February 19, 2019

Health Alerts
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| Which NSAID is Safest for Your Heart? | Gastroesophageal Reflux Disease (GERD) | Heart Attack Symptoms |
| Protect Yourself from Esophageal Cancer | Minerals that really mattter | Reduce Your Fall Risk |
| PLAY IT SAFE IN THE SUN | Living Safely On Your Own | ANGINA, What is it? |
| A Medication Reminder | Potentially Inappropriate Drugs for Older Adults | Clostridium difficile, A Dangerous Superbug |
| Calcium Supplements - How much REALLY? | Heart Failure | Should You Have Surgery For Sciatica? |
| Hand Washing 101 | How Low Should You Go? | Sleep Deprivation |
| Red Flag For Women |
Protect Yourself From Breast Cancer
October, each year, is breast cancer awareness month. In truth, every month should be breast cancer awareness month because as women age, the risk of developing breast cancer increases.

Patricia Ganz MD, director of Cancer Prevention and Control Research at UCLA's Jonsson Cancer Center says "early detection is the key." She also notes that early detection allows for higher cure rates and early cancers are easier to treat and don't always require invasive treatments such as chemotherapy, radiation or surgery.

In recent years there has been something of a mammogram controversy; nevertheless, the best way to help identify early breast cancer is to have regular mammograms and do breast self-exams one every month. These mammograms should be done every one or two years for women between the ages of 40 and 70. The benefit of mammograms after the age of 70 is often debated among the experts because of other factors including life expectancy, state of health etc. At that age you should discuss such matters with your doctor. The risk of contracting breast cancer in women doesn't start to decline until after the age of 84.

If you are uncertain as to how a Breast Self Exam (BSE)should be performed, here are the steps to follow:

  • STEP 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

    Here is what to look for:

    Breasts that are their usual size, shape and color.
    Breasts that are evenly shaped withour visible distortion or swelling.

    If you see any of the following changes, bring them to the attention of your doctor:

    Dimpling, puckering, or bulging of the skin.
    A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out.)
    Redness, soreness, rash, or swelling.

  • STEP 2: Now raise your arms and look for the same changes.

  • STEP 3: While you're at the mirror, look for any signs of fluid coming our of one or both nipples (this could be watery, milky, yellow fluid or blood.)

  • STEP 4; Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter.

    Cover the entire breast from top to bottom, side to side, from you collarbone to the top of your abdomen, and from your armpit to your cleavage.

    Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lwn. this up- and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts. For the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for deep tissue in the back. When you have reached deep tissue, you should be able to feel down to your ribcage.

  • STEP 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower, using the same movements described in STEP 4.
UCLA David Geffen School of Medicine. Breastcancer.org

Which NSAID is Safest for Your Heart?
Multiple studies have shown that people should take precautions when using nonsteroidal anti-inflamatory drugs (NSAIDS) to relieve pain, fever and inflamation because of the drugs' well-known cardiovascular risks.

To answer the question of how to choose the safest for various individuals, a group of scientists examined how various NSAIDs compared against each other when it came to heart safety. They published their findings in the journal PLoS Medicine from the Public Library of Science.

These researchers pooled data from observational studies of 2.7 million people at both high and low risk for cardiovascular disease. This allowed them to gather data about individual drugs and their risks when used in settings other than those in controlled clinical trials. The downside of observational studies is that a true cause and effect can't be established since other factors may influence results. The study also took into consideration the varying lengths of time people took NSAIDs in home settings rather than clinical trials.

What can considered unique about this meta-analysis is that it included people taking low and over-the-counter doses of NSAIDs. Most other meta-analyses have studied results that involved higher prescription doses.Both prescription and nonprescription naproxen was deemed the least likely NSAID to raise cardiovascular risk, with over-the-counter (OTC) ibuprofen a close second. The two NSAIDs with the highest risks are either no longer on the market (rofecoxib[Vioxx]) or not available in the United States (diclofenac).

Among low-risk people who take NSAIDs, the chance of a heart attack or other adverse cardiovascular event is small, and an occasional NSAID should cause no harm; however, NSAIDs significantly increase the risk of such and event in people with underlying heart disease and should be avoided whenever possible.

If you take NSAIDs for a prolonged period, talk to your doctor about the risks. Over time, large doses of NSAIDs can do damage to the kidney, a condition known as nephrotoxicity.

Individuals may also be susceptable to gastric distress that NSAIDs can cause. On average, people taking NSAIDs are four times more likely to develop gastrointestional complications such as bleeding and ulcers. Always take the lowest effective dose, and never exceed the maximum recommended dose unless instructed by your doctor.

The following information is from the table of findings relating to individual NSAIDs:
NAPROXIN is sold under the brand names ALEVE, ANAPROX, NAPRELAN, AND NAPROSYN. The findings indicate that both prescription and over-the-counter (OTC) doses are safest among NSAIDs for both high and low risk individuals.
IBUPROFIN is sold under the brand names ADVIL, MOTRIN AND NUPRIN and low doses of OTC are safest, but as prescription doses rise above 1,200mg a day, so does cardiac risk.
CELEOXIB is sold under the brand name CELEBREX and both high and low doses shoed a slightly increased cardiac risk, and the study authors say they would be "reluctant" to prescribe it to high-risk patients.
INDOMETHACIN is sold as INDOCIN and is considered high risk given its gastrointestinal and nervous system risks and the authors advise removing it from the market.
PIROXICAM is sold under the brand name FELDENE. The risk is similar to that of Naproxen, but it has a very high risk of serious gastrointestinal disturbances.
MELOXICAM is sold as MOBIC and has risks similar to that of ibuprofen and celeoxib, but it should be avoided by high-risk persons.
ETODOLAC is sold under the brand name LODINE. Sparse date make this a questionable choice. When compared with naproxen and ibuprofen, risk was similar, but on its own, some studies found it to be high isk.

Johns Hopkins Medicine, Health After 50
Volume 24, April 2012

Gastroesophageal Reflux Disease (GERD)
Many people, including some 79% of those with gastroesophageal reflux disease suffer heartburn that awakens them during the night. While this is by far the most common symptom of GERD, there are about 10-15% of people with gastroesophageal disease who do NOT have heartburn! Instead, they experience asthma, a chronic cough, chest pain, or laryngitis. These symptoms result when stomach acid refluxes into organs connected to the esophagus, such as the larynx, trachea and lungs.

Research reported in the journal Chest (Volume 127, page 1658 May 2005) shows that people who are overweight, drink a lot of carbonated beverages, snore, experience daytime sleepiness or insomnia, have a high blood pressure or asthma, or use anti-anxiety medications such as diazepam (Valium) are most likely to experience the problem.

The subjects were part of the Sleep Heart Health Study, a national trial that enrolled 15,314 people to investigate the link between breathing problems during sleep and cardiovascular disease. Among the questions was "how often in the past year, on average, have you been awakened during the night with heartburn or indigestion?" The responses indicated that 1/4 or 3,806 people, in this group reported the symptom at least twice a month. People with nighttime heartburn are at greater risk for more serious esophageal problems such as erosive esophagitis, Barrett's esophagus, and esophageal cancer.

With both obesity and GERD on the rise , medical researchers have found there to be a link between the two. An article in The American Journal of Gastroenterology examined the results of 20 studies involving more than 18,000 people with GERD. Overall, people who were overweight were 50% more likely to have GERD than normal weight people; obese individuals were more than twice as likely.

If you experience nighttime heartburn on a regular basis, or have bouts of asthma, a nagging cough or episodes of chest pain, talk with your doctor. In addition, try to control the risk factors identified in this study - for example, keep your weight and blood pressure under control and cut down on your soda intake.

Johns Hopkins Medicine and Johns Hopkins Health Alerts

Heart Attack Symptoms
If you think all heart attacks look like what you see in the movies and on television, with sudden chest-wrenching pain, your couldn't be more wrong! Actually, less than 5% of heart attacks are like the movies. In fact, most heart attacks begin with more subtle symptoms in both men and women. Furthermore, symptoms differ between men and women.

Men's Symptoms
  • Chest discomfort or pain: This discomfort or pain can feel like a tight ache, pressure, fullness or squeezing in the center of your chest lasting more than a few minutes. It is possible for this discomfort to come and go.
  • Upper Body Pain: Pain or discomfort may spread beyond your chest to your shoulders, arms, back, neck, teeth and jaw. You may have upper body pain with no chest discomfort.
  • Stomach Pain: Pain may extend downward into your abdominal area and may feel like heartburn.
  • Shortness of Breath: You may pant for breath or try to take in deep breaths. This often occurs before you develop chest discomfort or you may not experience any chest discomfort.
  • Anxiety: You may feel a sense of doom or feel as if you're having a panic attack for no apparent reason.
  • Lightheadedness: In addition to chest pressure, you may feel dizzy or feel like you might pass out.
  • Sweating: You may suddenly break into a sweat with cold, clammy skin.
  • Nausea and Vomiting: You may feel sick to your stomach or vomit.

If you have any of these symptoms, part of your heart muscle could be dying due to a lack of blood flow. Do not "tough it out" for more than five minutes. Call 911 or other EMS help and above all, DO NOT DRIVE YOURSELF TO THE HOSPITAL OR CLINIC unless it is absolutely a last resort option!!

As for the women, did you know that forty years ago the conventional wisdom of the day was that only men had heart attacks and women were somehow immune - a very serious misconception! In fact, since 1984 more women than men die of heart disease each year. One challenge, is that symptoms for women can be different from symptoms in men.The most prominent heart attack symptom in women is some type of pain, pressure or discomfort in the chest; but, it is not always severe or even the most prominent symptom women can have. Women are more likely than men to have heart atttack symptoms without chest pain or discomfort!

Women's Symptoms
  • Neck, shoulder, upper back, between the shoulder blades
  • Shortness of breath
  • Abdominal pain or heartburn
  • Nausea or Vomiting
  • Sweating
  • Lightheadedness or dizziness
  • Unusual fatigue

The foregoing symptoms, though appearing to be identical to those symptoms in men are more subtle and may be totally lacking in the obvious chest pain or discomfort associated with heart attacks. This may be because women tend to have blockages not only in their main arteries, but also in the smaller arteries that supply blood to the heart - a condition named small vessel heart disease or microvascular disease.Far too many women tend to show up in emergency rooms after much heart damage has already occurred because their symptoms are not those typically associated with a heart attack!

If you experience these symptoms or think you're having a heart attack, get emergency medical help immediately. Above all, DO NOT DRIVE YOURSELF to the emergency room unless there are no other options.

Mayo Clinic
August, 2011

Protect Yourself from Esophageal Cancer
The number of people diagnosed with cancer of the esophagus is rapidly increasing. While the exact cause of esophageal adnocarcinoma - the most common type of esphageal cancer - is unknown, the research suggests that the following measures may significantly reduce your risk:

Turn your back on tobacco. Because smoking damages the DNA in the cells lining your esophagus, smoking significantly increases your risk of cancer.
Eat more fruits and vegetables. About 15% of esophageal cancers can be linked to a diet low in fruits and vegetables, according to the American Cancer Society. Eating these foods raw may offfer even more protection.
Hold off an hot liquids. Drinking very hot liquids may damage esophageal cells, potentially leading to cancer according to some studies.
Maintain a healthy weight. Being obese, especially around the abdomen, has been linked to esophageal cancer.
Get a grip on GERD. If you have gastroesophageal disease (GERD), the constant exposure of your esophagus to stomach acids and bile can seriously damage your esophagus, possibly causing cancer. Having Barrett's esophagus, a complication of GERD, further increases your risk of cancer. If you have Barrett's esophagus or GERD, you would be wise to schedule an upper endoscopy on a routine basis to look for precancerous changes in the lining of your esophagus.

For more information on managing GERD, you can order the Johns Hopkins special digital report on GERD at http://www.johnshopkinshealthalerts.com/bookstore/digital.html. There is also an article regarding GERD on the Orcas Family Health Center Health Alerts Page.

John Hopkins Medicine Report
August 2011

Minerals that really mattter
It seems that vitamin and mineral recommendations are always changing so here are the latest dietary recommendations for four very important minerals:
In the dietary batle against high blood pressure, sodium restriction gets the glory but potassium is the real unsung hero. It helps rid the body of sodium and protects cells that line the blood-vessle walls. In addition to blunting the effects of sodium, a potassium rich diet is also associated with a reduced risk of bone loss, kidney stones, strokes and type 2 diabetes.

Unfortunately, nearly all Americans consume too much sodium and far to little potassium. A September 2010 study suggests what might happen if people corrected the sodium-potassium ratio. It found that even if sodium consumption stayed high, increasing potassium to the recommended levels (4,700 milligrams a day) could reduce the risk of heart disease mortality by up to 11% and stroke mortality by up to 15%.

So is it enough to simply take potassium supplements or use salt substitutes made with the mineral? Probably not since those are different forms of potassium and will likely not provide the same benefit as the form found naturally in foods.

Too much potassium is not a problem for most people, but certain medical conditions and drugs can interfere with the body's ability to get rid of the excess. You should talk with your doctor before increasing your potassium intake, even from food, if you have a disorder that causes potassium retention, such as diabetes, heart failure, or kidney disease. Additionally, seek your doctor's opinion if you take ACE inhibitors, such as lisinopril (Prinivil and generic) and ramipril (Altace and generic); angiotensin receptor blockers (ARBs), such as valsartan (Diovan); and potassium-sparing diuretics, such as spironolactone (Aldactone and generic).

Dietary Sources of Potassium
  • Potato, baked with skin,925mg
  • Avocado,1/2 cup, 585mg
  • Yogurt, plain low fat, 8oz, 575mg
  • Beans, boiled black,lentils,lima, kidney,pinto,1/2 Cup, 305to485mg
  • Greens, cooked spinach,swiss chard, 1/2 Cup, 420 to 480mg
  • Orange juice, 8oz, 475mg
  • Squash, winter, 1/2Cup, 450mg
  • Artichioke,medium, 425mg
  • Banana, meduim,420mg
  • Milk,skim,8oz, 410mg
  • Recommended daily intake for men and women, 4700mg
Magnesium together with potassium, helps to bolster bone by improving calcium absorption. Magnesium also protects against abnormal heart rhythems, blood clots, and high glucose levels.

Magnesium might be especially important for warding off or controlling type 2 diabetes. Several large studies have found that people who consume the most magnesium are less likely to develop type 2 diabetes or a contributing factor for it called insulin resistance.

People who already have the disease should talk to their doctor about supplemental magnesium, since evidence suggests that they might get help with long-term blood sugar control.

Dietary Sources of Magnesium
  • Halibut, 3oz, 90mg
  • Nuts, Almonds, cashews, peanuts, 1oz, 50-80mg
  • Spinach, cooked,1/2 Cup, 75mg
  • Yogurt, plain low fat, 8oz, 45mg
  • Beans, Baked,kidney,pinto, 1/2 Cup, 35-40mg
  • Avocado,1/2 Cup, 30mg
  • Banana, medium,30mg
  • Cereal, Oatmeal, 1/2 Cup, 30mg
  • Milk, Skim, 8oz,30mg
  • Recommended daily intake: Men 420mg; Women 320mg; Upper limit from supplements 350mg; no limit from food
About 60% of men and 80% of women don't get enough calcium from their diets. For years, the advice has been to make up the shortfall with supplements, but new research provides an argument for getting more from food.

The analysis, published online in August 2010 by the British Medical Journal, combined the results of 11 trials involving some 12,000 older people. Researchers concluded that treating 1,000 people with supplemental calcium for five years would prevent 26 fractures but would also lead to an additional 14 heart attacks, 10 strokes and 13 deaths. The analysis however did not look at studies that combined calcium with vitamin D, and evidence suggests that the combination more effectively prevents fractures. In addition, consuming healthy amounts of calcium, especially from food, might protect health in other ways, such as lowering blood pressure, helping to prevent breast and colon cancer, and easing premenstrual syndrome.

Altogether, the research provides an argument for getting most of your calcium from dietary sources. Aim for a least three daily servings of dairy or calcium-rich foods. If you do opt for a calcium pill, consider one that also contains vitamin D. Look for products with the "USP verified" seal on the label, which indicates that they meet quality standards set by the nonprofit U.S. Pharmacopoeia.

Dietary Sources of Calcium
  • Yogurt, Plain, low fat,8oz, 415mg
  • Sardines, with bones, canned, 30z, 325mg
  • Milk, skim,8oz, 300mg
  • Tofu,firm, made with calcium sulfate, 1/2 Cup, 300mg
  • Cheese, cheddar, mozzarella, 1oz, 185 to 205mg
  • Pink Salmon, with bones, canned, 3oz, 180mg
  • Greens, cooked, kale, spinach, turnip greens, 1/2 Cup, 50 to 120mg
  • Beans, boiled, great northern,navy, white, 1/2Cup, 60 to 80mg
  • Nuts, almonds, brazil, 1oz, 45 to 70mg
  • Orange, medium,60mg
  • Recommedned daily intake for men under 50 and premenopaausal women, 1000mg; Men 50 to 65, 1200mg; Men older than 65 and postmenopausal women 1200 to 1500mg; Upper limit from food and supplements, 2500mg
For lowering blood pressure, the most striking effect comes from cutting sodium from your diet while boosting the intake of potassium, magnesium and calcium. People who slash sodium intake to around 1500mg daily can drop their blod pressure by as much as 11 millimeters of mercury.(Blood pressure is measured in millimeters of mercury for both diastolic and systolic pressure).

Watching your sodium intake has other benefits too. Some studies have linked sodium to worsened asthma and an increased risk of stomach cancer; and, because sodium increases the excretion of calcium in urine, it could cause bone loss and kidney stones.

Because most sodium comes from processed, packaged, and restaurant foods, it's hard to cut back to 1500 mg without cooking from scratch most of the time and eating more fresh foods. For people with normal blood pressure and no risk factors, a more modest goal of 2300mg daily might help the upward creep of blood pressure that tends to occur with age.

Making the extra effort to cut back even further is warranted if you're African-American or have a family history of high blood pressure, or if your blood pressure is high or high-normal.

Consumer Reports on Health

Reduce Your Fall Risk
Age related changes in the inner ear can affect your hearing and your balance. Impaired hearing is one of the most common conditions in older adults. According to the National Institutes of Health (NIH), it affects 75% of those age 85 and older. It can make communication difficult and cause social isolation and depression; but, its effects can also can be more physical, because the inner ear is closely associated with balance - a fact underlined by recent research associating hearing loss with walking difficulties that increase the risk of falls.

It's normal with aging to experience a decline in both hearing and the balance nerve cells located in the inner ear. The latter control balance by providing ongoing feedback via nerve signals to the brain about the head's motion and position relative to gravity. Studies have shown that the reduction in the number of nerve cells in the vestibular system of the inner ear begins at about age 55. There can also be a decline in the nerve cells of the cerebellum - an area of the brain that is involved in balance and posture - and the brain stem, which receive those signals. In spite of any other health factors that may be involved, the study published in the Journal of the American Geriatrics Society does show a correlation between hearing loss and walking difficulties.

Taking steps to preserve your hearing could potentially improve your balance and help you avoid the walking difficulties that could put you at risk of falls. If you are suffering from dizziness or unsteadiness that affects your balance, consult with your doctor who can take steps to ensure that your vestibular system is functioning properly.

UCLA Medical Center, Division of Geriatrics

In the summer we all spend plenty of hours in the sun, so should you be concerned about melanoma - the deadliest form of skin cancer?

The rate of melanoma is rising more rapidly than that of any other cancer. The incidence has increased not only among younger (under age 30) Americans, but also among those age 60 and over.Older men in particular, have higher melanoma incidence and mortality rates than the general population. This year nearly 8,000 people will die of the disease, according to the National Cancer Institute, and about half of them will be white men over the age of 50.

Play it safe in the sun by observing the following tips:

  • First and foremost, limit sun exposure - especially from 10AM to 4PM, when the sun's rays are strongest.
  • Never use tanning beds or sun lamps, which can increase the melanoma risk.
  • Wear a wide-brimmed hat and sunglasses that protect your eyes from ultraviolet A and B rays (UVA and UVB).
  • Wear long sleeves and pants made with tightly woven fabrics.
  • Sit in the shade or under an umbrella at the beach, even if it's cloudy.
  • Wear sunscreen with a 30SPF or higher with wide spectrum UVA and UVB protection. Reapply often and liberally, especially after swimming or exercise. Consider using sun-screen with zinc oxide or titanium dioxide, physical sun blocking agents that offer maximum protection.
  • And finally, remember that you can get melanoma even if you wear sunscreen. Use it in conjunction with other measures.
Johns Hopkins Medical Letter, Health after 50

Living Safely On Your Own
According to the U.S. Census Bureau, more than six million adults age 75 and older lived alone in 2006. For many, the principal reason in doing so is independence; but it isn't always easy if struggling with a chronic illness or some disability. Then too, living alone has its own risks. You can't assume accidents like a fall won't happen to you; but this doesn't mean you shouldn't live by yourself. The answer is preparation.

Preparation is the key to safety when living alone. Start by creating a written and detailed Action Plan that will help protect you, and comfort those who worry about you being by yourself, in the event of an emergency.

These guidelines should be incorporated into your Action Plan:

  • Decide who you will call in an emergency (911 or a friend, neighbor, family member, etc.)Tape these phone numbers to back of every phone in the house and tell the people you've selected that they are on your emergency contact list.
  • Visualize how you are going to get to the telephone.Consider where the phones are and make sure there is a phone in the rooms you frequent the most; especially, the bathroom where many falls take place. Remember, you may have to crawl or slide to a phone.
  • Have daily conversations with friends or family. This will keep you socially engaged and at the same time provide a safety net - if you don't call or answer a call the person you talk to every day will know something may be wrong.
  • Have a document in an accessible place (like on the refrigerator or the bedroom bureau), listing your name SSA number, insurance information, and all other important medical information.
  • Consider getting a personal emergency response system that is worn around the neck or wrist. These allow you to press a button that immediately contacts emergency personnel in case of an accident.
  • Prepare your home. Home modifications will help preserve your independence and your safety. You can install simple solutions yourself - like high-watt-low energy light bulbs and nonslip pads on stairs, bathroom tiles, and furniture. Ask you doctor to prescribe a home evaluation in order to have a physical or occupational therapist assess your home and decide which medical equipment or renovations would be best for you. Medicare may pay for evaluations and equipment if deemed medically necessary.
If you decide that you need help, visit these web-sites for information regarding home care agencies in or near your area:
  • Medicare (www.medicare.gov) Scroll down to the bottom left of the home page to find the link "Compare Home Health Agencies In Your Area". Click to find Medicare approved home health agencies near you, along with information on your rights as a home health patient and what to expect when you hire an aide or nurse.
  • Eldercare (www.eldercare.gov/Eldercare.net) This web-site allows you to search by zip code, city, or state to find caretaker resources, along with other helpful news regarding living alone and aging.
  • Independent Living Centers (www.virtualcil.net/cils) to locate organizations in your area that help older people who live alone.
Johns Hopkins Medical Letter

ANGINA, What is it?
Angina,usually marked by discomfort in the chest, is one of the most ubiquitous signs of cardiovascular disease. This intermittent condition affects more that 9.8 million Americans, according to the American Heart Association. Pain from angina is a warning sign that the heart muscle is not getting enough oxygenated blood.

The most common cause of angina is coronary heart disease, defined by narrowing or blockages in the coronary arteries, which carry the blood to the heart. As we age, arteries can become clogged with a cholesterol-laden substance called plaque, particularily in those who smoke, are sedentary, are obese, or who consume a diet high in saturated fats.

Classic angina symptoms include heaviness, aching, or pressure below the breastbone. During a typical episode of angina, cardiac nerves and pain receptors in the heart convey feelings of chest discomfort to the brain. Also, there are the less traditional symptoms, including shortness of breath, nausea, tingling, sweating, dizziness and pain in the teeth.

Women are more likely than men to experience the less traditional symptoms. The concern is that some women may ignore these symptoms because they do not recognize them as angina.

It must be added that chest pain doesn't always signal angina. Other potrential sources of chest discomfort include acid reflux, a pulled muscle or muscle tension, gallstones, inflammation in the cartilage of the ribs, and problems in the spine's cervical region. This said, it is best to remember that ANY chest discomfort warrants and examination by your doctor.

Johns Hopkins Medical Letter

A Medication Reminder
Taking medication as prescribed is an essential part of caring for yourself while you are ill, but a recent study from Emory University found that 20-50% of patients take their medications incorrectly. Reminders, like pill boxes labeled with days of the week can help people keep track of their medications. And now the federal Agency for Healthcare Research and Quality (AHRQ) has created a pill card to give you another way to remember what you need to take and how to take it.

You can find the AHRQ card template on the Internet at ( www.ahrq.gov/qual/pillcard/pillcard.htm) and print it out or save it to your personal computer so you can customize it with your own medication instructions.

To avoid medication mix-ups, the AHRQ recommends that you describe each type of pill - its shape and color, for instance - and note any distinct markings if two pills look alike. To help with this, the AHRQ website contains images of pills that you can copy, color on the computer, and add to your pill card. You can also do this by hand.

Keep your pill card near your medications or in a visible place, like on the refrigerator or bathroom mirror.

Review your pill card with your doctor periodically to make sure that your dosages are correct and that you're not still taking anything that you do not need. Also, check with your pharmacist if you notice a change in the color, shape or size of your pills - generic medicines in particular often change appearance.

The Johns Hopkins Medical Letter

Potentially Inappropriate Drugs for Older Adults
As the years add up, it's not unusual for the number of daily medications we take to increase.Older persons may have trouble tolerating medications better suited for younger patients.

One of the most important steps you can take to protect yourself is to supply all of your doctors, particularly specialists, with as complete a medical status as possible, including a list of conditions you have and the drugs and supplements you take.

The following 33 drugs are considered to be potentially inappropriate for patients 65 years of age and older and may result in various adverse effects:

DRUG(generic/brand name) ADVERSE EFFECTS

  • Barbiturates(Nembutol, Mebarol, Amobarbital, Butabarbital, Pentabarbital, Secobarbital) Highly addictive,more adverse effects than most sedatives
  • Flurazepam(Dalmane, Somnol, Novo-Flupam, Apo-Flurazepam)May cause Central Nervous System (CNS) problems
  • Meprobamate(Equanil, Meprospan 200, Meprospan 400, Probate, Apo-Meprobamate Highly addictive
  • Chlorpropamide(Diabinese, NovoPropamide, Apo-Chlorpropamide)Prolonged hypoglycemia-Low blood sugar
  • Meperidine(Demerol) Confusion,CNS problems
  • Pentazocine(Talwin, Talwin Nx)Confusion,Hallucinations
  • Trimethobenzamide(Tigan,Stemetic,Tebamide, Tribenzagan, Trimazide)Can effect motor control
  • Belladonna alkaloids(Donnatal,Barbidonna)Hallucinations,confusion
  • Dicylomine(Bentyl, Bentylol, Spasmoban, Formulex) Nausea,Hallucinations
  • Hyoscyamine(Levsin,Hyosol, A-Spas-S/L, Cystospaz, Levbid, Levsinex Timecaps, Symax SL) Arrhythmia,dizziness,blurred vision
  • Propantheline(Pro-Banthine)Arrhythmia,dizziness,blurred vision
  • Carisoprodol(Soma,Vanadom)Poorly tolerated,weakness
  • Chlorzoxazone(Parafon Forte DSC, Remular-S, Paraflex) Poorly tolerated,weakness
  • Cyclobenzaprine(Flexeril)Poorly tolerated,weakness
  • Metaxalone(Skelaxin)Poorly tolerated,weakness,sedation
  • Methocarbamol(Robaxin)Poorly tolerated,weakness,sedation
  • Amitriptyline(Elavil)Poorly tolerated,sedative effects unpleasant
  • Chlordiazepoxide(Librium)Strong sedation,Adverse CNS effects
  • Diazepam(Valium)Prolonged sedation,risk of falls
  • Doxepin(Sinequan)Poorly tolerated,sedative effects unpleasant
  • Indomethacin(Indocin)Adverse CNS effects
  • Dipyridamole(Persatine)Sudden blood pressure drop
  • Ticlopidine(Ticlid)Anti-clotting,more toxic than aspirin
  • Methyldopa(Aldomet,Aldoril)Low resting heart rate,exacerbate depression
  • Reserpine(Harmonyl, Serpasil, Serpalan, Novoreserpine) Depression,sedation, blood pressure drop
  • Dispyramide(Norpace, Norpace CR)Could induce heart failure,other complications
  • Oxybutynin(Ditropan,Ditropan XL,Oxytrol)Weakness, sedation, poor tolerance
  • Chlorpheniramine(Chlor-Trimeton,Aller-Chlor, Chlorate, Chlo-Amine)Increased heart rate,disorientation
  • Cyproheptadine(Periactin)Increased heart rate, disorientation
  • Diphenhydramine(Benadryl,Nytol)Increased heart rate, disorientation
  • Hydroxyzine(Vistaril,Rezine, Atarax)Increased heart rate, disorientation
  • Promethazine(Pheneragan, Promacot)Increased heart rate, disorientation
  • Propoxyphene(Darvon, Darvon-N)Highly addictive;avoid if depressed with suicidal thoughts.
UCLA Medical Center, Division of Geriatrics and Johns Hopkins Medical Letter, Health After 50
September 2008

Clostridium difficile, A Dangerous Superbug
There are probably very few of us who haven't been hospitalized at one time or another. Illnesses that you acquire during a stay in a hospital or longterm care facility are by no means new; however, in recent years, the infections have reached epidemic proportions in these institutions world wide. One of the most widespread and potentially serious of these illnesses is caused by the bacterium Clostridium difficile. This superbug is also known as Clostridium difficile Colitis, C.diff, C.difficile, Antibiotic Associated Colitis, CD, AACD and CDC.

C.difficile is a rising threat. Few Americans had heard of this intestinal bug until a study sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC) showed the prevalence of C.Diff is 20 times higher than previous estimates. Findings suggest that on a average day, nearly 7,200 hospitalized patients - 13 of every 100- are colonized or, more often, infected with C.diff, and about 300 patients will not survive it.

C.difficile bacteria are everywhere in the environment. Three percent of healthy humans carry it in the gut, but carriage rates in hospital patients tend to be much higher, and elderly persons being treated with antibiotics are most at risk of developing infections.This happens because the antibiotics administered kill the "friendly" gut flora and C.Diff flourishes as a result. In fact, Hospital infections kill 90,000 Americans a year. These bacteria produce spores when they encounter unfavorable conditions. Transmission of infection is through the ingestion of these spores which can survive on surfaces, floors and even clothing for years and, with the exception of chlorine bleach, are resistant to many disinfectants and antiseptics, including alcohol hand gel. Do not conclude that C.difficile is confined exclusively to hospitals and similar institutions. It's also a growing problem among otherwise healthy people and the problem is growing worse. It is, according to the Centers for Disease Control, responsible for tens of thousands of cases of diarrhea.

Some people who are infected with C.difficile never become sick, though they can still spread the infection. Others have bouts of watery diarrhea with nausea and abdominal pain and cramping. And, an increasing number of persons develop severe inflammations of the colon. Complications of C.difficile infections include dehydration, kidney failure, bowel perforation, toxic megacolon and death. Signs and symptoms of this potentially life threatening illness include profuse, watery diarrhea 10 or more times a day, a fever, often greater than 101F, abdominal pain which may be severe, blood or pus in the stool, nausea, dehydration and weight loss.

Although more people with no known risk factors, including children, are contracting C.difficile infections, your risk is greatest if you:

    Are taking or recently have taken antibiotics, especially ampicillin, amoxicillin, clindamycin, fluoroquinolones and cephalosporins. Other antimicrobials, including antiviral and antifungal drugs, and chemotherapy medications also can lead to increased risk.

    Are 65 years of age or older. Older adults have a disproportionately high infection rate.

    Have a serious underlying illness or weakened immune system.

    Are or have recently been hospitalized, especially for an extended period. In general, larger hospitals have higher infection rates than do smaller hospitals.

    Live in a nursing home or longterm care facility. Often the infection spreads when patients are transferred from hospitals to other facilities.

    Have had abdominal surgery.

    Have a chronic colon disease such as inflammatory bowel disease or colorectal cancer.

    Take prescription or over-the-counter antacids. By reducing stomach acid, these drugs may allow C.difficile to pass more easily into the intestine.

    Have had a previous C.difficile infection.

Among the steps you can take to stop C.difficile from infecting you is to take antibiotics only when absolutely necessary and, even then, ask your Doctor to prescribe one that has a narrow range that you take for the shortest period of time so as to disrupt intestinal bacteria the least. You my also consider Probiotic Supplements which help replace beneficial bacteria that antibiotics destroy. Only Saccharomyces boulardi has proved effective in C.difficile infections however. Last of all, the simplest and one of the best preventatives is to wash, wash, wash your hands! See Hand Washing 101 article on this same Health Alerts Page.

To learn more, Consumers Union offers information on states requiring hospitals to report infection rates. Go to www.stophospitalinfections.org/learn.html and click on "State Hospital Infection Disclosure Laws." Also, the Leapfrog Groups website www.leapfroggroup.org provides ratings of 1,300 U.S. hospitals and information on infection prevention measures. You can also Google the Centers for Medicare & Medicaid Services, at hospitalcompare.hhs.gov that reports quality information on hospitals. The Committee to Reduce Infection Deaths, hospitalinfection.org. and finally, the Society for Healthcare Epidemiology of America. Go to shea-online.org and click on "Patient Guides."

Society for General Microbiology

Mayo Clinic

The Association for Professionals in Infection Control and Epidemiology

Calcium Supplements - How much REALLY?
Many people take calcium supplements to help stave off bone loss, but how much calcium you actually get from a supplement is not as straightforward as it may seem. In nature, calcium exists only as a compound (such as calcium carbonate or calcium citrate). Each compound contains a different amount of "elemental" calcium which is the important ingredient needed for bone health.

When you take a calcium supplement, it's the amount of elemental calcium that's the key to bone health. If the amount isn't clearly stated on the bottle, check the Nutrition Facts label, which will include how much elemental calcium - often listed simply as "calcium" - is in a serving size. The following example illustrates the point. Tums Ultra 1000 contains 1,000mg of calcium carbonate per tablet, BUT only 40% of the calcium carbonate is elemental calcium, meaning one tablet has only 400mg of the essential mineral needed.

Too many times the recommended serving size on the supplement label does not meet your daily calcium requirement. Again using the same simple example, Tums Ultra 1000 lists a serving size as two tablets, adding up to 800mg of calcium - not nearly enough for adults over the age of 50, who should get 1,200 to 1,500mg a day.

If you have questions about the correct dosage, ask your doctor or health care provider how many pills you should take per day. Also, it's best to spread out your daily dosage of calcium so you don't take more than 600mg of elemental calcium at one time; the body absorbs larger amounts less efficiently. Finally, take calcium carbonate with meals, because this type of calcium is absorbed better in the presence of stomach acid.

The Johns Hopkins Medical Letter

Heart Failure
The words "heart failure" certainly sound scary. If you've been told that you have heart failure or you're at risk, you may fear that your heart is about to quit working at any second! What heart failure really means is that your heart isn't working as well as it should. Your heart muscle has weakened, and it can't pump enough oxygen-rich blood to meet all of your body's needs. With proper treatment, many people with heart failure experience an improvement of symptoms and heart function and live relatively normal lives.

If you've been diagnosed with heart failure or have been told that you may be at risk, it's important that you work with your doctor to develop a treatment plan that addresses your needs and the severity of your disease. The two basic components of most treatment plans are medication and lifestyle changes.

The best way to respond to heart failure is to educate yourself, listen to your doctor's advice and pay attention to what your body is telling you.

Warning signs of heart failure tend to develop gradually. Because they come on slowly, in the disease's early stages, signs and symptoms may be missed or attributed to another condition. Here are some of the most common signs and symptoms of heart failure and some of what causes them.

Shortness of Breath- Because the heart can't pump blood fast enough, it "backs up" in the veins that connect the lungs to the heart causing fluid to leak into the lungs, producing shortness of breath, especially when lying down.

Cough or Wheezing-Similar to shortness of breath, the leaking fluid into the lungs produces a cough or wheeze.

Swelling of Body Tissues-When blood flow back to the heart slows, fluid builds up in tissues such as the lungs, feet, legs and abdomen. The kidneys also become less efficient in disposing of water and sodium. making tissues more susceptible to fluid retention.

Weight Gain- Fluid retention causes weight gain

Fatigue-With a reduced supply of freshly oxygenated blood to meet the body's needs, blood is diverted away from less vital organs, particularly muscles in the arms and legs, making them more susceptible to fatigue.

Reduced Appetite and Nausea-The digestive system receives less blood, thereby reducing appetite and causing digestive problems.

Difficulty Concentrating-Changes in blood components, such as an increase in sodium, can affect alertness, as can not getting enough blood to the brain.

Increased Heart Rate-To try to make up for its reduced capacity to pump blood, the heart beats faster.

Mayo Clinic Health Letter Special Report

Should You Have Surgery For Sciatica?
If you have sciatica and find that rest and pain medication are not working to relieve your pain, should you consider surgery? Recent research provides the answer.

Sciatica refers to leg pain caused by a herniated disk in the spine that presses on the sciatic nerve. People with sciatica often experience intense pain that radiates into the buttocks, down the thighs, and into the calves, and often into the feet.

Surgery can provide fast pain relief for sciatica, but you might do just as well without an operation, a study finds.

In this study, researchers randomly assigned 281 people with sciatica for at least six weeks to have surgery to decompress the nerve; or, to receive conservative treatments such as pain medication and exercise. On average, people who had sciatica surgery felt their leg pain was better after four weeks while it took about 12 weeks for those who did not have surgery to note improvement. But within one year, 95% of the study participants said they felt significantly better, no matter which sciatica treatment they had.

Bottom line advice: If you are experiencing searing pain or numbness in your leg from sciatica and conservative treatment is not working, then surgery may be right for you. On the other hand, if you feel you can handle the leg pain and are willing to postpone sciatica surgery, you might find that you don't need it. Always discuss options with your doctor.

The New England Journal of MedicineVolume 356, page 2245

Hand Washing 101
One of the things that you didn't learn in kindergarten and, in all probability, didn't learn from your Mom either is how to effectively wash your hands! That may sound silly to you but, in truth, the best defense against bacteria, even the dreaded super-bugs like Methicillin-resistant Staphylococcus (MRSA) and Clostridium difficile (C.diff), is to keep your hands scrupulously clean. This is how you should do it:

Use warm water, not hot water and not cold water because hot water is hard on the hands and cold water will inhibit the sudsing of soap.

Next, you do not have to use expensive antibacterial soaps to try to kill the germs but you do need to work up a substantial lather of soap suds to dislodge the bacteria and suspend them in the suds.

While lathering your hands be sure to soap every millimeter of skin, including the thumbs, between the fingers, the backs of the hands and the undersides of the fingernails. Use a nail brush to be even more effective.

Now rinse your hands thoroughly with warm water to remove every last trace of soap suds (and germs).

Now that you have done such a great job, do not negate you efforts by grabbing the faucet tap (loaded with germs) or a door knob (especially in a public restroom). Instead use a paper towel to shut off the water and to open the door. That will go a long way in preserving the cleanliness of your hands.

Last of all - teach a child how to wash his or her hands!

How Low Should You Go?
Aggressively treating high blood pressure may not be good medicine after age 80, according to a new study reported in the Journal of the American Geriatrics Society (Volume 55, page 383)

In this study, researchers looked at the medical records of more that 4,000 veterans age 80 and older with high blood pressure. Participants who lowered their blood pressure to just below the upper limit of normal - 139/89 mm Hg - were less likely to die of any cause over a five year period than those who reduced their blood pressure to lower levels. This relationship held when the researchers took into account other illnesses that can lead to premature death.

These findings do not contradict current guidelines that recommend lowering blood pressure to below 140/90 mm Hg. But they do suggest that aggressive lowering of blood pressure beyond this level could be harmful for people over age 80, possibly because of reduced blood flow to vital organs.

If you are 80 or older and experience any symptoms of aggressive blood-pressure lowering such as dizziness, weakness, or thinking problems tell your doctor who then may make changes to your treatment regimen.

Johns Hopkins Health Alerts, Hypertension and Stroke
August 2008

Sleep Deprivation
When you are sleep deprived, cognition is one of the first functions to decline. Shortchange yourself on sleep by staying up late, continue this night after night, and you ultimately shortchange your memory. And if the problem is not resolved, your memory - and your brain - will not be functioning in the best way possible.

As people get older, a decrease begins in both the total time sleeping and the amount of time spent in the stage of sleep associated with dreaming. A newborn sleeps 16 hours per day. In contrast, the baby's 30-year-old mother sleeps six hours per day (if she's lucky), and only one quarter of this time ,or two hours, is occupied by the deepest stage of sleep.

Starting in middle age (between 46 and 60), not only does the amount of sleep per night start to decrease, but also the character of the sleep changes, People at these ages spend less time in the stage of sleep associated with dreaming and more time in the lighter stages.

As people get older, they are more likely to shift the time when they sleep, some going to bed and to sleep earlier and waking up earlier. Others are the opposite, staying up late into the night and sleeping much of the day. When people are in their 80s, these changes are even more pronounced. Their total time asleep per day may be only six or seven hours, including time spent in daytime naps. Even though a person may take several naps a day, the total time sleeping in naps is rarely over an hour. The idea that older individuals should sleep soundly for eight to ten hours is clearly wrong.

As a rule of thumb, one hour of sleep is required for two hours of being awake. As we get older, that ratio becomes closer to 45 minutes of sleep for each two hours awake. In other words, throughout the day you gradually accumulate a "sleep debt." By the end of a 16 hour day, a younger person owes the "sleep bank" eight hours. In contrast, an older person has a sleep debt of only about six hours. By the end of a week, you may have accumulated a sleep debt of 8 to 10 hours.

If you don't allow enough time for sleep, you become sleep deprived. Besides being sleepy during the daytime, sleep-deprived people often have problems with their thinking. They are slower to learn new things, they may have problems with their memory, and their ability to make judgements may be faulty, enough so that they may think they are starting to "lose it" when the real problem is not enough sleep.

Elderly people do not recover from sleep deprivation as quickly as younger people. In experimental situations where people are kept awake for 24 hours, those in their 70s take at least a day longer to recover from their subsequent daytime sleepiness than younger people. Gender may also make a difference in the time it takes to recover from sleep deprivation; women seem to be able to recover faster than men.

Johns Hopkins Memory Bulletin

Red Flag For Women
Contrary to typical portrayals in movies and on TV, heart attacks don't always have a sudden, intense onset. A recent study finds that for women, chronic chest pain may signal a future heart problem.

Although no one likes to think about having a heart attack,would you know what to do if you were? Even if you know what to do, would you follow through and more importantly, would you do it quickly?

According to the National Heart, Lung, and Blood Institute close to one million people in the United States have heart attacks each year; and, about one fifth of them die. Half of the deaths occur in the first hour after heart attack symptoms start and before the person reaches a hospital. These numbers underscore the importance of recognizing heart attack symptoms quickly and responding to these symptoms just as quickly,

Now a study in the European Heart Journal (Volume 27, page 1408) reports that for women, persistent chest pain may be a waning of future heart problems - even when a woman has no evidence of blockages in her coronary arteries.

The findings come from a study known as WISE, a government-funded project designed to evaluate chest pain in women - a task that is less straightforward than in men. The central issue is that women are much more likely than men to suffer long-term chest pain in the absence of any large artery blockages. But that doesn't mean their chest pain is innocuous.

Among women in the study with no signs of clogged arteries, those with persistent chest pain for at least a year were more that twice as likely to suffer a heart attack, stroke or other cardiovascular complication over the next five years. The study included 637 women whose chest pain and other potential symptoms of coronary heart disease were evaluated by angiography (an x-ray examination of blood vessels that can detect blockages).

The take home message is if you are a woman, you should not simply live with chronic chest pain if angiography fails to detect artery blockages. Instead, you should ask your doctor about ways you can reduce any heart risk factors you have. Remember, a healthy diet and regular physical activity are two of the most important ways.

Johns Hopkins Health Alerts


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