Grand Rounds at Dartmouth 7/26/2013

Rare diseases are often given importance at Grand Rounds everywhere. Dartmouth is no exception. Esoteric is exciting, in medicine too!

Today's topic Hepato-Renal Syndrome by Dr Block, is remarkably rare. It is a manifestation of end stage liver disease. We hear about MELD scores and renal/ kidney cortical venoconstriction. International Ascites Club... gets a good laugh. They have criteria to diagnose it. Type 1 die quickly without liver transplantation. Other types..2,3,4 live somewhat longer.

New to me, fancy markers of Acute Kidney injury, Cystatin C and NGAL are talked about. More esoterica. Mayo does these tests. Apparently the results of these do not help patients. But keep your eyes out for these anyway. Great on rounds to impress your colleagues! And for high scores on tests!

At DHMC they have not done too many trans venous kidney biopsies, Dr Block says. Can help clarify the causes of the kidney problems. In expert hands it is listed as safe.

Sympathetic nervous system activation in HRS makes the kidney avidly reab sorb sodium.
There is more blood flow to the liver and gut, less to kidney and brain.

Prevention of HRS was discussed. Could give daily Norflox. Also use Pentoxyfylline in Alcoholic Hepatitis. Not used much apparently at DHMC.

Over a hundred people paid for with patient $$, either their medical insurance or their taxes, heard
this discussion in the beautiful weather controlled auditorium. Some watched the live telecast. Others not present either provided care in clinic or hospital or were recovering from night call.

Much more common ailments affecting us were saved fro another day.

If you have read this far skip and go to my blog about Tylenol, an under recognized liver toxin at less than large doses. Usual doses of Tylenol can be toxic. Depending on how much glutathione you have to detoxify NAPQI, a metabolic product of Tylenol.

Or check Wikipedia about NSAIDs, widely prescribed group of drugs and bought directly under names such as Advil, Motrin, Naproxen etc that have under recognized gut inflammation and kidney toxicity in population studies.

It just is not as exciting as esoteric diseases such as HRS.

The patient discussed did well. Mortality postponed by 8 weeks per the speaker. A liver transplant would help longer.MARS could keep these patients a alive as a bridge till transplant is available. A machine that does this was borrowed from Yale on another patient but was unsuccessful in preventing death. But everything possible is often done.

The patient died despite a TIPS done later. Interesting.

Prevention is slow steady work.  Who will tell people what will keep them well in our fee for service system?

Everyone clapped at the end of the talk. 

Questions followed and comments.

I did not speak up about the futility of such end stage care.

I did not speak up about the huge expenses incurred by such care or the costs of conferences that teach doctors about esoteric diseases.

Someone did. 

That was good. 

We Doctors do care. 








dartmouth

Doctor Vinod's Wellness Blog: TURMERIC - A spoonful a day keeps the doctor away.

Doctor Vinod's Wellness Blog: TURMERIC - A spoonful a day keeps the doctor away.

Fever is good

To sell Tylenol/Crocin/Paracetamol  we were brain washed with TV ads telling all how doctors used it in hospitals for fever most commonly. These ads ran for  decades in the 70's, 80's and some in the 90's.

They were very effective, both for the lay public and nurses and doctors.

I tried over many years to break the automatic Tylenol for fever habit but it was too ingrained in all health care providers. Nobody gave it any thought. If they had it would have been natural to question how a mechanism present throughout the human and animal kingdoms was anything but not protective. If they had given it thought it would be easy to believe that fever was good.

That is how holistic practitioners think.

Scientists want proof. Nurses and doctors are supposed to be scientific .

Well proof is evident in the whole animal kingdom as shown in multiple elegant experiments. In humans and animals everything that fights infection works better when our temperature goes up.

Fever is beneficial. It also guides us better than blood tests if we are getting better, and convinces us to stay in bed as our body goes about its job to get us well. Once we lower our fever we are fooled into thinking we are well and rush to take on the world. Till the fever comes back, after all we are still sick.

The elderly infirm and infants tolerate high fever poorly and controlling it in just those circumstances are warranted.

Otherwise let fever alone, rest, stay warm, drink fluids. It will come down over a few hours. It may go up again. Fever most often is highest late at night. I always asked my patients to keep track of their highest fever at night over time as a way to assess improvement over days.

If you just have fever and muscle aches but otherwise feel ok, the above approach is ok. Seek medical care if you have pain anywhere and fever, cough and fever, bad headache and fever, vomiting or diarrhea and fever. Especially if symptoms other than fever progresses.  Height of fever does not help much once beyond 101F.

Cough and chest pain on the side, go in for a chest x ray. Single joint pain and fever go in, Burning in  urine, abdominal pain and fever also needs an evaluation.  Check your symptoms on Google, also to see what is going on in the community for flu activity. And remember live at peace with your bacteria in your colon. Avoid antibiotics if you can. Wait it out, paying attention to symptoms, appetite and just how you feel. Do not be afraid of fever. Wait it out. Hopefully someone is there to pamper you.

Tylenol is toxic, more than most health care practitioners understand.

It should be a no brainer to let fever, a God given natural defense mechanism do its work.

But once we are brain washed we follow without thought.

I know I have tried to change colleagues.

Now trying once again!

Maybe you can spread the word.

Vinod

Tylenol/Crocin, Liver failure, Alcohol, Medication interactions

Fever fights infection. In all species and humans fever is the First line of defence and lowering fever increases mortality.

Frustrating to see how marketing is used to blitz the people of the devloping world from the famous brand names of the corporate world. Be it sugar laden Coke or liver toxic Tylenol/Crocin.

We travelled to Sri Lanka for the first time this winter. it was lovely.
It was sad to see that almost every small shop in the marketplace had a sign selling Crocin. The technique is also rampant in India. The brand du jour pays for the sign and the small shop gets to also display their own name.

Crocin is Tylenol in N America. Acetaminophen and paracetamol are other names. It is sold worldwide.

This commonly used drug is toxic especially when combined with other drugs or alcohol. It's toxicity has been underestimated. Unfortunately most people, doctors being no exception, just assume it is safe and that it can be taken with impunity. The truth is acetaminophen would never be approved by the FDA in the 21 st century.

Few years ago, 4 grams per day was listed in every hospitalized patient s  chart as the safe daily upper limit. Concern of liver toxicity was the reason. Then a few years ago the maximum daily dose in hospital was reduced to 2 grams per day. The maximum dosage is confusing. Read the FDA advisory here. FDA also wants to get rid of Extra Strength 500 mg pills and limit largest Crocin/Tylenol to 325mg. The seller however likes to sell more!

There is real concern for liver toxicity if patients take doses just slightly more than recommended or for more than just a few days. Chronic use depletes glutathione in the liver, essential to our liver's detoxification system.

Adding alcohol to chronic use makes Tylenol much more dangerous. Few know this. Just 2-3 drinks and some Tylenol for a headache could kill you. Destroy your liver.

Besides alcohol other interactions with medications are also dangerous. Thus statins which millions take for cholesterol phobia, the Azoles taken for candida and other fungal infections, and the hidden Tylenol in many pain and fever and sleep aids all make Tylenol the most dangerous liver destroyer for humanity. The numbers are astounding.

Tylenol and asthma is associated!

I avoid Tylenol or limit it to 1 gram a day, never more than 7 days.

And never for fever.
On importance of fever more next week.

E Coli, She coli, He coli, NO ME COLI

Bleach your kitchen counters. Kill all microbes. Is that wise? Let us understand the risks.

Cases of food poisoning have increased since the 70’s. Strawberries, sprouts and now spinach. And green onions. All from mega producers and consumers of millions of pounds yearly of the products.

"In the spring and summer of 1982, McDonald's held a special promotion -- two burgers for the price of one -- that led to the first reported outbreak of E Coli a food-borne bacterial infection that now sweeps the nation with some regularity." McDonald's, Jack in the Box, Schwan, Taco Bell, Taco John ...the beat goes on and on!

Concentration in agriculture processes of meat, dairy and vegetable production and increasing importation of fruits and vegetables from countries with poor hygiene is likely the major reason. "Billions of farm animals are overcrowded in stressful, unsanitary sheds, pens, cages and stalls; no wonder we are increasingly plagued with infectious food-borne diseases. Animal factories are a public health threat. We shouldn't have to cook the crap out of our food." Michael Greger, M.D in the Wall Street Journal.

A second reason is increased use of medicines that shut off the stomach acid. With acid shut off our God given food sterilizer, our strongly acid stomachs, cannot work. Food contaminated with smaller numbers of food poisoning bacteria thus causes disease.

A third reason, especially for the dramatic 500% increase in outbreaks at restaurants, is the poorly
paid workforce at franchise restaurants. This results in rapid turnover, low morale and inadequate training.

The fourth reason is clearly non intuitive. Use of plastic gloves has been pushed at street fairs, restaurants and cafeterias in schools and hospitals,.Our hands have oils on them with natural antibacterial activity. Gloves, machine made, have no such activity. Actually the increased moisture and warmth under the gloves provides a perfect incubator allowing bacteria to thrive. People wearing gloves contaminate them more over time - they itch and scratch the same places that contaminate our ungloved hands. Don't believe me just stand afar and see for yourself.. Gloves give a false sense of security so hand washing is a low priority.

The Solution lies in having a two tier system of regulation in agriculture, food and meat production. One should be for the small scale producer and one for the corporate.mega producer of the same. In
biological systems small mistakes are magnified.

Large scale production should be actively discouraged. ..."half the nation's states now have reported cases of human E. coli 0157:H7 infection,"

Mistakes by small producers have limited impact. Small producers sell locally . Their customers know them. Small producers are directly accountable to the people. Neither the government nor the courts are needed. The small have a healthy regard for power. Large corporations, with their public relation machines and lawyers, do not and have become increasingly unaccountable to the people, their government and the courts.

More regulations have been proposed. "Officials Consider Spinach Labeling Plan"
Regulations only drive the small producer out. In biological systems that is courting disaster.
E.F. Schumacher, Nobel Prize winning author, has written a beautiful book “Small is Beautiful, Economics as if People Mattered"

In the case of food, small indeed is beautiful.
Small has less pesticides,
Small has less antibiotics,
Small has less hormones,
Small is actually cheaper
Small uses less energy..
It is local. It is safer.

Please eat food we know, from people we know.

And handwashing with solid soap and water is all that is needed. The CDC also has other thoughts

Do not get caught up in this media frenzy.
Understand the risks. Read "Eat Your Spinach" by Marc Siegel in the Wall Street Journal Sept 18th.

10,000 people have died in rollovers accidents EACH year for the last 10 as SUV's became popular. That is what we need to regulate not spinach!

E Coli, She coli, He coli, NO ME COLI.

Why we become deaf

I used to love going to India.

But progress came rapidly. Now I go because my family is there. And like others leave the city every chance I get.

Motors,  electric and gasoline took over all aspects of life. Everyone wanted to do everything faster and quiet was owned in common by all so like our clean air was free for all to plunder.

And each year the horns got more in number as well as loudness. The honk of the car became a scream. As noise ( link to noise and health) increased the noise makers became noisier

The old bus horns became the ear splitting air horns.

 The old train whistles became louder. And people became angry?

And more, And more became deaf. WHY. Read this link also.

And a long article in Hindi that I wrote for Rajasthan Patrika when the train whistle at night first got

to me in 2006! Available by email only.

Horn bajaana Gaali dena!

Exercise the bane of modernity