Meetings Attended

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2011

September 30, 2011 Johannes Koch, MD of Virginia Mason Medical Center joined the phalanx of academic gastroenterologists who evince great concern to identify colon cancer early, yet ignore the most cost-effective method. That is the two step process used in Australia and other countries. Everyone is offered the safer and more affordable test for blood in the stool, and colonoscopy performed only if there is bleeding or some other risk factor.

Dr Koch competently reviewed techniques that give people the greatest benefit from a colonoscopy. No question that his techniques should always be used so people get the benefit they deserve from colonoscopy. And he is not alone in attending only to "how do we do this technique well" and ignoring the question "how do we make sure we do not subject people to this procedure unnecessarily?"

Please see our newsletter series on this topic at http://rienstraclinic.com/newsletter/2010/August/ .

September 16, 2011 Jane Hoyt Buckner, MD, Member and Director, Translational Research at Benaroya Research Institute at Virginia Mason, outlined the role of a kind of white blood cell involved in autoimmune illness.

We generally divide white cells into major groups, one of which is the lymphocyte. She discussed a kind of lymphocyte called the CD4 lymphocyte, a cell that distinguishes self from non-self. In all of us, there are always a very few CD4 lymphocytes that are programmed to call an attack on our own tissues, but in most of us they do not cause a problem.

The thymus gland produces what are called naïve T-cells, which go out into the circulation and respond to one of many available interleukin signals and differentiate into different types of T-cell on that basis. Th17 cells are driven by certain signals to increase in number and cause rheumatoid arthritis, psoriasis, and other autoimmune illnesses. Further, while we have regulatory systems to control autoimmunity, these cells resists such regulation.

Work progresses to control the Th17 cells, with variable results so far.

June 17, 2011 Stuart J. Farber, MD, directs the Palliative Care Service at the University of Washington School of Medicine. He titled his talk "Words that Work: Sharing Poor Prognosis in Advanced Illness."

Some families feel to give up hope is to invite death. So, "how do you make decisions? How do we decide how to treat your loved one with respect?"

"If you ever got so sick that you couldn't speak for yourself, who would you want to speak for you?" "Have you talked to them about that?" "If you were seriously ill, what level of recovery would you need so that after all the treatment you would say 'I'm glad you did that"?

June 10, 2011 James Lord, MD, of the Virginia Mason Medical Center reviewed "Primary Care and Management Updates for Inflammatory Bowel Disease (IBD)." This disease can require, as it progresses, treatment with drugs that suppress the immune system. In that case, not only does the patient face a higher risk from communicable illness such as influenza and hepatitis B, but they face more danger from the process of vaccination with live vaccines such as yellow fever, shingles, oral polio, and others. Therefore, vaccination for these while the disease is quiescent can protect them from future problems.

Also, such people face a higher risk of colon cancer and require special screening.

June 3, 2011 James R. Holm, MD, specializes in hyperbaric medicine at the Virginia Mason Medical Center. Sometimes during illness, accident (especially while diving), or medical procedures, gas can enter the blood vessels and impair circulation. This can cause death, stroke or loss of circulation to an extremity.

When we start an IV on someone, sometimes a very small amount of air may enter the vein. This just about never causes a problem, as just about all of us can tolerate about an ounce of air injected into a vein and suffer no problems. However, more than an ounce into a vein can cause a problem, and very little into an artery usually causes severe problems. As it turns out, bubbles of gas in the circulation initiate inflammatory processes in the blood vessels, and this may be a primary element of injury.

The treatment includes hyperbaric oxygenization through the use of a high-pressure chamber such as used to treat divers for decompression sickness ("the bends"). The increased pressure shrinks the bubbles, increases diffusion of gas out of the bubble into the tissues, and decreases inflammation.

May 27, 2011 Kelly M. McMasters, MD, of the University of Louisville in Kentucky reviewed treatment of melanoma. He reviewed treatment of advanced melanoma. Early diagnosis really is our best course of action. Better you go to your doctor nine times for a skin lesion that turns out to be nothing than to the miss the one time it is something.

May 20, 2011 Lucian L. Leape, MD, a Professor of Health Policy at Harvard reviewed patient safety. As I walked to the auditorium to hear this talk, past the emergency department, it struck me that I was walking through a place that harbors dangers greater than most other indoor spaces you visit. In this place, needles are placed in veins and substances injected. We do these things because nature or lifestyle or something else, an accident, say, has placed that person's health or life in danger. If we correctly conceive and execute our interventions, we can mitigate these dangers, but there is often just one way to do it right and there are many ways to do these things wrong. When we do surgery, many things can go wrong. Even oral medications, especially in combination, can harm people.

Once we have been in pain for years with, say, a degenerating knee, hope can lead us to conclude that, yes, this time our surgeon is right, that complications will not occur, that we will walk out of the hospital free of pain, and mobile.

Patient safety starts with the recognition of something we easily forget, because they don't often make themselves apparent, the hazards.

Your safety depends not just upon the skills of your entire medical team, but on your own preventive activities and your intelligent collaboration with your health care team.

May 13, 2011 John Frederick, MD, psychiatrist at Virginia-Mason Clinic reviewed attention-deficit disorder. About 4% of adults in the US have this, There must be impairment to qualify for diagnosis, usually easily distracted, impulsive decision making, difficulty stopping activity or behaviors when they should do so, starting tasks before understanding it, all this occurring in various settings. Connors' Continuous Performance Test takes about 14 minutes on a computer and quantifies some of the above measures.

Aside from stimulant drugs, guanfacine and clonidine stimulate the alpha-2a noradrenalin receptor, the former having less side effects.

People can easily fake having ADHD as a way of obtaining stimulant drugs.

April 29, 2011 Adrian Reuben, MBBS, FRCP, FACG (Dr Reuben is British, hence the unfamiliar initials), a Professor of Medicine and specialist in the Division of Gastroenterology and Hepatology at the Medical University of South Carolina in Charleston, discussed drug-induced liver injury (DILI).

Liver toxicity occurs in about 14 per 100,000 drug exposures, and in those in whom it occurs, about 5% die.

April 22, 2011 Edmond J. Raker, MD, vascular surgeon at Virginia Mason Medical Center presented an update on carotid artery disease.

April 20, 2011 Dmitri Vasin, MD, nephrologist, reviewed treatment of hypertension, pointing out that various drugs may lower blood pressure equally, but patients on perindopril, ramipril, indapamide, chlorthalidone, or amplodipine will live significantly longer than those on other blood pressure drugs.

April 15, 2011 Oneil S. Bains, MD, a sleep specialist at the Virginia Mason Medical Center reviewed insomnia. About a third of the population have insomnia 5 nights a month, and ten percent have it over half the time. All of us will have poor sleep when we are stressed.

Normal sleep efficiency is 85% or higher, that is, if in bed 7 hours, then they would be asleep at least 85% of that time, or 6 hours.

Sleep restriction therapy works much better than sleep hygiene. If stopping sedative, restrict sleep and taper.

Doxepin, an old tricyclic anti-depressant, has just been approved for sleep. Even though used in doses much less than for depression, they can cause weight gain. Sleep medication will provide 6 or 7 hours of sleep, so do not use them too some on the evening. There is nothing that will give you eight hours of sleep and have you wake up without a hangover.

April 8, 2011 Daniel O'Connell, PhD, consults with major medical centers to improve physician performance.

Medical school teaches us how to reach a diagnosis and how to treat each illness. No matter how well we do this, patients often do not feel entirely happy about their interactions with us. We focus on the illness as we see it, but miss their individual concerns.

O'Connell pointed out that there are better and worse ways to help people adopt better health habits.

Some people are naturally effective teachers, parents, or physicians; the rest of us can perform better if we adopt the methods used by the superstars. Their methods are easy to understand and to copy. Patient surveys show that these methods work.

April 1, 2011 Tony Berendt, MD, Director of Infection Prevention and Control and Consultant Physician, Bone Infection Unit at the Nuffield Orthopaedic Centre NHS Trust, Oxford, UK, titled his talk "Managing Bone and Joint Infections; A Multidisciplinary Odyssey, the Flying Dutchman, or the Rime of the Ancient Mariner?"

Anyone signing on to a joint replacement knows they face a risk of infection at the surgical site, and though risks are low, and every preventive measure is taken, such infectinos do occur. In the US these cost about a quarter of a million dollars a year and an unknown number of lives. Diabetes makes such infections more common, and diabetes affects many among the older population who require joint replacement.

Given the increased numbers of older people with weakening conditions such as diabetes, and the increased need for and availability of joint replacements, the number of such infections is rising rapidly. Even with continuing advances in treatment, prolonged treatment and loss of the joint occur frequestly.

March 25, 2011 The Pierce County Medical Society sponsored an all-day conference on treatment of chronic non-cancer pain. While opiates sometimes are necessary in this situation, they are only really effective as part of a comphensive program including exercise, relaxation techniques, and emotional work. Often, people can transition off the opiates and regain an improved ability to live a more normal life without reduction in pain control. Frequently the best outcome is a life with manageable pain. Efforts to eliminate pain entirely are doomed by our nervous system's need to be aware of the outside world, and usually end up as opiate addiction.

March 18, 2011 Otto S. Lin, MD, a gastroenterologist at the Virginia Mason Clinic, addressed "Issues in Colon Cancer Screening: High Risk Screening and Alternative Screening Modalities."

In his talk, he did not discuss the current preferred alternative, the immunochemical fecal occult blood test, which we discussed in our newsletter at http://rienstraclinic.com/newsletter/2010/August/ . Instead he compared his recommended techneiques against the outdated card test. (A test Labcorp has not offered in some time.)

March 11, 2011 Kathleen Horan, MD, of the Virginia Mason Medical Center. Many illnesses can cause a prolonged (years long) cough, among which are tuberculosis. As it turns out, there are microorganisms in the same family (the Mycobacteria) that can infect humans as well. They are not contagious as TB is, are much more difficult to diagnose, and sometimes are better off left alone rather than being treated. These bacteria most often live in the normal lung without causing illness.

The incidence of non-tuberculous mycobacterial lung disease seems to be rising (now about 4 per 100,000 persons per year) at the same time that tuberculosis is decreasing. Some wonder if the decreased prevalence of tuberculosis in the population (resulting in reduced immune system exposure to the Mycobacteria) leads to reduced immunity to the Mycobacteria, hence a greater incidence of these opportunistic infections.

This condition occurs more in taller lighter weight women with chest wall deformities, who have a higher incidence of the cystic fibrosis gene, or who use acid suppressing agents.

Non-tuberculous mycobacteria resist chlorine (in tap water) and many antibiotics, and generally are treated with other forms of pulmonary care and exercise, surgery, or if required, some difficult-to-tolerate antibiotics. Since they are resistant to chlorine, some think that water purification with chlorine may be reducing other bacteria in our drinking water at the expense of increased exposure to mycobacteria. Of course, discontinuing chlorination of drinking water would certainly result in much worse problems than mycobacteria.

March 4, 2011 A panel of doctors at the Virginia Mason Medical Center discussed an occasional post-operative problem, which is that some individuals develop lethargy and other brain dysfunction after anesthesia. As well, some develop such mental dysfunction after serious illness. For example, people used routinely to die following sapsis, which is circulatory collapse associated with bacterial invasion of the bloodstream. Now, aggressive interventions can prevent death in over 80% of these people, but often at the price of prolonged cognitive dysfunction impairing daily activity.

February 25 to 27, 2011 The American Society for Nutrition held its annual meeting in San Francisco to address advances and controversies in nutrition. Speakers addressed vitamin D, noting that deficiency indeed is widespread and affects many body systems. Weight gain and weight loss carry risks of nutrient deficiency, as does bariatric surgery. Our brain has several methods of sensing our fat stores and governing appetite, but the high-fat modern diet can confuse this homeostatic mechanism.

Speakers debated the importance of sodium in the diet, there being arguments on both sides.

E Ravussin MD reviewed research showing that calorie restriction in animals prolongs life, then pointed our that at his age, the mid-sixties, if he permanently reduced his daily caloric intake by 30% he could expect to gain two months of life.

Certain anti-aging mechanisms, such as SIRT3, maintain function better in people who exercise compared to those who don't. Muscle bulk indicates how well these anti-aging mechanisms perform; exercise promotes these systems very well in aging people.

February 11, 2011 Mitchell Kronenberg, PhD, President and Chief Scientific Officer of the La Jolla Institute for Allergy & Immunology in La Jolla, California reviewed the physiology of inflammatory bowel disease (IBD) in certain mice. The immune system plays the major role in the such illness. He discussed the various cells, receptors, and signalling molecules of the immune system and how these relate to the severity of IBD.

He has identified a molecule called DTLA which, if targeted with a drug, might help reduce symptmos in these mice, and, if we are lucky, people. The HVEM receptor plays another vital role.

January 21, 2011 Kevin L. Winthrop MD, MPH, a professor of infectious disease, reviewed the drugs used for cancer and for autoimmune illness such as rheumatoid arthritis. While these medications can have almost miraculous benefit for people with those categories of illness, they do increase the risk of opportunistic infection. Etanercept caused less infections than others, and the DMARDs used in rheumatoid arthritis were least likely of all to result in infection.

Serum interferon-gamma release assay (IGRA) can detect TB in people with BCG vaccination, more specific than skin testing, but drugs that down-regulate TNF interfere with the assay.

People who take madications affecting the immune system, and their doctors, need to remain alert to the possiblity of infection with staph, TB, histoplasmasis, coccidiomycoses, or other usually less aggressive organisms.

January 12, 2011 Dr Jakjeh Nikomborirak specializes in sleep. Our culture holds unrealistic expectations about sleep. To learn more, see our newsletter at http://rienstraclinic.com/newsletter/2011/March/.

January 7, 2011 Heart disease is the leading cause of death in the US. Half of people who die from heart disease have no warning symptoms.