Saturday, May 29, 2010


Evidence, (not Experience) Based Medicine (EBM)is a new paradigm that has brought a better clarity of diagnosis and treatment to the medical community. Previously, physicians would use anecdotal, inductive reasoning with pathophysiology of disease, previous teaching, with its tremendous prejudice and biases to make clinical decisions in both diagnosis and treatment. Much of how we practiced was never scientifically proven, but taught to us that we took as the Gospel. Some of this included old wives’ tales and consensus opinion. The latter was when a committee of experts in a field voted on how to diagnose and treat. But with EBM the “Evidence” is put through rigorous statistics, reviewed and re-reviewed. This gave physicians the tools needed to enhance their clinical decision, utilizing both theory and statistical modeling. Doctors are discouraged to use their own beliefs and value system and encouraged to be “objective.” Back in 1972, A. Cochrane MD PhD advocated computerized literature for EBM. This is now a reality. Scientific studies are included in the Cochrane database, which as of 2010 has over 3500 systemic reviews and still growing. It is easily accessible to both doctors and their patients. Medline and Pubmed are several of the sites to obtained these on the Internet.

Evidence Base Medicine will always be a work in progress as new studies are completed. Guidelines for diagnoses and treatment are being worked into the fabric of everyday clinical practice. But what about Experience Base Medicine? Does Experience of years of practice count for naught? If the hallmark of good medicine is Evidence Based on double blinded studies involving a large number of patients, then how about the single individual, perhaps you, influence the diagnosis and treatment and what your physician will do to the next patient who has the same medical problem? It is his experience with you and as many others like you that he has in his conscious and unconscious mind that gives him the perspective to make that very unique and personal determination for your best result.

My first clinical rotation as an acting intern was in 1962. Now 48 years later, I may not be any smarter, but I am wiser because of the experience of the years of practice. Of course I review the databases, but the thousands of patients, and tons of medical journals I read along with the hundreds of medical conferences that I participated and attended should and does give me a different perspective on how I practice medicine. After all, Medicine is a science of uncertainty based on the art of probability. Like most practitioners I always want the very best for the patient and unless some catastrophe (stroke, acute mental illness etc) occurs in my life, I am on the top of my game. Despite my years, I practice what I preach and remain as vibrant now as I was fifty years ago.

Quoting from my Medical hero, Sir William Osler, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” He also said “The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.” Also “One of the first duties of the physician is to educate the masses not to take medicine” and “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”

So what is Experience? Experience is multifaceted and very fickle. It involves facets of intellect and consciousness which occur in combinations of thought, perception, memory, emotion, will and imagination. Importantly it must also include unconscious cognitive processes that at times are fragmentary and fleeting so they can crystallize over time to produce an original concept. It depends on one’s individual ability to process data, to store and internalize it. The implicit knowledge of clinical experience has been called "knowing in practice.” This method of knowing allows the experienced physician to arrive at a diagnosis after only a few moments of history taking, although it would be difficult to explain the method for arriving at this diagnosis.

Knowing in practice has three important roles in clinical medicine. Diagnostic expertise can only be developed with experience. The development of the motor skills involved in medical practice--feeling an enlarged liver, for example--requires practice as well. Physicians also learn to hear what patients are saying and develop an understanding, “hearing between the lines”. From my years of teaching medical students and young doctors, I know that good doctors are born, not made. Some have it and others will never get it!

Sunday, May 23, 2010


To have a friend, you must be one!
A person needs same sex close good friends or just a friend, for both happiness and health. There are differences between friends and acquaintances. A friend is a person with whom someone shares extremely strong interpersonal ties. Whereas an acquaintance, the sharing of emotional ties isn't present. An example would be a colleague with whom you enjoy eating dinner, but would not look to for emotional support. Friends do things for each other without expectation of repayment. Friends encourage their friends to lead more healthy lifestyles; Friends encourage their ally to seek help and access services, when needed; A friend enhances their friend’s coping skills in dealing with illness and other health problems; and Good friends actually affect physiological pathways that are protective of health. There are some connotation differences between certain types or circumstances between friends, such as;

Buddy: In the USA, guys often refer to each other as 'buddies', for example, introducing a male friend as their 'buddy', or a circle of male friends as 'buddies'.
Soul mate: the name given to someone who is considered the ultimate, true, and eternal half of the other's soul, in which the two are now and forever meant to be together.
Pen pal: people who have a relationship via postal correspondence. They may or may not have met each other in person and share friendship, between each other.
Internet friendship: a form of friendship, not romance, which takes place over the Internet.
Comrade: means "ally", "friend", or in a military sense. This is the feeling of affinity that draws people together in time of war or when people have a mutual enemy or even a common goal.

Many friendships are not enduring, not necessarily for selfish reasons, but because of misunderstandings. A parting of the ways is usually painful for both who feel that they have been harmed or injured by the other. Both loose because of the split. A good way to maintain a friendship is to have a policy once the pair decide that they really like each other.


(Or if you are in a middle of one wait until you both cool down)

1. We will never fight in Public.
2. We will never touch or talk to each other in a harmful or abusive way.
3. We will never bring up unrelated items from the past.
4. We will never indicate that we will no longer be friends.
5. We will call a “time out” if conflict elevates to a damaging level.
6. We will work out our problem-Failure is not an option!

Sunday, May 16, 2010

Bilirubin - An Internal Protector

Two scientific premises have recently come together: “lowering uric acid decreases death and aging” and “elevation of bile” (bilirubin) does the same. An inexpensive drug, Probenecid can improve both of these. In the Journal of the American Medical Association, researchers reviewed the literature showing that elevation of uric acid (hyperuricemia) is not only a predictor of gout but is commonly present in new onset high blood pressure. Other previously documented research supports elevation of uric acid causes cardiovascular disease to include stroke, heart attack, and peripheral vascular problems.

In 1998, Louis J. Ignarro won the Nobel Prize for his discovery of Nitric Oxide's role in cardiovascular health. Uric acid was subsequently shown to reduce nitric oxide levels in the lining of arteries, causing them to be more easily damaged. A well controlled double-blind study in lowering of uric acid artificially with the drug Allopurinol resulted in a significant reduction in Blood Pressure. As noted in the past, hypertension is a significant risk factor in cardiovascular disease because of its role in atherosclerosis, stress to the heart, and acceleration of the inflammatory processes of the body.

Bile (bilirverdin/bilirubin) was long considered a merely metabolic waste product from the breakdown of red blood cells and was discarded in the liver. Bile in the intestinal tract functions to markedly improve our fat digestion. For the last twenty years, this pigment has been shown to decrease experimental hardening of the arteries, prevent blood clotting, and reduce the risk of damage to the brain after a Stroke. It has been recognized to have an anti-inflammatory, antioxidant, and cyto-protective properties.

The NHANES (National Health and Nutrition Examination Survey), conducted every decade for the last fifty years, represents a cross-section of our population and surveys over 13,000 patients. The survey shows that people who had higher bilirubin had a significantly reduced incidence of neurological damage due to Stroke, plus a decreased incidence of Heart Attacks and peripheral vascular disease. The study was carefully controlled for other risk factors to include hypertension, diabetes, lipids, homocysteine, C-reactive protein, and body weight. Those that had significant liver disease, a very common cause of very high bilirubin, were not included. It has been long noted that people with high bilirubin, for whatever reason, have far less hardening of the arteries. A rare, benign, inherited elevation of Bilirubin, called Gilbert’s disease, has also been shown to increase longevity. These findings are suggestive that elevation of Bilirubin is an important defense mechanism against atherosclerosis and protective for neurologic injury in the setting of stroke. The well tolerated Probenecid, as noted above, not only lowers Uric Acid but raises bilirubin.

A strategy for a decrease of vascular disease and all accrued benefits is to have your doctor prescribe Probenecid 500 mg a day. It is still used to treat High Uric Acid. This will raise the bilirubin slightly and significantly give anti-inflammatory and cyto-protective effects to increase longevity. Normal bilirubins are from 0.1 to 1.3 and if the bilirubin is between 1.1 and 2.0, you are much better off. People do not become jaundiced unless their bilirubin is over 3.0. Another ploy without using the doctor is to consume a fair amount of ox bile, also this drug would lower the Uric Acid to the ideal which is less than 5. This would not only improve your lipids and your bowels, but will raise the bilirubin to protective levels. Although a double-blind study has yet to be done, it is almost a no-brainer to consider this healthy strategy.

Monday, May 10, 2010


Proton pump inhibitors (PPIs) are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. Almost all patients and most doctors think of them as a class of important and generally safe medicines to prevent the release of stomach acid. But they may cause more problems than they solve. PPIs are among the most widely prescribed classes of medications for symptoms of Acid Reflux, Peptic Ulcer, and part of the therapy for H pylori infection (thought to be the cause of Ulcers of the stomach and duodenum). Around for the last 20 years, Prilosec (omiprazole) is today over the counter (need no Rx). Other name brands of this third largest class of medicines (113.4 billion in yearly sales) is Nexium, Aciphex, Prevacid, Prononix, and the latest Kapidex. But according to the Archives of Internal Medicine, May 10, 2010 in which there were 6 articles and an editorial, there are more problems than fixes with these bandaid drugs.

Common adverse effects include: headache, nausea, abdominal pain, fatigue, and dizziness. Rarely rash, itch, flatulence, constipation, anxiety, and depression are listed as side effects. But what was not commonly known until recently is decreased vitamin B12 and other vital micro-nutrients absorption, elevation of Homocysteine, Bacterial Pneumonia, C difficle diarrhea, and Osteoporosis happens frequently. In a study of 135,000 people 50 or older, those taking high doses of PPIs for longer than one year have been found to be 2.6 times more likely to break a hip. Those taking smaller doses for 1 to 4 years were 1.2 to 1.6 times more likely to break a hip. Proton pump inhibitors significantly decreased the effect of clopidogrel (Plavix) a commonly used drug to prevent heart attacks. A 2009 report in Gastroenterology suggests that PPI use may cause dependency by increasing gastro-intestinal symptoms if they are discontinued. The whole process of digestion with the activation of pancreatic enzymes, the release of bile, and the propulsion of food down the intestine is initiated by ACID. God gave us this for good reason, and man should not try to outsmart Him!

Heartburn, the main symptom of acid reflux occurs in over 50% of our population. Some studies show that many people do not have significant reflux despite their complaints and more than a few have reflux and no symptoms. It’s believed that the cause of acid reflux is a weakening of the “valve” between the stomach and the esophagus, most often due to hiatal hernia, which allows stomach acids to pass into the esophagus. PPIs are also prescribed for ulcers, coughing, hoarseness and asthma from reflux, as well as a condition called Barrett’s Esophagus. This is both over diagnosed and over treated by over worried doctors and their patients because in rare instances can lead to a form of cancer of the esophagus. Heartburn usually occurs after meals or when lying down, regurgitation (bringing up of refluxed liquids into the mouth) and nausea happens in addition to the above. In as many as 20% of heartburn, it is not too much acid, but not enough that causes symptoms of acid reflux. These folks are then treated with acid (Betaine-HCL)

Heartburn can often be handled without medicines. Frequent small meals, waiting 2 hours before lying down, 4 inch blocks under the headboard of the bed, weight loss, staying away from the foods that aggravate the symptom (spice, gluten, fat, caffeine, alcohol), and not smoking do help. Taking a walk after eating may ease the hiatal hernia, but better is to drink a quart of fluid before eating and jump up and down 10 times to bring the hernia from your chest cavity into your abdomen. Also physically pushing it down before eating by squeezing and pushing the mid upper abdomen with your fingers towards the umbilicus. Another method is by taking a deep breath standing, then exhale while bending over and wrapping your arms around the lower chest and hug tightly. The consumption of Tums or Rolaids work in the majority of cases. The use of a ½ teaspoon of baking soda in a ½ glass of water several times a day may aid as well. If all else fails Over The Counter Cimetidine (Tagamet) which also fortifies the immune system and tends to prevent cancer and infections is a good choice every other day. If the symptoms are severe and nothing helps then the PPIs for a short time can be used while taking micronutrients such as Iron, Magnesium, Calcium, etc. as well as an occasional injection of B12. To be forewarned is to be forearmed and do not take PPIs without forethought.

Friday, May 7, 2010


This metal is found in small-amounts in fish, processed meats, dairy products, eggs, potatoes and some veggies. Even with eating the above, it is less than one tenth of what is needed to keep our brain working the best it can. It has also been used with success in alleviating the pain from migraine and cluster headaches, leucopenia (low white blood cell counts), juvenile convulsive disease, alcoholism and liver disorders. It also been reported that patients with myopia (nearsightedness) and glaucoma often benefit from the slight dehydrating effect of lithium on the eye, resulting in improvement in vision and reduction of intraocular pressure.

Over two thousand years ago, it had been noticed that the waters of certain mineral springs seemed to have curative powers for people suffering from demonic possession and in“excitable nervousness”. In the second century A.D., the Greek physician Seranus Ephesios recommended natural waters such as alkaline springs as a treatment for mania. Over the ensuing two millennia, countless people have “taken the waters” for a variety of ailments, real and imagined, at fashionable (and not so fashionable) spas throughout the world, particularly in Europe. Lithium is so effective in controlling the mood extremes of bipolar disorder that to this day it is still used in the treatment of both manic and manic-depressive disease. The fact that lithium controls both mania and depression (the former more effectively than the latter) is both wonderful and puzzling, as it suggests that both of these conditions are, somehow, symptoms of the same underlying neurochemical disturbance.

Lithium’s mechanism of action on the brain is still unknown, speculative; it may affect the levels of the neurotransmitters serotonin and norepinephrine in the brain. There is also evidence that lithium inhibits the action of inositol monophosphatase and several other enzymes that play key roles in mood-related neuromodulation (a complex type of signaling process related to neurotransmission). Also in Alzheimers, there is a decrease of the amylold/beta plaques and neuro-fibrillatory tangles that are the hallmark of this disorder. Lithium protects against neuronal death very much like the drug for Alzheimer’s disease, Namenda, by decreasing glutamate induced excitotoxcity. The latter is caused by our neurotransmiiter because of stress and is a cause of Alzheimer's. Excessive amounts of glutamate, the brain's most prevalent transmitter damages our brain cells. Lithuum stimulates the protective Brain Derived Neurotropic Factor(BDNF),which is essential for the development and maintenance of healthy neurons. One further mechanism has been described recently. This is it stimulates the growth of new brain cells, a process called neurogenesis. The increases of grey matter which is mostly the supporting tissue, the glial cells, we now feel play a role in the maintenance of a healthy brain. This drug/supplement was in the past thought to be helpful in the preservation of the neurons in M.S. and ALS, but recent double blind studies showed little or no effect.

Medically only Lithium Carbonate in therapeutic doses are used for the FDA indicated psychiatric uses. This requires a prescription. It is very inexpensive in that it has been generic for the last 25 years. The dose of 6O0-18OOmg day is usually required for this treatment.

I have used this mineral for the management of viral, drug induced and congenital leukopenia that seems to respond within two weeks. In these low white count returns in as much time in the hereditary variety. In drug or viral cases, it may have thwarted a significant bacterial that can result from low white blood cells. It is important that the blood is monitored periodically on long term therapy so that the therapeutic range of .5 to l.5mm/l is obtained. If lower than this, there may be poor results. If higher, there may be negative effects on the kidneys and can cause tremors and psychosis. Even in the desired range after many months lithium can cause electrolyte abnormalities and low thyroid and these too must be monitored. Much smaller doses of other non- prescriptive lithium salts such as orate, aspartate and chloride are used with varying success. I have used 300 to 350 mg daily of the prescriptive carbonate without monitoring. Time will tell if this will help those that ask for it. But at least it is safe and inexpensive. According to the complimentary literature, the orate salt is safer and more effective since it improves the specific effects of lithium many-fold by increasing lithium bio-utilization. The orotates transport the lithium to the membranes of mitochondria, lysosomes and the glial cells. Lithium orotate stabilizes the lysosomal membranes and prevents the enzyme reactions that are responsible for the sodium depletion and dehydration effects of other lithium salts. Because of the superior bioavailability of lithium orotate, the therapeutic dosage is much less than prescription forms of lithium. For example, in cases of severe depression, the therapeutic dosage of lithium orotate is 150 mg/day. This is compared to 900-1800 mg of the prescription forms. In this dosage range of lithium orotate, there are no adverse lithium side reactions and no need for monitoring blood serum measurements.

Saturday, May 1, 2010


Vitamin Bh, or Inositol, is an organic natural chemical alcohol almost identical to glucose which exists as myo-inositol in our bodies. Inositol or its phosphates and associated lipids are found in many foods, in particular, in grains with high bran content, nuts, beans, and fruit, especially cantaloupe, melons and oranges.

It was classified as a member of the B vitamins, Bh. However, because it is produced by the human body from glucose, it is not an essential nutrient and therefore not a true vitamin. But in times of stress it may not be enough for the ideal body function. Greater amounts do help some medical issues.

Inositol and some of its metabolites function as the basis for a number of signaling and secondary messenger molecules. They are involved in a number of biological processes, including getting the stimulated insulin receptor to turn the nucleus on, gene expression, serotonin modulation and nerve conduction. Also inositol is used as building blocks of our cellular membrane, regulating intracellular calcium, and as a lipotropic.

As a lipotropic, it mobilizes fat to include cholesterol. Here it is potentiated by choline. We have used it in our weight loss patients with some success. It also rids the liver of excessive fat (NASH-NonAlcoholic SteatoHepatosis) which is almost becoming an epidemic due to our obesity. Because of fat mobilization and it’s insulin potentiating effect it has been clinically used with PCOS (PolyCystic Ovary Syndrome) effectively. Some preliminary results of studies on high dose inositol supplements show promising results for people suffering from pychiatric problems such as bulimia, panic disorder, OCD, and depression. It also helps directly (nerve improvement) and indirectly (better diabetic control) on diabetic neuropathy and other peripheral neuropathies.

Inositol has been used to decrease lithium toxicity and to strengthen hair, helping it to retain moisture. It is taken orally and is an ingredient in some shampoo formulas. There is no RDA on Inositol, but an extra 1 gram a day may be prudent. To treat the conditions noted above, 12 to 18 grams are used. It takes 3 to 4 weeks to see results. It is available in 500 mg and 1000 mg caps as well as a powder in which 1 teaspoon is 4 grams. The price is variable and may be affected by the fact that it is often used to “cut” cocaine.