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  • January 14, 2022

    By Allison Larson, MD

    Whether you’re a winter sports enthusiast or spend the season curled up by the fireplace, the low humidity, bitter winds, and dry indoor heat that accompany cold weather can deplete your skin’s natural moisture. Dry skin is not only painful, uncomfortable, and irritating; it also can lead to skin conditions such as eczema, which results in itchy, red, bumpy skin patches. 


    Follow these six tips to prevent and treat skin damage caused by winter dryness.


    1. Do: Wear sunscreen all year long.

    UV rays can easily penetrate cloudy skies to dry out exposed skin. And when the sun is shining, snow and ice reflect its rays, increasing UV exposure. 


    Getting a sunburn can cause severe dryness, premature aging of the skin, and skin cancer. Snow or shine, apply sunscreen before participating in any outdoor activity during the winter—especially if you take a tropical vacation to escape the cold; your skin is less accustomed to sunlight and more likely to burn quickly.


    The American Academy of Dermatology (AAD) recommends sunscreen that offers protection against both UVA and UVB rays, and offers a sun protection factor (SPF) of at least 30.


    That being said, if you are considering laser skin treatments to reduce wrinkles, hair, blemishes, or acne scars, winter is a better time to receive these procedures. Sun exposure shortly after a treatment increases the risk of hyperpigmentation (darkening of the skin), and people are less likely to spend time outside during the winter.


    Related reading: 7 Simple Ways to Protect Your Skin in the Sun

    2. Do: Skip products with drying ingredients.

    Soaps or facial products you use in warm weather with no issues may irritate your skin during colder seasons. This is because they contain ingredients that can cause dryness, but the effects aren’t noticeable until they’re worsened by the dry winter climate.

    You may need to take a break from:

    • Anti-acne medications containing benzoyl peroxide or salicylic acid
    • Antibacterial and detergent-based soap
    • Anything containing fragrance, from soap to hand sanitizer

    Hand washing and the use of hand sanitizer, which contains a high level of skin-drying alcohol, cannot be avoided; we need to maintain good hand hygiene to stop the spread of germs. If your job or lifestyle requires frequent hand washing or sanitizing, routinely apply hand cream throughout the day as well.


    During the COVID-19 pandemic, I have seen a lot of people develop hand dermatitis—a condition with itchy, burning skin that can swell and blister—due to constant hand washing. Sometimes the fix is as simple as changing the soap they're using. Sensitive-skin soap is the best product for dry skin; it typically foams up less but still cleans the skin efficiently.


    3. Do: Pay closer attention to thick skin.

    Areas of thin skin, such as the face and backs of your hands, are usually exposed to the wind and sun the most. It’s easy to tell when they start drying out. But the thick skin on your palms and bottoms of your feet is also prone to dryness—and tends to receive less attention.


    When thick skin gets dry, fissures form. You’ll see the surface turn white and scaly; then deep, linear cracks will appear. It isn’t as pliable as thin skin. When you’re constantly on your feet or using your hands to work, cook, and everything in between, dry thick skin cracks instead of flexing with your movements. 


    To soften cracked skin, gently massage a heavy-duty moisturizer—such as Vaseline—into the affected area once or twice a day. You can also talk with your doctor about using a skin-safe adhesive to close the fissures and help them heal faster.


    Related reading:  Follow these 5 Tips for Healthy Skin

    4. Don’t believe the myth that drinking more water will fix dry skin.

    Contrary to popular belief, the amount of water or fluids you drink does not play a major role in skin hydration—unless you’re severely dehydrated. In the winter, especially, dry skin is caused by external elements; it should be treated from the outside as well. 


    The best way to keep skin hydrated and healthy is to apply fragrance-free cream or ointment—not lotion—to damp skin after a shower or bath.
    Some people need additional moisturizers for their hands, legs, or other areas prone to dryness.

    While some lotions are made better than others, most are a combination of water and powder that evaporates quickly. Creams and ointments work better because they contain ingredients that can help rebuild your skin barrier. 

    Look for products with ceramide, a fatty acid that helps rebuild the fat and protein barrier that holds your skin cells together. The AAD also recommends moisturizing ingredients such as:

    • Dimethicone
    • Glycerin
    • Jojoba oil
    • Lanolin
    • Mineral oil
    • Petrolatum
    • Shea butter

    For severely dry skin, you can try a “wet wrap” technique:

    1. Rinse a pair of tight-fitting pajamas in warm water and wring them out so they’re damp, not wet.
    2. Apply cream or ointment to your skin.
    3. Put on the damp pajamas, followed by a pair of dry pajamas, and wear the ensemble for several hours.

    Dampness makes your skin more permeable and better able to absorb hydrating products. If the wet wrap or over-the-counter products aren’t working for you, talk with a dermatologist about prescription skin hydration options. 

    Drinking more water isn’t the answer to dry winter skin. The best solution is to apply fragrance-free cream or ointment directly to damp skin. Get more cold weather #SkinCareTips from a dermatologist in this blog: https://bit.ly/3KbVUA1.
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    5. Don’t confuse skin conditions with dryness.

    Skin conditions are often mistaken for dry skin because peeling or flaking are common symptoms. Redness of the skin or itching in addition to dryness and flaking indicates a skin condition that may need more than an over-the-counter moisturizer.


    Skin cells are anchored together by a lipid and protein layer (like a brick and mortar wall). With very dry skin, the seal on this wall or barrier is not fully intact and water evaporates out of the skin’s surface. The skin will become itchy and red in addition to scaly or flaky. If you experience these symptoms, visit with a dermatologist.

    6. Don’t wait for symptoms to take care of dry skin.

    Be proactive—the best way to maintain moisture is to apply hydrating creams and ointments directly to your skin on a regular basis. Start by applying them as part of your morning routine. Once you get used to that, add a nighttime application. And carry a container of it when you’re on the go or keep it in an easily accessible location at work.

     

    You can’t avoid dry air, but you can take precautions to reduce its harsh effects on your skin. If over-the-counter products don’t seem to help, our dermatologists can provide an individualized treatment plan. Hydrated skin is healthy skin!


    Does your skin get drier as the air gets colder?

    Our dermatologists can help.

    Call 202-877-DOCS (3627) or Request an Appointment

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  • July 23, 2018

    By MedStar Health

    Research shows that running is a great way to reduce stress, stay in shape, and lose weight. But, as many both new and experienced runners know, it can also come with its fair share of running injuries.

    What are the most common running injuries?

    Forty-two percent of all running-related injuries affect the knee. The most common running ailments are:

    • Patellofemoral pain: pain around the kneecap
    • IT band issues: pain around the outside of the knee
    • Plantar fasciitis: pain in the arch or heel of the foot
    • Shin problems: usually bone pain, typically the tibia

    What makes runners so prone to these injuries?

    Most running-related injuries are due to overuse, meaning they stem from overtraining and improper techniques.

    A lot of these injuries also come from muscular imbalances. Weak hip muscles and tight ankles, for example, are issues that are common within the general population. Training errors combined with these imbalances tend to make runners more prone to injury.

    Despite the fact that there are a number of potential injuries related to running, these injuries are typically quick fixes. That’s GREAT news for runners!

    What are some signs of running injuries?

    Overuse injuries tend to come on gradually, unlike instantaneous issues. Because of this gradual development, our bodies typically send us a few warning signs.

    If the problem is tendon pain, runners will usually experience stiffness and soreness, specifically at the beginning of their workout. As they continue exercising, this pain tends to dissipate.

    With a bone-stress injury, runners may experience tenderness directly on or over a bone. Unlike tendon pain, this pain tends to get worse as you run. Worsening pain is a definite red flag, and might be a sign that an X-ray or MRI is in order to determine the root cause of the pain.

    Treating different types of running pain

    Whether you’ve been running for years or just started last week, figuring out the seriousness of an injury can be tough. The more you run, the more familiar you will become with your own body and the types of pain you may experience.

    Some injuries are self-treatable. For example, if you’re experiencing tightness, you can stretch more or try foam-rolling.

    Other injuries may require some—dare I say it— time off. One common problem that runners face is that they don’t typically like to stop running, and that’s okay. While you may need to scale back on your training, recovery can still be active. Runners can try slowing down, shortening their runs, or even participating in some other type of cardio exercise, like biking or swimming. If no improvement is made after recovery or rest, it might be time to see a medical professional.

    The key to finding the right physician is seeking out someone who knows and understands runners and running fundamentals. These specialists are more likely to suggest modifications to training, rather than those two, dreaded words: “stop running.”

    How can I reduce my risk of a running injury?

    One of the most effective ways to reduce your risk of running-related injury is to cross-train. This concept might be foreign, as many runners tend to be focus solely on running when it comes to their exercise. However, biking, swimming, running on an anti-gravity treadmill, and strength and flexibility training are all key aspects of a well-rounded running program. While increasing speed and mileage are important, being inclusive with your workouts will keep you balanced, and reduce your risk of developing an overuse injury.

    Choosing the right pair of running shoes can also be crucial to your training and injury prevention. Running specialty stores have specialists who will analyze your gait and make recommendations on the right shoe category for you.

    One more key element of a well-rounded routine is implementing a solid warmup, such as a slow jog or dynamic stretching before you run. Getting your body acclimated to the exercise prior to jumping right in can also help prevent injury.

    Is running worth the injury risk?

    Y-E-S, yes!

    By-and-large, running is very healthy. It can reduce stress, help with weight management, and aid in lowering blood pressure. By far, these benefits outweigh the injury risks.

    Although many running myths insinuate that running can cause knee and other joint issues, there is no research to back up these claims. In fact, there is a much higher percentage of the general population who need knee and joint replacements than those in the running population. The number-one factor that leads to these types of procedures is obesity, which runners tend to avoid.


    Want more insight?

    Get ready for your next running event with the experts at MedStar Health. Watch as we tackle the most common running injuries (and how to treat them), nutrition, and advances in sports medicine training technology.

    Want to learn more about how we can help you live a healthy life? Click the button below to view the list of our services.

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  • July 17, 2018

    By Susmeeta Tewari Sharma, MD

    As the American Cancer Society notes, doctors diagnose about 10,000 pituitary tumors each year in the United States. However, that’s actually just a fraction of the number of tumors that people likely develop on their pituitary glands. If you picture 100 people in a room, about 10 to 15 of them could develop a pituitary tumor sometime during their lives. In fact, one review of multiple studies found that the prevalence of benign (noncancerous) pituitary tumors is approximately 17 percent.

    Pituitary tumors are quite common, and some types are much more so than others. However, all pituitary tumors have one similar quality: They require an expert team to spot the symptoms, make an accurate diagnosis and provide the right treatment. Pituitary tumors are classified by the type of hormones they secrete. Each type of tumor causes different symptoms and can require different treatments.

    LISTEN: Dr. Sharma discusses pituitary tumor symptoms and treatments on the Medical Intel podcast.

    Prolactin-secreting pituitary tumors

    Symptoms

    Prolactin-secreting pituitary tumors, also known as lactotroph adenomas, are among the most common pituitary tumors we see. These account for about 40 percent of pituitary tumors. These tumors are functional, which means they secrete hormones—specifically prolactin, a hormone involved in the development of the glands that produce breast milk.

    When a pituitary tumor produces prolactin, it throws off the body’s natural levels. In women, this can lead to a number of symptoms, including:

    • Breast pain
    • Feeling of breast fullness
    • Infertility
    • Irregular periods
    • Unnecessary breast milk production

    Men’s symptoms can include:

    • Decreased hair growth
    • Decreased sex drive
    • Erectile dysfunction
    • Infertility
    • Low energy levels

    These symptoms can appear for other reasons besides a pituitary tumor. Our first step always is to assess a patient’s hormone levels to see if they are out of normal range. If they are, we then can take the next steps to confirm whether it’s because of a pituitary tumor. We can use magnetic resonance imaging (MRI) or other scans to examine the pituitary gland and the surrounding area inside the brain.

    Early diagnosis is key. Without treatment, a growing pituitary tumor can compress the pituitary gland and prevent it from releasing life-sustaining hormones, including cortisol (which affects metabolism and immune response) and thyroid-stimulating hormone (TSH, which affects the thyroid, metabolism, heart, digestive system, muscle control and other areas). A large pituitary tumor also can cause vision problems as it compresses the optic nerves, which relay information from the eyes to the brain.

     
    Without treatment, a #pituitary tumor can block the release of life-sustaining #hormones to the body. bit.ly/2zO5TLM via @MedStarWHC

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    Treatment

    We can treat 80 to 90 percent of prolactin-secreting tumors successfully with medications called dopamine agonists. These drugs shrink the tumor and, over time, keep it from releasing too much prolactin.

    We used this approach to treat a young man who had been referred to the MedStar Pituitary Center after he had failed the vision test for his driver’s license. His eye doctor referred him to Dr. Martin P. Kolsky, a neuro-ophthalmologist on our team. Dr. Kolsky found that this patient had a loss of peripheral vision on both sides, which can be caused by a pituitary tumor. The patient’s MRI showed a large tumor compressing his optic nerves.

    Ordinarily, large tumors require surgery. But we found that his prolactin level was close to 6,000 nanograms per milliliter (ng/ml), even though the normal level for a man is less than 23 ng/mL. This result led us to instead prescribe a medication called cabergoline, which is returning his prolactin to normal levels and shrinking his tumor. As of January 2018, his tumor was about 60 percent smaller, he had regained full vision in both eyes, and we are hopeful that the tumor will continue to shrink without the need for surgery.

    Growth-hormone-secreting pituitary tumors

    Symptoms

    Growth-hormone-secreting tumors, also known as somatotroph adenomas, are a little less common. These account for 20 percent of the pituitary tumors doctors diagnose. Growth hormone, or GH, regulates the body’s normal growth processes. In children who are still growing, too much GH can lead to gigantism, which causes a child to grow very tall. However, if a patient is done growing, excessive GH can cause acromegaly, a condition that can cause:

    Treatment

    Our first step when we suspect a growth-hormone-secreting tumor is to test the patient’s hormone levels. We need to make sure they don’t have a very rare co-secreting tumor, also known as a plurihormonal adenoma, that makes more than one type of hormone.

    The next step is surgery to remove the tumor. These tumors often are larger than other types because the changes in a patient’s features can be hard to notice right away and thus difficult to detect early. And sometimes, the symptoms are misdiagnosed as something else entirely.

    For example, we had a patient who originally went to a dental surgeon for jaw surgery. His main complaint was that he had lost his smile. His lower jaw had started to protrude outward, and his upper teeth weren’t visible anymore when he smiled.

    One of our dental surgery colleagues here at MedStar Washington Hospital Center looked at his X-rays and saw that the bone inside the skull where the pituitary gland is located looked enlarged. He referred the young man to the MedStar Pituitary Center for evaluation. Sure enough, we found high GH levels and a GH-secreting pituitary tumor. After surgery to remove it, the patient’s hormone levels are much lower, and we are continuing to lower those levels with monthly medical therapy.

    Our team treatment approach for pituitary tumors

    No one doctor can treat a pituitary tumor on their own. Many experts must work together when we suspect a patient has a pituitary tumor:

    • An endocrinologist has to test the patient’s hormone levels
    • A neuro-ophthalmologist with expertise in how these tumors affect vision
    • A neuroradiologist with access to the latest MRI techniques and technology
    • An experienced neurosurgeon if surgery is needed
    • Radiation oncology experts with access to advanced radiosurgery tools if the patient can’t undergo neurosurgery or has residual tumor after surgery

    Our pituitary tumor team discusses all the options to come up with a personalized treatment plan for each patient. We look at each patient as a whole, not a set of symptoms.

    I understand the fear and nervousness that many patients have when we tell them they have a pituitary tumor. But it’s important to remember that no one needs to go through this alone. Our team’s experience with these tumors gives our patients an edge, and our top priority is to provide the care they need as quickly and safely as possible.

    Call 202-877-3627 or click below to make an appointment with a specialist from the MedStar Pituitary Center.

    Request an Appointment

  • July 16, 2018

    By MedStar Health

    Traveling can be a nice way to unwind and explore new places. It also can present challenges–such as, maintaining your healthy diet or making sure to bring with you everything you need. This can be especially true if you have type 2 diabetes.

    If you’re one of the almost 30 million people in the United States who have type 2 diabetes, accounting for about nine percent of the population, you know following a moderated diet and taking proper medication are part of maintaining healthy blood sugar levels. Here are four tips to help keep your blood sugar in check while on the go.

    1. Properly Manage Medications

    Taking your medications properly while traveling is as important as making healthy food choices. People with type 2 diabetes often carry insulin and glucose monitoring supplies with them. Taking medication and monitoring on the go can quickly become overwhelming without a little planning. Here are a few tips to make it easier:

    • Pack all supplies in your carry-on, not in your checked luggage. This provides easy access and prevents diabetes emergencies if your luggage gets lost in transit.
    • Take medications in the original prescription containers and bring your prescription with you in case you get delayed or lose your supplies.
    • Bring more medications and supplies than you need in case there’s no pharmacy nearby or your return is delayed.\
    • Keep pills and monitoring supplies at room temperature, and keep insulin and injectable medications cool. Be careful using hotel refrigerators that might freeze and damage your supplies.

    If you’ll be traveling across time zones, schedule your meals for destination time to help you adjust. For advice on adjusting medication times, consult with your provider.

    2. Plan Snacks and Meals Ahead of Time

    You never want to take a vacation from healthy eating—especially if you have diabetes. One of the most effective ways to maintain a healthy diet is to make healthy snacks ahead of time. Prepping snacks makes it easier to avoid impulse purchases of less nutritious foods at gas stations or at the airport. It’s also wise to keep food handy in case your blood sugar becomes too low.

    I suggest prepping healthy snacks in zip-bags, such as:

    • Protein: Cheese, nuts, and meal bars.
    • Carbohydrates: Pretzels and crackers. These are lower in fat than most other carb choices.
    • Simple sugar (for hypoglycemia or low blood sugar): Medications can put you at risk for low blood sugar. Try lifesavers, glucose gel, or tablets to maintain your blood sugar.
    It’s never good to vacation from healthy eating—especially for those with type 2 diabetes. Planning healthy meals in advance is one way to avoid bad eating habits, via @MedStarHealth.
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    3. Drink Enough Liquids

    Staying hydrated is an important step in maintaining your blood sugar levels. Type 2 diabetes means you’re more prone to suffering from dehydration. Drinking water is important because it helps the kidneys flush excess sugar out of the body when glucose levels are high.

    Here are some suggestions to stay hydrated:

    • Keep a bottle of water with you when traveling. Drinking water may be hard to find on planes, trains, ships, and at your destination.
    • Drink more water when in the sun, active, or flying.
    • Find out if the local water is safe to drink. If not, use bottled water to drink and brush your teeth.
    • Drink more water in dry climates, even if it’s not hot.
    • Drink sugar free sport drink mixes to replenish electrolytes.
    • Avoid mixed drinks containing lots of sugar and calories.
    • Avoid alcohol on an empty stomach; always have it with a snack to avoid hypoglycemia.

    It’s important to keep in mind how critical hydration is to your health.

    4. Balance Calories In and Calories Out

    To keep blood sugar levels in a healthy range, it’s important people with type 2 diabetes balance the amount of calories they are eating with the amount they are burning. For example, if you’re burning more calories by sightseeing, shopping, walking, swimming, cycling, or climbing, you might need to eat more. If you are less active than usual, you might need less food than usual. Monitoring blood glucose levels daily through home monitors will help determine how you’re doing. You can use the American Heart Association’s glucose tracker to keep track.

    Planning trips can be overwhelming, especially when it’s last minute. Make sure to take time before your next trip to keep your stress low and your blood sugar in check.

    Are you suffering from diabetic foot or need to see a wound healing specialist? Click below to learn about the services provided at the Center for Wound Healing, Hyperbaric Medicine, and Limb Salvage at MedStar Good Samaritan Hospital.

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  • July 11, 2018

    By MedStar Health

    Heart valve disease, a malfunction of one or more of the valves that allow blood to flow through the heart, affects roughly 2.5 percent of the U.S. population. More than 6 million people live in the Washington area, which means we can expect more than 152,000 people in our community to have some form of heart valve disease. Fifteen percent of people 75 and older have some problem with their heart valves’ function.

    Symptoms of heart valve disease often build over time and can vary depending on the valve that’s affected:

    • Aortic valve: chest pain, shortness of breath and fainting
    • Mitral valve: shortness of breath and swelling of the extremities
    • Tricuspid valve: swollen feet and liver congestion (decreased liver function)

    Too many people suffer for years with these symptoms, but they shouldn’t. We offer advanced treatment options, ranging from medication alone to minimally invasive procedures that don’t require opening up the chest at all.

    LISTEN: Dr. Thourani discusses options to treat heart valve disease in the Medical Intel podcast.

    Early detection of heart valve disease is key

    Heart valve diseases are relatively easy to diagnose. They’re often first detected by primary care doctors during a routine physical exam by listening with a stethoscope. If your doctor hears a certain kind of heart murmur that indicates a type of heart valve disease, they’ll likely refer you to a cardiologist for a transthoracic echocardiogram. This test uses ultrasound to create an image of the heart and let your cardiologist see how your valves are working.

    If we find evidence of heart valve disease, you need to be seen by a heart valve specialist. We have a dedicated team of specialists who care for patients with mild, moderate, or severe heart valve disease.

    Related reading: The heart care team: Dedicated experts for every patient 

    Treatment options for mild or moderate heart valve disease

    Mild or moderate heart valve disease do not require surgical therapy, but do require close observation with a cardiologist to help manage potential symptoms.

    Today, we can treat many of these patients with blood pressure and cholesterol medication, and many will never require heart valve surgery. The earlier in the disease that we start treatment, the more likely it is that we can avoid surgery and prevent the disease from becoming severe.

    High #bloodpressure and #cholesterol that aren’t under control can raise your risk for #heart #valvedisease. bit.ly/2zyNOBn via @MedStarWHC

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    Treatment options for severe heart valve disease

    We are the only provider within 50 miles of the greater Washington area that offers all of these latest treatments for heart valve disease. With all of the latest technologies available to us in the numerous trials, we have the capability to sometimes treat patients who are otherwise untreatable.

    Ten years ago, our main treatment for severe heart valve disease was a procedure called sternotomy, which involves an incision in the sternum, or the breastbone. Today, a lot of patients are candidates for minimally invasive options, which require smaller incisions or none at all. This means we can treat patients who might not be able to withstand regular surgery.

    We can access your affected heart valve without opening up the chest by inserting thin, flexible tubes called catheters into two other areas of the body:

    • Between the ribs: This procedure is called thoracotomy.
    • Through the artery or vein in the groin: This is an even less-invasive procedure than thoracotomy and requires no incision.

    In the transcatheter procedure, we pass a catheter through the artery or veins and into the heart. From there, we can repair or replace the affected heart valve. You’ll likely go home a day or two after your procedure with either a tiny incision or, most commonly, no incision at all.

    For example, I once treated a woman in her 80s who’d been told repeatedly that her mitral valve disease was untreatable. She was a high-risk patient who couldn’t have traditional surgery. With just a little needle stick in the vein in her groin and a simple catheter procedure, we were able to repair her mitral valve. Before this patient came to us, she was depressed and homebound, unable to enjoy life because her disease held her back. Now she’s able to spend more time with her kids and grandkids.

    As our population continues to age, we are going to see more people who will need treatment for heart valve disease. With our dedicated team of specialists and our expertise with the latest technologies, I am confident that we will be able to help more patients with heart valve disease enjoy healthier, fuller lives.

    Do you have more questions about heart valve repair? Call 202-877-3627 or click below to make an appointment with a cardiac surgeon.

    Request an Appointment

  • July 09, 2018

    By K. Eric De Jonge, MD

    According to the Centers for Medicare and Medicaid Services, the typical Medicare patient sees two primary care providers and five medical specialists in a year. Sixty percent of seniors are taking three or more medications at a time. And many emergency room visits for older adults are due to adverse drug events.

    As a geriatrician, I spend my time overseeing the care of elderly patients and often see problems with medication management. When I meet a new patient, it’s common to discover that he or she is taking 10 to 15 medications. Those medications have accumulated over many years, leading to a higher burden of side effects than benefits. It can lead to a perfect storm of a medication toxicity.

    The Situation

    Too many medications

    Doctors prescribe medications for specific reasons, and the list gets longer over time. Different doctors see the patient for various conditions, and each doctor prescribes medications separately.

    As patients age, their metabolisms slow, so medications remain in the body longer, and have a greater impact. Less muscle and more fat cause the body to hold on to some meds longer. Kidney function slows down, and medications metabolized by the liver are slower to clear.

    Side effects

    As the number of medications increases, so does the risk of side effects, especially for patients in their 80s and 90s. With many medications prescribed by several different doctors, common side effects can include:

    • Constipation
    • Confusion
    • Low blood pressure

    The problem can get worse when other medications are prescribed to treat side effects.

    Complicated regimens

    A National Institutes of Health (NIH) study found 90 percent of seniors age 65 and over take at least one prescription and as many as 55 percent of them take their medications incorrectly. Many elderly patients are on a complicated medication regimen, with doses at several times a day. Medications often have confusing names or look similar, which makes for more mistakes, especially for patients with dementia.

    Different physicians could prescribe medications that are dangerous when mixed. For example, a patient could be prescribed an opioid from one doctor, and a sedating sleeping medicine from another, and the combination can be risky.

    OTC meds can be overused. NSAIDs such as aspirin or ibuprofen can cause gastrointestinal distress and bleeding while acetaminophen can cause liver toxicity.

    The Solutions

    Designate one primary care physician

    Patients need one captain of the ship—a single doctor or a primary care team.  That person or team manages the whole medication list, understanding the benefits and risks of every drug. Periodic review of medication lists can eliminate drugs the patient no longer needs, so the patient gets the right medication, at the right dose, for the right condition.

    Keep an up-to-date list of all medications

    Patients—and their family members—can do their part. Keeping an up-to-date list of all medications at all times is essential. That list should be electronically updated, and should include OTC medications, vitamins and herbal remedies.

    Start low, go slow

    As patients age, they may react more strongly to medications.  For that reason, “start low, go slow” is a valuable maxim.  For example, for the anti-depressant sertraline, one should start patients at the lowest dose and gradually increase the dosage, until the patient has a positive effect with minimum side effect.

    Simplify the medication regimen

    We can often safely cut the total number of medications in half for a new patient.  Prescribing a medication three or four times a day is asking for failure.  Once-a-day dosing is the gold standard, to ensure that the patient takes the right medication each time.

    Use one pharmacy when possible

    The pharmacist can identify medications that are contraindicated or duplicated, if the medication list resides at one pharmacy.  If patients use one pharmacy, the pharmacist can look for interactions, and educate patients about possible side effects.

    It’s important that we provide comfort and relieve suffering for people at all stages of life.  The vast majority of elderly patients do not develop a drug dependency on opiates; in fact, a good number use less than they need.  And in the later phase of life, medications can be stopped or adjusted, to focus mainly on relief of symptoms with minimal side effect.

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  • July 03, 2018

    By Matthew Schreiber, MD

    A September 2017 report from the Centers for Disease Control and Prevention (CDC) shows that the number of Americans who have died from chronic respiratory diseases, particularly chronic obstructive pulmonary disease, known as COPD, has skyrocketed over the past 35 years. COPD is now the third-leading cause of death in the U.S.

    The prevalence of COPD varies considerably by state, and Washington, D.C., seems to be doing quite well, with 4.6 percent of its residents reported having COPD. Neighboring states Maryland reported 5.9 percent, Virginia reported 6.1 percent and West Virginia reported 8.9 percent.

    But if you dive into the data a little bit deeper, D.C. is a tale of two cities. There are a number of factors the CDC and the National Institutes of Health (NIH) found relating to their COPD reporting. This is how it breaks down in D.C.:

    • 2.1 percent of white respondents reported they had COPD
    • 6.7 percent of African-American population reported they had COPD

    LISTEN: Dr. Schreiber discusses COPD prevalence, risks and treatments in the Medical Intel podcast.

    What factors into this statistic?

    Our city’s 4.6 percent COPD rate is the overall average of patient populations in our city. Other factors associated with COPD in D.C. are:

    • 19.9 percent of people with the disease are unable to work
    • 9.6 percent have less than a high school education
    • 2.2 percent are age 18 to 44
    • 10 percent are age 75 or older

    While 4.6 percent is at the low end of the national levels, groups in our district develop this condition at levels higher than the national average. So, even though D.C. overall is below the national level, we have work to do.

    Only 4.6 percent of D.C. residents reported having COPD, a much lower rate than neighboring states. But if you dive into the data a little bit deeper, D.C. is a tale of two cities.  https://bit.ly/2KM0upQ  via @MedStarWHC

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    Risk factors for COPD

    COPD is a chronic condition, so once you have it, you have it for life. It might not progress quickly, but it doesn’t go away. People with COPD have restricted lungs and have trouble moving air out of their chest. The disease is caused by long-term exposure to irritants by inhaling something that can damage your lungs over and over again.

    Cigarettes

    It seems like common knowledge now, but the idea that cigarettes are a risk factor for COPD is relatively new. Similarly, we didn’t have studies that showed cigarettes caused things, such as lung cancer until the 1950s, nor did we have a surgeon general’s warning about the damages of smoking until the 1960s and ’70s.

    Since the early 1900s, there has been a lot of effort to get people to use cigarettes. We’re only now seeing the consequences of that effort, because there is often a significant time lag between when someone starts smoking and when they will experience reduced lung function. The recent sharp increase in COPD is considered to be largely related to the peak in smoking rates decades ago.

    Other inhalants

    Workplace chemicals and harmful pollutants can also irritate and damage the lungs. We ask our patients about their lifestyle, if they worked around or were frequently exposed to smoke or fires, or if they were exposed to chemicals or other inhaled irritants. We ask if they wore a mask in their workplace or wish they had.

    Genetics

    Some people are born with low levels of a protein made in the liver, which can lead to losing lung function faster than the average person, lung damage and COPD.

    Unlike muscle and bones, the lungs mature by age 20 to 25. After that, their function naturally declines. Lungs are remarkable when you consider their lifelong duration and how much lung function we all have. Our lungs develop enough into our late teens and early 20s that we are given such a surplus that we could die from something else well before a breathing issue ever arises. But when you experience these exposures, have genetics that predispose your lungs to losing function faster than the average person or get older and start to have symptoms, you certainly should come to your doctor to evaluate your lungs.

    What will reduce COPD risk?

    Quit smoking

    Research shows quitting smoking will have the greatest impact on reducing your risk for COPD. The CDC reports on risk factors for people with a lifetime history of at least 100 cigarettes. Many people who don’t claim to be smokers have smoked 100 cigarettes in their lifetime. For example, some people only smoke when they’re out on the weekend. The truth is, it only takes two years of weekends until you’ve had a hundred cigarettes.

    Clearly, the people who are most at risk are smokers. The question is: Who becomes a smoker? There are a number of scholars who have looked into the influence of the tobacco industry on public health. As an example, research has shown there is a disproportionate amount of advertising for tobacco products in poor neighborhoods. So, the question “Who becomes the smokers?” is a bigger question of social structure.

    When to seek testing

    If you have a strong family history of COPD—for example, if your parents or siblings have been diagnosed—there could be a genetic factor: a deficiency in a protein called alpha-1 antitrypsin, which is rare, but it gets passed along in families. Genetic testing is a good choice if there’s a higher-than-average risk for COPD in your family.

    If you are or have been in a job that has exposure to substances that irritate your lungs, it’s a good idea to talk to your primary care physician or a pulmonologist about your risks and if you should get tested. Also, you should consider pulmonary function testing if you have a persistent cough. If we catch COPD early, we can manage symptoms and encourage patients to make lifestyle changes that may keep the disease from progressing.

    COPD diagnosis

    The only way to diagnose COPD is with a test called spirometry. This breathing test looks for obstruction in the lungs. An individual will blow into a tube connected to a small computer to measure how much air comes out in the very first second and how much air they are able to get out in total. People with COPD can get the air out, they just can’t do it quickly.

    When I ask people with normal lung function to blow out for the six seconds it takes for that test, it’s hard. At the end, they’re really trying to push out that last bit of air. For people who have lung obstruction, sometimes they’re still blowing out at 13, 14 or 15 seconds. That’s how long it takes to get all the air out because it’s very slow.

    You can’t diagnose COPD with a CT scan, an X-ray, stethoscope, physical exam or medical history. Unfortunately, this still happens all the time, such as in the COPD data reporting in our district and in individual states. In D.C., for example, three out of 10 people reported they never had a spirometry test, yet they were given a diagnosis of COPD. This most likely is based on the symptoms they had, but there are other things that could be causing their symptoms, which is why getting tested is so important.

    Spirometry can be done in primary care clinics, and we do it in our pulmonary care clinic. If needed, we can send people for additional testing with full pulmonary function tests, which are done in our hospital facilities without being admitted as a patient.

    What caused the spike in COPD?

    There was a landmark study in which a group of researchers developed a diagram showing the natural progression of our lungs throughout life. It’s called the Fletcher-Peto curve, and what they showed is that we have our best lungs at about 20 to 25 years old.

    For individuals who have vulnerable lungs or damage from smoking or pollutants—even those who have quit smoking or are removed from inhalants—the lungs never grow back. But the rate of decline slows down if they do quit smoking or remove the exposure.

    Identifying a large uptick in COPD now is actually the recognition of what has been going on in people’s lungs for the last 20 or 30 years. For example, if a 50-year-old quits smoking, they may not have symptoms until they’re 75, so they might not be tested for COPD for decades. But someone who’s 73 may quit smoking after never having symptoms, but then, two years later (also at 75), they start having lung problems that deteriorate their quality of life. In both patients, they likely had COPD much longer than they realize.

    Unfortunately, the second patient in the above scenario is far too common. Many patients come to the pulmonary clinic a year after they’ve quit smoking; they may be on oxygen or can’t go up three steps to their house. In truth, the scary thing is not necessarily death with COPD; it’s years of disability. It may be losing your independence, getting winded taking a shower or eating a meal because the extra work of breathing is more than the lungs can handle. These are the kind of life-changing events that are so problematic with COPD—it takes away your freedom. Almost two-thirds of people with COPD surveyed in D.C. reported some exercise limitation because of breathing trouble.

    How COPD patients can address their health

    I counsel patients every day on smoking cessation and safe physical activity. I also refer patients to pulmonary rehabilitation, which includes respiratory therapists trained in methods to help manage your breathing better and make progress in activities. We talk about nutrition, being physically fit and being preventative about other aspects of health, such as getting vaccinations where they’re appropriate.

    Medications have been shown to help lung function even before there are symptoms of COPD. Inhalers are effective preventive medicines, but sometimes patients resist using them because they’re breathing well at that time. I counsel that you wouldn’t wait until you’re having a heart attack or a stroke to start taking your blood pressure medicine, even though you feel fine. Sometimes taking a pill seems to be simpler for patients than using an inhaler. There is more coordination necessary when using an inhaler, and a lot of people use them wrong, such as spraying the inhalant into the back of the throat. We need to get the medicine down into your lungs. Doctors and respiratory therapists can serve a key role in educating patients on proper technique.

    The preventive nature of inhalers means that we may be able to stop you from having a flare-up this year, which would otherwise affect your lung function next year. Things we prescribe in the pulmonary clinic are not always just to make you feel better; they’re also to prevent you from some other event, because nature is still going to cause those lungs to decline a bit. If I can keep you out of an urgent care or hospital with a condition that’s going to make you decline even faster and help to keep you independent and active, then I’m doing my job.

    Our society has a healthy and appropriate fear of heart disease, stroke, diabetes and hypertension, and so people don’t mind being tested for, or taking medications for those conditions. I don’t think we are there yet with breathing disorders. I think in some ways that this is a blessing, because it’s only relatively recently that COPD has become a common disease. While we’ve been aggressively dealing with COPD for 40 or 50 years, we have a lot of catching up to do quickly, in D.C., and far beyond.

     

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