Great editorial on the changing medical times…


Great editorial on the changing medical times… In a recent Family Medicine journal one physician poetically writes about that contemporary medical practice is a continuous process of updating medical practices and frank change.  “Choosing Wisely” is a new practice which identifies wasteful and unnecessary medical care (including tests, treatments and procedures).

Oftentimes, patients and physicians alike would like to continue doing the same testing as was done before.  (For example, the antiquated annual pap smear.)  Change is inevitable.  Every test we order or treatment/procedure we perform carries the possibility of harm as well as the opportunity for benefit.  Often the elimination of testing is due to new information, not to cutting medical costs.  The goal is to decrease wasteful, unnecessary medical care that may harm without the possibility of benefit.

For more information on Choosing Wisely..

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Proton pump weaning…


Proton pump weaning…  Many patients are on PPIs (like omeprazole) for gastroesophageal reflux disease.  It is thought that PPIs should only be used on a short-term basis for conditions like reflux or erosive esophagitis.

Consider stopping the PPI medication and instead take an over-the-counter H2-blocker (like Zantac or Pepcid).   Also, do “behavioral modification” like avoid food triggers (spicy or acidic foods, tobacco, alcohol, mint), eat smaller meals, and do not lie down within 3 hours of eating.

If you are unable to wean off of PPIs, then you should ask your doctor for ambulatory esophageal pH and impedance monitoring.  This will help discern if you have a functional syndrome or reflux.  Lifelong PPI treatment should not be done until this testing is done according to the “new best practices statement.”

I hope this helps.

Posted in General Medicine- Adults, medication issues, Uncategorized | Tagged , , , , , ,

Traveling soon? See your family doctor for pretravel medical advice!

Pre-travel medical consultation will review many aspects of your trip– your destination, itinerary, medical history, immunization history and other details.   The best time to be seen is 6 weeks before departure to maximize benefit of immunizations and other preventive measures.

Did you know that the most common vaccine-preventable illnesses in international travelers are hepatitis A (awful diarrhea) and influenza (fever and cough).    Malaria prophylaxis is offered to travelers to endemic regions.  It is also beneficial for the traveler to use personal protection measures such as applying permethrin to clothing, using permethrin-impregnated bed net and effective insect repellant.  The most effective insect repellents contain 20 to 50% DEET or 20% picaridin.

What should you expect at your visit?  Your physician will review your medical history including immunization records, medications, allergies, and medical conditions.

The physician will discuss your destination, administer appropriate travel-specific vaccines (like typhoid fever, yellow fever, Japanese encephalitis, rabies, and cholera), give you a prescription for antibiotics (or Imodium) to take in case you come down with traveler’s diarrhea.

A few more pearls about traveler’s diarrhea…

  • taking medications that reduce gastric acidity (like proton pump inhibitors or antacids) significantly increases the risk of traveler’s diarrhea.
  • It has been shown that traditional advice, like avoiding food from street vendors and tap water and ice has NOT been shown to reduce the incidence of traveler’s diarrhea.
  • Conversely, hand washing DOES reduce the risk by 30% and alcohol-based hand sanitizers also significantly reduce the risk of traveler’s diarrhea.
  • Taking Pepto-Bismol two tablets four times a day for the entire trip reduces the risk by 50%.

Other discussion topics are travel-specific risks such as altitude sickness, safe sex practices (think Zika virus, STDs and HIV transmission) and emergency medical evacuation insurance.

Pregnant?  Most airlines will let you travel until 36 weeks gestation.

Want more information?



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Premenstrual dysphoric disorder. What is it? How to treat it?

sad photos/ bahkubean/ 1287879564

Premenstrual dysphoric disorder “PMDD”, aka “PMS.”  The strict criteria of this disorder affects up to 12% of women, although 80% of women report at least one physical (or psychiatric) symptom during the luteal phase (last 2 weeks of their “month”).  Most women do not report significant impairment of their lives.

The symptoms fluctuate, meaning if one year they are severe monthly, the next year they may feel fine.  Women who gained weight or had a stressful event in the past year are much more likely to have symptoms of premenstrual syndrome compared to those who did not.

Why does this happen?  Every month a woman’s hormone levels change.  The cyclical changes in estrogen and progesterone levels may trigger the symptoms.

What are the symptoms?

  • Angry outbursts
  • Confusion.  Depression
  • Social withdrawal.
  • Breast tenderness.
  • Headache.
  • Swelling of hands or feet.
  • Weight gain.
  • Abdominal bloating.
  • Anxiety.
  • Irritability.

Treatment focuses on relieving the psychiatric and physical symptoms.  Options include…

  • Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMS and PMDD    These medications can be taken continually or can be taken just during the luteal phase monthly.
  • Serotonin aSNRIs can also be used, although this is “off-label” meaning that the FDA has not specifically approved these medications for this medical indication.
  •  Oral contraceptives “The Pill” works best when it is used “continuously” meaning treat with active birth control pills for 112 days at a time.
  • Other medications like calcium  or Vitamin D supplementation or herbal preparations (like saffron, ginkgo, peppermint, angelica root, turmeric, tangerine leaf, bitter orange, St. John’s wort) were not found to help symptoms.

I hope this helps.

Posted in Emotional health, General Medicine- Adults, menstrual issues, Women's Health | Tagged , , , , , , , , ,

Want better eye health?


There are four common conditions that cause vision loss as we age.

  • Diabetic retinopathy.  If you have diabetes, you should be seen by an ophthalmologist.  The timeframe for starting these yearly eye visits are 5 years after type1 diabetes and at the time of diagnosis of type2 diabetes.  When your diabetes is under better control, this decreases the risk of progression to diabetic retinopathy (when the back part of the eye makes new fragile blood vessels that can bleed).   Two new studies show that taking fenofibrate (a pill to help cholesterol) can increase the time to the first laser treatment and slows the overall progression of diabetic retinopathy, regardless of its effect on lipids.
  • Age-related macular degeneration.  This is a common eye disorder with vision loss and difficulty seeing in the dark.  Those with mild to moderate macular degeneration may benefit from a slowing of progression by taking vitamins lutein plus zeaxanthin.  In initial studies there was a combination of vitamins that was found to be harmful.  Be aware that omega-3 fatty acids did not help eye health.  And, beta-carotene supplements were associated with increased lung cancer rates among smokers.  Of to, lutein plus zeaxanthin did not offer benefit in the general study population (those without any age-related macular degeneration).
  • Glaucoma.  Get screened for glaucoma (increased pressure in the eye) especially if you have the risk factors of a family history of glaucoma, or are African American or hispanic.  Diagnosis of glaucoma involves measurement of intraocular pressure and an evaluation of the optic disc and an automated visual field test.  Medicated eye drops lower the intraocular pressure and can delay the progression of vision loss.  Medical therapy works well, but there is often poor adherence to the drop regimen. Surgery is also available.
  • Cataracts.  As you age, you may appreciate decreased vision, sensitivity to glare or difficulty with nighttime vision.  These are signs of a cataract, or clouding of the corner.  Surgery is the only effective treatment for cataracts that compromise vision.  To decrease cataract progression, limit eye exposure to ultraviolet light and do not smoke.  Supplemental vitamins do not slow cataract progression.

I hope this helps.



Posted in Diabetes, eye, food, General Medicine- Adults, Uncategorized | Tagged , , , , , , , , , ,

I won a teaching award!

I won a teaching award this weekend. The family medicine resident physicians awarded me “Outstanding Faculty Preceptor” at the University of Nevada Reno Family Medicine Residency Program.  

What an honor!

My passion is family medicine and teaching and mentoring.

Find your passion.

Posted in Uncategorized

Fecal transplant, anyone?!

Fecal transplant, anyone?  Yes, this is a viable treatment.Fecal transplantation is used to treat an intestinal infection called Clostridium difficile or “c. diff.”

The clinical spectrum of C. difficile infection can vary from asymptomatic or mild diarrhea all the way to a life threatening inflammatory bowel condition.  At times this colitis requires emergency surgery, with removal of the colon.

What is the treatment of c. diff?  Initial antibiotic treatment for mild to moderate c. diff infection consists of metronidazole.  More complicated or severe infections may require vancomycin.

What is the cure rate?  Up to 90% have a clinical cure after initial treatment.  However, the recurrence rate after an initial infection are 15 to 30%.  The recurrence rate is up to 50% for patients with three occurrences of c. diff.

Why fecal transplant?  It is thought that disruption in the micro-biome of the intestine can make patients more susceptible to recurrences of c. diff.  So, to repopulate the intestine with a healthy, robust micro-biome has been shown to lead to success rates of up to 85% in those with recurrent infections.

How is this done? The fecal material is donated and is rigorously tested for infectious disease screening, similar to blood donor screening   Most recently freeze-dried stool has been put into oral capsules and the patient swallows it.

How much does this cost?  It can be expensive as most insurance providers do not cover this treatment.  It is considered an experimental treatment as the long-term safety and effectiveness is unknown.  More studies are needed.

canary photos/ taksidia/ 1249605102

Posted in colon, General Medicine- Adults, infections, Uncategorized | Tagged , , , , , , , , , , ,