This much maligned beverage has again made headlines for being – surprise – a healthy beverage. Now this is no huge revelation to me as I feel positively suicidal before I have my first morning cup-a-joe. Coffee extends my life every morning.

Coffee got its bad reputation from associating with undesirables. People are natural multi-taskers. They like to do something while they smoke, sometimes combining smoking, drinking, and talking all at once.

Coffee, or whiskey, was perhaps used to wash down the bad taste of the smoke. The result was coffee was considered a co-conspirator with cigarettes in research showing increased mouth, throat and lung cancer. It turns out it was all the cigarettes. Combine cigarettes with the most innocent of beverages (dandelion wine, mint tea, mother’s milk), and the results will be the same. The coffee was simply an innocent bystander.

The latest research on coffee is the result of a “Mega- study.” Mega-anything sounds impressive, but a mega- study is a powerful statistical technique to combine dozens of smaller, weaker studies and get a big strong study – and hopefully some bullet- proof answers.

This time the analysis showed stroke risk was significantly lower among coffee drinkers. When all the usual suspects for stroke (hypertension, high cholesterol, diabetes), were accounted for, coffee drinkers came out ahead.

But cutting down on the stroke risk is only the puff of steam in the volcano of coffee benefits. Coffee is low-cal. If you like it black, it’s like celery, takes more calories to digest than it contains. Even with sugar and a splash of cream, it’s less than 50 calories. That is half the calories of most soda, juices or margaritas.

Perhaps coffee can save us from the obesity epidemic, venti mocha with whip notwithstanding.

Coffee has antioxidants, those magical molecules that are believed to help everything, including aging. No guarantees that coffee will make you any younger, but the risk of heart disease is lower in coffee drinkers. Colon cancer, gall bladder disease and Parkinson’s are all less frequent in roasted bean enthusiasts. Even the risk of diabetes is lower.

But coffee is not for the faint of stomach. The acid level in the stomach is measurably increased by coffee, as any college student up late for finals will attest. There are also better beverages for insomniacs. Caffeine when taken in excess can turn you into a jittery mess, again channeling my undergraduate years.

But strokes are nasty things and any way to avoid one is a blessing.

Also good to not sleep through your life.

As always,

Take care.

Dr. B.

We give our mothers one special day a year to really demonstrate our love and affection – Mother’s Day – which, in case you didn’t realize, pops up on the calendar this Sunday (May 13).

We’ve been celebrating this holiday for more than a century. Mother’s Day is a time-honored tradition that was first initiated in the United States in 1907 and is now celebrated by other countries worldwide.

Many husbands and children struggle to come up with a solid plan to celebrate Mother’s Day. And that’s certainly not surprising! Who typically is the brains and planner behind any holiday? That’s right – Mom.

The typical ideas for Mother’s Day involve a family outing for brunch or an elegant dinner.

While nothing is wrong with these time-honored ways to give Mom a special day, why not try something a little different this year – and give Mom some good health, too (no, we’re not suggesting “ruining” the celebration!).

Since a typical day for many Moms involves dealing with a variety of stress, a great gift relieves the stress and keeps Mom healthy in mind and body.

Here are a few healthy ideas that will make Mom happy:

1. Prepare Mom a homemade spa package: A pretty basket or bag that includes soaps, lotions, loofah, candles, pedicure kit.

2. Buy Mom a massage: A deep massaging of the muscles and the tissues can go a long way in keeping Mom healthy and relieve any stress. Additional benefits from a message are improved blood circulation, clearer skin, lower blood pressure,, and possibly improved immune system.

3. Soothing music: A relaxing concert in a park with a picnic (Remember the healthy fruits and vegetables!).

4. Breakfast in bed: Yes, a classic idea. Make sure to give Mom some great fresh fruit, whole grains, and low fat protein such non-fat yogurt with sliced strawberries and granola.

5. Bring mom to the flowers: Instead of buying Mom flowers, have the family visit a botanical garden. A walk around the grounds is not only good exercise, it also gives Mom the opportunity to pick out flowers or a plant as a Mother’s Day gift. Of course, watch the allergies!

6. Battle-free zone: leave the family feuds and strife at the door – nothing gets Mom’s blood pressure rising like a family fight.

Finally, give Mom a hug – it might be the healthiest thing you can do for her on Mother’s Day and will be the best gift of all!

Dr. Alesia J. Wagner
Dr. Wagner is a Regional Medical Director in Southern California for U.S. HealthWorks Medical Group.

This is not obvious from outside the professions, but the evidence is all around us. The surgeon is a much more glamorous specialty; life and death sometimes literally rest in a surgeon’s hands. The surgeon is richly rewarded for sometimes heroic efforts, and is among the highest paid and most respected of any specialist.

The medicine man (internist) spends time in the much less dramatic pursuit of disease prevention and cure through medications. This is a quiet and thoughtful profession, but much like the tortoise and hare, the medicine man is winning.

This struggle was highlighted last week by studies showing that antibiotic treatment is as safe and effective as surgery for acute appendicitis (and a whole lot less miserable for the patient).

That is the exact opposite to the training surgeons received for the last 50 years. We believed that antibiotics never cured an appendicitis, it just made it harder to diagnose, thus delaying surgical treatment until after it burst (peritonitis).

So we will see a lot less appendectomies in the future. Score: Medicine 1,
Surgery 0.

Thinking about life and death surgery, the cardiovascular (heart) surgeon has no equal.

But the triple bypass is steadily losing ground to prevention and alternative treatments. Medications like statins to reduce cholesterol and blood pressure medications are keeping the vast number of patients from even getting coronary artery disease. Even if you get coronary artery disease, the chances are that your treatment will be an angioplasty/stent rather that having your “chest cracked.”

There is a reason they call it chest cracking! That’s 2/0, in the Medicine Man’s favor – if you are keeping score.

Ulcer surgery used to be one of the most commonly performed operations. Then came the invention of Tagamet, a class of acid reducers light years ahead of antacids (acid neutralizers). Then came the proton pump inhibitors (Prilosec), which was the knockout blow that virtually eliminated ulcer surgery.

Cancer has always been first and foremost a surgical disease. What is more appealing than cutting the cancer out? These days, the answer is a lot of things. Prostate cancer was always treated with prostate removal, and a frequent complication was impotence.

Now oral medications like antiandrogens, or alternative treatments like radiation, have dramatically decreased the number of prostates we remove, and the number of people needing Viagra is also reduced.

Breast cancer was first treated with the big operation: radical mastectomy. This evolved into simple mastectomy, now lumpectomy, or even just needle biopsy. Medical treatment for breast cancer does a better and less traumatic job of curing many of these unfortunate problems for women.

In fact, just about pick your cancer, and the treatment has dramatically moved from surgical to medical in the last 30 years.

But never fear, orthopedics can be a safe haven for underemployed surgeons. A pill for a broken bone is still a while away. But I wouldn’t quite classify it with teleportation; we may come up with something.

Having trained in general surgery, and then practiced occupational medicine for the last 30 years, the sweep of change I’ve seen has been dramatic. Every year we find new magic pills that retire another scalpel.

Call me a wimp, but I’ll take my Lipitor and Tenormin; and eat walnuts if I want to hear a cracking sound.

Take care.

Dr. B.

Assuming the world keeps spinning, alcohol will be consumed by many and there will be ill-advised forays into the land of inebriation.

Perhaps we can mitigate the damage with some timely advice – things you never want to do while drunk.

1.  Get a tattoo. Tattoos are the leading cause of Hepatitis C in this country. More Americans die of Hepatitis C than AIDS. The Hep C virus is in blood and is difficult to kill. It is easily transmitted while getting a tattoo if absolute sterility isn’t maintained. Get your tattoo when you are sober enough to judge the cleanliness of the tattoo parlor, or settle for a piercing – earrings rarely cause major complications.
2. Get pregnant. Alcohol impairs your higher cortical functions. This is your rational self, the place where reasoning, judgment and “the brakes” reside. Evolutionarily older brain is less affected by alcohol. It is your inner cave man/woman. This version of you is only concerned with the more basic emotions, like hunger and lust. You don’t want to get dragged off by the hair to a cave.
3. Get married. Someone once said “questions of marriage and divorce should be made in cold blood.” You need your rational self to consider such decisions. Getting married is easy and fun; putting up with each other for the rest of your life is a little more challenging.
4. Mix Chemicals. Alcohol is a respiratory depressant. Narcotics are also respiratory depressants. Moderate drinking chased with a couple of oxys or Vicodin can be a deadly combination.
5. Mix Chemicals, Part 2- Stimulants. Cocaine, methamphetamine and ecstasy are all stimulants. Take any of these and you are now a “drunk in motion.” Not more coordinated or a better driver or rational decision maker; just in motion. Think of this as looking for trouble; you are now a human pinball.
6. Drink more. If you are awake and feeling pleasant, this is as good as it gets. More alcohol will seem like a very fine idea, but it isn’t. Trust me on this. Vomiting on your shoes, or your date, does very little to improve your social life. On second thought, it may prevent 1, 2 or 3, which are all worse.
7. Sign legal documents. We already discussed marriage licenses; but car loan documents, mortgages or wireless contracts are equally ill advised when drunk. Save these things for when your brain is working at its best.
8. Be profound.
9. Break-up, make up or significantly change an ongoing relationship.
10. Drive. Almost half of the serious and fatal car crashes involve alcohol. Over 20,000 people die each year. You have a better chance of surviving an encounter with a Great White shark than staying out of trouble in a car. A designated driver or cab fare is an absolute necessity.

Take care and stay safe.

Dr. B

Image: Suat Eman / FreeDigitalPhotos.net

Avastin is kind of an exotic medication, not one I’ve had occasion to prescribe, since it is used only for cancer chemotherapy. But apparently, larceny lives in the pharmaceutical world as well.

I’ve heard of counterfeit watches and Cuban cigars, and even the intentionally mislabeled nice piece of fish. If they say it’s Hawaiian Ono, how would I know if it’s actually Grouper or Fillet of Sunfish for that matter? I picture a guy in a trench coat with pill bottles lining the inside saying: “Want to buy some cheap Viagra?”

But the economics must be compelling to work for the dark side. The retail price for a small vial of Avastin is somewhere in excess of $2,500. It comes in a little glass medicine bottle that would hold about a teaspoon worth of liquid, and is about a quarter filled with crystalline white powder. That’s what you get for $2,500 these days!

Avastin, like a lot of chemotherapy drugs, often makes you nauseated when you take it. And to be getting chemotherapy in the first place, you have to be pretty sick. Chemotherapy is an inexact science, since not all tumors respond. So counterfeit Avastin may be the perfect crime. Many patients, and even doctors, would never figure it out.

And then there is the placebo response. Non medically-trained people are surprised by the reliability and the strength of “the cure” simply by placebo effect. The placebo is no small-time lame excuse for treatment, but it is often the reason a treatment works (although few would admit it).

Two weeks ago, National Public Radio ran a story about putting the world’s best violinists in a large dark area and letting them blindly play Stradivarius and other lesser violins. The musicians picked the best sounding, most exquisite to play instruments and were very surprised to have mostly chosen modern violins of no great reputation. Placebo effect apparently makes even Stradivarius violins sound and play better.

So do we need to be suspicious of the next bottle of pills we get (even if they work)?

The pharmaceutical manufacturing industry is complex and widely scattered geographically. The medication you took this morning may well have been made in a factory in India, even if it’s a trade name (non-generic) drug.

The foreign manufacturer is inspected by the local government, as well as, the drug company it is working for. Shipments are quality inspected and carefully tracked from creation to arrival at the local pharmacy. The DEA is involved when they hit American soil. But these countries are on the other side of the planet, and mischief is possible, given enough incentive.

Fortunately circumstances usually work against that.

Most treatment courses of very expensive medications are brief, like the exotic IV antibiotic, or chemotherapeutic drug. So few actual doses are given that there usually isn’t the market to make a counterfeit drug profitable.

Longer term medications are often obvious enough in their effects that people can do their own quality control. For instance, you can check your blood pressure on your antihypertensive medication, or your cholesterol on your statin. And, even though generics take up a large segment of the market, they are not expensive enough to induce larceny.

So while there will never be a shortage of charlatans trying to sell you Laetrile or the latest snake oil cure for cancer or ingrown toenails, these fakes won’t likely be showing up in the bottle of pills you bring home from the local doctor or pharmacy.

Take Care.

Dr. B

Hepatitis C is a liver infection caused by a virus that is a cousin of the better known and much more glamorous Hepatitis B virus.

Hepatitis C is a sneaky bugger; we didn’t even have a name or a test for it when I was in medical school (which was not that long ago). We just called in Non A/Non B, we knew what it wasn’t, but not what it was. This virus can live for a while on surfaces that appear to be clean. And even worse, when you get it, most of the time, you don’t even know you are sick, but sick you are, or will be.

Hepatitis C is a sleek, lean, killing machine. This virus is elegant in design, just enough RNA to reproduce itself wrapped up in a bullet proof jacket. It can live through a lot of mistreatment; both on the outside (before you get it) and the inside (after you get it). Hepatitis C can live on a clean, dry-appearing surface for up to a week and remain infectious. It is killed by alcohol and bleach disinfectants, but the virus is tiny and can hide in the nooks and crevices of equipment that is blood contaminated.

You get infected with Hepatitis C when live viral particles get inside you. This used to be a disease of the heroin enthusiast. High doses of narcotics make people sloppy about sterile technique – imagine that. Needles and syringes are shared as are the blood-borne viruses like hepatitis C. These days the innocent tattoo is the leading cause of Hepatitis C. A tattoo is a million tiny injections. There is bleeding involved and it can get messy. If there is the tiniest trace of blood on equipment from the last tattoo, you have a new “blood brother” (or sister).

The problem with Hepatitis C is that it smolders along for years, totally unknown to you, and one day, out of nowhere, you have big trouble. Big trouble here means liver cirrhosis, liver failure or liver cancer.

When you first get Hepatitis C, it is a pretty mild disease; a little fatigue, muscle pain, poor appetite, that sort of non-specific thing. Most people don’t even know they are sick. The few that feel sick will feel better on their own. The virus, however, persists in your liver 80% of the time.

This low grade infection of your liver is death (to the liver) by a thousand cuts. The liver slowly, silently, and steadily scars until up to a third of people get cirrhosis over 20 or 30 years. Cancer of the liver is also 20 times more common in Hepatitis C infected patients.

Cirrhosis is no fun because the blood that can‘t get through the liver, goes around it. Sometimes these veins break from the pressure, and you bleed, vigorously. Liver failure is also problematic as your liver detoxifies and filters everything you take in. You need a functional liver.

What about treatment? Treatment is successful in clearing the virus from your liver a little more than half the time, but the treatment isn’t easy. Interferon is used with other anti-viral drugs for up to a year. This is not for the faint of heart. If the Hepatitis C virus doesn’t clear, it can result in liver failure and liver transplant. Over 100 million people have undiagnosed Hepatitis C in the world.

But there is some good news, you can have sex and not get hepatitis C, you just can’t be sexy and get a tattoo. And, if you ever need a blood transfusion, the blood you get will be Hepatitis C-free and safer than it has ever been before.

Given this terrible disease burden, medicine is working full time on new and more effective treatments for Hepatitis C and trying to develop a vaccine. Try to stay out of trouble until the choices are better.

Take care

Dr B

Japanese cuisine has worldwide popularity and nothing is more synonymous with Japanese food than sushi.

The term sushi is associated with raw fish dishes that we see as healthy culinary art forms that many people feel taste great. The forms and traditional types vary greatly. Raw seafood is the foundation for dishes that are consumed and stand on their own merit. Many presentations also include rice, nori and numerous other ingredients, such as vegetables and some seafood that may already be cooked.

However, sushi isn’t limited to raw fish and rice. Condiments such as soy sauce, wasabi paste (a distinctive cousin to horseradish), tofu, soy beans, eggs and mayonnaise are often components to some dishes.

Fish is a wonderful source of high quality lean protein. It is low in saturated fats, cholesterol, and carbohydrates. Salmon, mackerel, herring and tuna are rich in omega-3 fatty acids, which are linked to many health benefits.

Tofu, soy beans, nori, the dried seaweed wrapper commonly used in “rolls,” are all excellent nutrient sources of minerals, calcium, vitamin D, folic acid and antioxidants. Not all ingredients are limited to raw fish. Shrimp, eel, geoduck and crab are often cooked before they are featured in a roll.

The wide array of creative rolls and styles seems endless with something to suit any taste. One must be thoughtful about some of the ingredients in some contemporary rolls, like cream cheese, fried foods, mayonnaise, and soy sauce that greatly increase the calories, sodium and fat contained in your dish. Overall, the benefits of enjoying sushi and sashimi are diverse and outstanding.

The risks of eating sushi are very low, but are worthy of consideration. The general contamination of seafood with mercury is virtually unavoidable. Unfortunately, this neurotoxin contaminates all open waters of rivers, lakes and oceans. Some caution should be exercised in choices of fish variety and quantities consumed by those who are at greatest risk of mercury consumption.

Women who are pregnant, nursing or planning to get pregnant, young children, elderly or people who have a compromised immune system, should limit their consumption of seafood to only 12 ounces per week.

Some species of seafood are likely to have higher mercury levels, such as tuna, swordfish, shark and mackerel. This doesn’t mean that they need to be avoided entirely. They just need to be consumed in limited quantities, emphasizing variety with other kinds of seafood that may be lower in mercury content, such as salmon, trout, crab and shrimp.

There are additional risks with undercooked or raw seafood that remain low if products are handled and stored properly. There are FDA guidelines for the industry that include freezing fish for precise amount of time to kill parasites.

Still, poor handling or dishonest vendors can provide tainted food that is contaminated with bacteria or parasites. The most common symptoms from eating contaminated raw fish are nausea, vomiting, diarrhea, abdominal pain, headache and fever. One must rely on a reputable dealer and trust your restaurateur to provide sanitary products of high quality. Although eating raw seafood is simply a greater risk than cooked fish, experts agree the health benefits outweigh the risks.

Enjoy the nutritional benefits of a wonderful culinary art with thoughtfulness and peace of mind. Also keep in mind to strive for variety and eat sensible portions.

By Dr. Bruce Kaler

Image: piyato / FreeDigitalPhotos.net

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The Pertussis vaccine became available in 1940 and there was a steady decline of this deadly childhood disease in the U.S. until 1980. More cases are now being reported among adults and adolescents who experience a milder, but just as stubborn form of the disease as infants. Since pertussis initially resembles other common colds, the disease is probably under reported.

Babies under the age of 1 get the infection from those who are closest to them. Family members, friends and caregivers are usually the source. We have only recognized in recent years the role of adults around an infant to be a potentially dangerous reservoir of the disease. Adults are susceptible to pertussis because the vaccine they received as children wanes over five to 10 years. If one member of a household has whooping cough, there’s a 90 to 100 percent chance that other susceptible household members will also catch it.

The vaccine is administered at 2, 4 and 6 months of age. A fourth dose is administered between 12 and 18 months, and a fifth after age 4. Teens need another booster shot between 11 and 18. All adults should have a single adult booster of Tdap (tetanus, diphtheria, and acellular pertussis) vaccine.

Even when a baby is vaccinated, they may not be fully protected until they have received at least three doses of the infant pertussis vaccine. In order to create a “cocoon of safety” around an infant, those in close contact with the baby should receive a single dose of Tdap.

Whooping cough is spread easily through mucus droplets, broadcast by profound coughing and sneezing. It can take three weeks or more to develop symptoms after exposure to the infection. Individuals can give whooping cough to others until they’ve been treated with antibiotics for five days, or until coughing for 21 days.

The swelling and inflammation to airways is actually caused by toxins secreted by the bacteria. After 21 days of the infection the bacteria will die off, but has already released damaging toxins.

Early recognition and treatment is important to minimizing the effects and preventing spread of the acute infection to others. Pertussis causes spells of coughing that makes it hard for a child to eat, drink, or breathe. The cough is often followed by a “whooping” sound as the person gasps for air, which is how the condition got its name. Some historians referred to the disease as the “100-day cough.”

Serious side effects from the coughing fits are common in children. The choking and gasping can be fatal in children under the age of 1. The disease is most serious in infants, especially those too young to get the vaccine or not fully protected. Babies with whooping cough are often hospitalized. With older kids and adults, the disease is milder and can cause several weeks of exhausting coughs. Although rarely fatal in adults and older children, time lost from school and work is substantial.

Early detection is important in limiting the spread of whooping cough. Appropriate antibiotic therapy for the person suffering from the condition and their close contacts needs to be started as soon as possible. Late recognition and treatment fails to change the course of the disease. Many weeks of coughing by the affected individual will continue even if the spread is limited.

Testing specimens from a nasal swab can be helpful in identifying pertussis only in the first couple weeks. Many patients don’t seek medical evaluation until later and the results of testing also causes further delay. Precise recognition can be difficult. Treatment is often started in the context of clinical symptoms and known outbreak in the community.

This punctuates the importance of prevention and a proactive approach to immunizations of both children and adults in the community. The best way to help protect babies against pertussis is to get infant vaccinations in a timely fashion. Adolescents and adults should have a single dose of Tdap booster.

By Dr. Bruce Kaler

Image: Sura Nualpradid / FreeDigitalPhotos.net

Obesity causes elevated blood pressure, heart attacks, strokes and kidney failure. The extra weight wears out the joints in the legs so total knee and hip replacements are performed more frequently, and at a younger age, in the obese. Reassemble this box and the price tag adds up to $150 billion per year for obesity-caused disease, just in this country.

Think a few people are looking for an answer? We may have found one.

Qnexa is a combination of two older medications that appears to have somewhat magical and unexpected properties when put together in just the right amount.

The two medications that make up Qnexa are Phentermine (of fen-phen fame) and Topamax. Phentermine is an older diet medication, which is in the family of stimulants. Don’t worry, the heart problems in Fen-phen were all because of the Fenfluramine, which is no longer available.

Topamax is an anti-convulsant (anti-epileptic) that has been around a while and is used to treat migraines and chronic pain, as well as epilepsy. So you add these two medications, experiment with the right amount, and duration of each, and almost like magic, people start losing weight.

The magic seems to be in the details. The phentermine-to-Topamax ratio that is used is roughly 1 to 6. The actual dosages studied are anywhere from roughly 50% of maximum doses of each to merely 10%.

They have also adjusted the release of the medications to prolong the effect in the body (also allows once daily dosing).

Now, more than a few people will be thinking of making “do it yourself” Qnexa by getting a prescription for both medications – that would be a very bad idea.

The actual medication has been approved by the FDA advisory panel; but it took two times through to get that. The full FDA hasn’t approval this (necessary to allow your doctor to prescribe it). Approval is anticipated later this year. In the meantime, do-it-yourself pharmaceutical research is dicey at best.

Probably worth remembering that one of these medications has seen trouble before (fen-phen). There have also been a good dozen drugs taken off the market in the last 10 years for safety reasons, and they had been fully approved by the FDA.

Qnexa isn’t there yet.

But does it really work? Three large studies have looked into the safety and effectiveness of this medication. The FDA’s minimum “bar” for effectiveness (in a weight loss medication) is 5% weight loss after one year of therapy. Qnexa had no problem meeting that, and in fact had closer to 15% weight loss after a year’s therapy.

The mechanism of action is appetite suppression; you don’t get hungry.

There were no surprising side effects, most were mild and did not limit treatment. Side effects tended to be gastro-intestinal; some nausea, constipation and numbness and tingling in a rare patient.

Keep in mind that new medications and combinations are tested on a few thousand people, not the millions of people that a hot new prescription drug will see. Statistically rare occurrences require big numbers to identify. It is reassuring however, that there are no serious scientific concerns about this new combination medication.

Will Qnexa be the next big pharmaceutical wonder drug, the billion dollar pill? Will it undo some of the damage the fast food nation has done on our heart health? Or will having a good answer for weight loss just make us eat even less carefully?

I think next year’s New Year’s Resolution is going to be a lot easier to keep.

Take Care.

Dr B.

Image: Michelle Meiklejohn / FreeDigitalPhotos.net