infections and even minor viral illnesses can cause acute respiratory failure. This can cause the need for intensive care and mechanical ventilation.

As it was mentioned before, smoking tobacco is the main culprit for this condition. It is never too late to stop smoking. COPD progression may not be stopped but it may be slowed down significantly. There are several medications that can be used in order to treat symptoms and reduce the functional obstruction in the airways. A physician will help any patient regarding smoking cessation and the treatment of COPD.

Marco A. Ramos MD

Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

Alzheimer's Disease Genetics Explained

Alzheimer’s Disease (AD) is a chronic degenerative disease of the brain which leads to progressive dementia, which is the loss of the mental faculties of a person. Memory, personality, judgement and reasoning can get severely impaired. The development of AD has a strong genetic component, which may be complicated to understand, but I will try to simplify it here.

There is a gene called APOE. This gene encodes a protein called apolipoprotein E. There are 3 variants of the APOE gene (ε2, ε3, ε4). Each of us inherits 2 variants of the gene, so we all are either ε2/ε2, or ε2/ε3, or ε3/ε3, or ε3/ε4 or ε4/ε4 or ε2/ε4. 

The combination ε4/ε4 has the highest possibility of AD. According to one study, at 85 years of age, people with this combination would have a possibility of 51-52% of developing the disease if male, and 60-68% if female. The combination with the lowest possibility is ε2/ε2, it has a 4-5% possibility of AD if male and 6-8% if female. All the other combinations are in between.

It is important to note that this gene is not the only one associated with AD. If you know your particular combination, it is best to consult a healthcare provider for proper advice.

Marco A. Ramos MD

Further reading here:: http://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&term=9343467

3 Important Things Patients Need to Know About Telemedicine

Technology is improving and advancing fast. What was impossible just a few years ago, is becoming possible now. Nowadays, a physician can see a patient, interview him or her, auscultate, examine the skin, prescribe medications and document in an electronic medical record, without being physically by the patient’s side. 

The first issue that needs to be brought up is the location of the medical act. It has been defined that the medical act occurs where the patient is located. This has consequences regarding licensing and regulations. As it is well known, in the United States, licensing goes state by state, so the physician has to be licensed in the state where the patient is located. This means that, so as the doctor is licensed in the state where the patient is located (and the state medical board is OK with it) the physician can be located anywhere in the world and see, listen and treat a patient.

A second issue is the question of insurance reimbursement. As of today, not all insurance plans reimburse for telemedicine services, although this is increasing by the day. The patients have to be aware if a service rendered by telemedicine will be reimbursed by a particular insurance plan if not paying out of pocket.

The third issue is that there are some specialties that are more ready for telemedicine, than others. For example, Neurology and Psychiatry have been using this services for some years. The surgical specialties (due to the nature of their service) have not quite embraced it yet. It is not impossible to think that in the future, a surgeon might operate remotely, using devices similar to joysticks.

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

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

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