General

The Heart, Myocardial Cell In Disease

As we began our series of discussion on how the cell can be analyzed to determine disease, we start with the Heart, Myocardial Cell, the principle functional unit of the heart organ.

Click on the image below regarding heart and myocardial cell physiology and pathophysiology.

Heart, Myocardial Cell Physiology; For Every P-wave, a QRS complex should follow; P wave to P-wave are spaced apart by approximately 1.2 to 2.0 seconds during a sinus rhythm.The Electrical System of the HEART; A 12-Lead EKG allows monitoring various walls of the heart to determine which part of the heart muscle, i.e. lateral, anterior, posterior, or septal, that may be damaged due to low or blocked blood supply to the heart muscle cell, or other abnormalityFLOW of Blood Through HEART; Deoxygenated blood comes from the upper and lower parts of the body through the vena caval system; then travels through the right heart, passing through the pulmonary arteries to the lung, and is then returned back as Oxygenated Blood to the left heart via the pulmonary veins, and finally exits the heart through the aortic valve to the rest of the the body.  This pumping cycle is repeated continuously throughout life. Chambers and Valves of the HEART; The closing of the valves gives the heart sounds that are heard during auscultation with stethoscope; The first heart sound (S1) is closing of the Atrial Valves (Tricuspid valve, and Bicuspid or Mitral Valve); and the closing of the semilunar valves (Pulmonary Valve and Aortic Valve) gives the S2 sound.  Any sound between or before those two sounds, such as S3, S4, heart murmur, etc, are abnormal HEART SOUNDS. The valves and closed chambers allow for blood to FLOW in a one direction, with dynamic pressure shifts.

Millions of Americans suffer from heart disease of one type or another. The heart, being a single organ, is one of the most important organs in the human organ systems. The principle function of the heart is to pump blood throughout the circulatory system, creating a positive dynamic mechanical pressure for cells to exchange gaseous substances, like oxygen and carbon dioxide among other, as well as to exchange nutrients, other chemical substances, and cellular waste.  In order for the heart to pump blood throughout the human circulation, it requires a dynamic muscular activity to generate a certain degree of pressure.  Without ceasing, the heart keeps a steady beat, of about 70 beats per minute depending on certain physiological conditions to generate this pressure. A series of electrical pacing, typically under the influence of an internal based electrical nodal system (sinus atrial node, AV node; Bundle of His, Right and Left Bundle Branch, and Purkinje fibers) along with the neural and endocrine systems, create a constant influx and out flux of electrical ions, starting from the atrium, moving to septum, and eventually ventricular myocardium through a sinus rhythm.

Heart Disease can essentially be divided into FOUR main categories: 1) Congenital,where the heart anatomy has abnormal structure that comes about during the fetal stage of human development, such abnormal structural diseases of the heart include abnormal heart valves, septal defects, etc; 2) Electrical, where the rhythm of the heart is dysfunctional due to genetics or other chemically/structurally induced disruption in the electrical flow through the heart; 3)  Coronary, where the blood vessels that supply the heart proper are compromised due in part principally to atherosclerotic plaques or blood clots; and 4) Myocardial, where the muscle of the heart is dysfunctional due to dying heart muscle cells (Myocardial infarction/Acute Heart attack) secondary to lack of oxygen or chemical toxicity,pathogens, cellular infiltrations, inflammation, hypertrophic or hypotrophic heart muscle cell, or scar tissue formation, or abnormal fatty tissue infiltration, for example. The main type of heart disease for adults in the USA which causes high morbidity and mortality, is principally in the myocardium, which is comprised of cardiac type muscle cells. If the heart muscle cell is developmentally, physiologically and structurally sound, then myocardial cells will function appropriately. (For the sake of brevity, the specific nature of how the cardiac muscle cell respond to this influx and out flux of ions, ie. the biochemical nature of cardiac muscle cell contraction is not discussed.  But suffice to say, if genetically sound, this process takes place without disruption.)  The unique electrical system of the heart and the coronary vessels are two components that keep the myocardial cell functioning appropriately.

Screening Exams that patients should know about when determining if their heart is functioning appropriately:

We recommend the following:

1) Patients who are forty (40) years of age or older, should at least have a baseline 12-LEAD, electrocardiogram (EKG) performed to determine if their heart rhythm is appropriate or if there is ischemic heart disease, S-T segment elevation (low flow of blood through coronary vessels, Coronary Artery Disease-CAD), or if there are signs of previous or active heart muscle damage, S-T segment depression,Q-wave, i.e. heart attack/Myocardial infarction, or myocardial hypertrophy from high blood pressure for instance, which would be demonstrated by large, SPIKED, QRS complex.

2)  Patients who have a personal and/or family history of early heart disease, ie heart disease before the age of forty (40) should have baseline 12-LEAD, EKG and other screening exams, including genotyping for genetic risks, done sooner and on a routine basis

3) All adults regardless of age, should be familiar with certain risk factors that place persons at risk of heart disease.  Among others, they include:

a) Male gender at any age, or female gender after age fifty (50)

b) History of tobacco use, or alcohol use, illicit drugs, chemotherapy, etc

c) Diabetes

d) High blood pressure

e) Obesity

f) High Cholesterol

g) Sedentary life-style

h) Clinical or Sub-clinical Hyperthyroidism,Low-TSH hormone (over active thyroid gland) in Female Gender

4) Anyone, REGARDLESS OF AGE,  with symptoms related to chest pain, shortness of breath, dizziness, palpitations, fatigue,fainting, obstructive sleep apnea, etc, should immediately seek the advice of a health care provider for further appropriate diagnostic work-up (including EKG, certain types of laboratory tests, stress tests, Echocardiogram (ECHO), Holter monitor, SLEEP STUDIES while monitoring electrical rhythm of heart, or other heart/vascular scans as appropriate), treatment, and/or management.

 

You only have ONE heart, and typically ONE shot, during life, to protect it!!

 

MDC-Atlanta remains committed to keeping patients informed for better quality health care!


Fundamental Concepts of Human Disease

Basic Concepts of Human Disease

Click on the above link  

Did you know that every organic or physical disease can essentially be determined by studying the human cell?  There are more than 200 different types of cells in the  human body, and all together, the human body is comprised of literally, billions of cells. So in a word, the cell is essentially a biological, dynamic- “machine” with a principle operation to keep the human being functioning through a concept known as “homeostasis.”  (Definition of Machine as used here: an assembly of interconnected components arranged to transmit or modify force in order to perform useful work). Cells group together to form different types of tissues such as epithelial, stromal (muscle, bone, fibrous connective tissue, cartilage, blood tissue), and neural tissues.  What’s so amazing about this human body composition is how the different types of tissues are arranged in layers, essentially from external outer covering (epithelial) to middle covering (stromal tissue and accessory structures), to inner covering (motor/neural covering), and to internal outer covering or support structure/attachment structure (adventitial stromal tissue) with such an arrangement that is set up to keep the tissues working collectively to  actively respond to its outer world and for continuation of survival of the human organism.  These tissues group together to form different types of organs (heart, lung, kidney, liver, colon, small intestine, skin, pancreas, etc) to create eleven (11) different types of organ SYSTEMS (cardiovascular, respiratory, digestive, integumentary, lymphatic and immune, endocrine, reproductive, genitourinary, skeletal, muscular, and nervous) known collectively as the human being.

Back to the cell, which is essentially how we study disease.  If all components of the cell are intact and functioning appropriately  from birth to death, then human disease can not be manifested.  But of course, we know that this is not the case.  So the cell, being created from a union of  male and female sex cells, goes through life challenges, either from genetic mishaps, abnormal congenital changes,mere aging processes, adverse environmental influences such as pathogens (bacteria, fungi, viruses, parasites, etc), chemical injuries (medication, tobacco use, iilicit drugs, alcohol, certain dietary substance, etc), or physical insults, all of which MANIFEST AS HUMAN DISEASES. (please refer to Our Archival Section: Classifying Human Diseases).

A Cartoon Image of the HUMAN CELL, Three dimensional. Remember: every matter that exits, including human cells, is essentially comprised of different chemical structures.  When it all boils down, studying chemical structures of the cells lead to accurate diagnosis of many types of  diseases. Nanotechnology is rapidly advancing into how we study disease of the human cell leading to faster and more precise diagnoses.Cell membrane; the principle source for the cell's communication with its outer environment! This is where it all begins in studying Human Disease, i.e. obtaining information about the cell! AND, analyzing chemical structures that are illustrated in the above image allows one to determine human disease!!!!

Example of an Epithelial Cell (Squamous Cell) as viewed under the microscope; the epithelial cell is covered with bacteria (giving the cell a hazy-appearance), as this is an example of Bacterial Vaginosis (sample taken from a Pap smear).  This patient was also diagnosed with High-grade Squamous Intra-epithelial Lesion (HSIL), confirmed by Positive High risk HPV testing, and Cervical Tissue, Biopsy.  Notice the smaller squamous cells scattered in the background with increased N:C ratio, nuclear hypercrhomasis, and irregular nuclear contours

The cell has basic structure and function.  Most cells are comprised of a cell barrier (known as cell, plasma membrane), cytoplasm/cytosol with different organelles (small intracellular units used to synthesize, package, and transport proteins, destroy foreign substances absorbed by the cell, generate cellular energy, or to simply carry different compositions of the cell to various parts, or even moving the cell itself, etc), and then the nucleus where DNA/RNA are synthesized through a complex, collaborate process, as well as the central operation for producing new cells.  Essentially the cell uses different proteins to carry out its day to day function. In fact, proteins are most important because they give a cell its structure, regulate the internal and external cellular chemical compositions through enzymatic reaction, and allow the cell to communicate with other cells through cell-membrane, cytoplasmic, and nuclear receptors.   Now what’s most important is the cell’s ability to communicate and respond to its outer environment.  The cell is essentially an electrical biological entity, i.e. using electrolytes like sodium, potassium, chloride, and calcium, among other chemical compounds to generative an electrical potential gradient and dynamic electrical activity about its cell membrane  barrier.  In fact, without this electrical dynamic potential gradient, i.e static 0- potential gradient, then the cell is DEAD. Now cells respond to its environment or communicate with other cells through chemical activities about its plasma membrane which houses receptors, the activities of which may originate through other electrical activity (neural, motor, etc), or through chemical substances secreted from other cells (cytokines or hormones) or substances secreted by invading pathogens.

The cell is extremely resilient, which means that it has to lose more than 50% of its cellular activity before it is rendered pathological or diseased, and thus why there is such as remarkable reserve capability for certain types of cells.

We investigate and analyze the pathology of the cell (cytopathology/histopathology) by observing the cellular structure with regards to the number of cells, sizes and shapes of cells, in relationship to nucleus or other cellular components or other cells (typically as viewed under a light microscope).  We also investigate and analyze the pathology of the cell (pathophysiology) by what is secreted by the cell or  that which is leaked out of the cell into the blood stream or body fluids during cell injury or cell death, such as enzymes/proteins (specific to liver, or kidney, prostate, pancreas, gallbladder, adrenal, thyroid, specific tumor cell, or cardiac muscle, for example), fats, other type proteins, carbohydrates (sugar/glucose), and electrolytes, etc.  We investigate the secretion or leakage of these chemical components of the cell by using high tech, typically automated analyzer-machines in the clinical laboratory which are under National and International standards, guidelines and quality control/quality assurance systems.  This essentially gives us clues about the human cell in disease that would be needed in drawing a final conclusion for medical treatment and management, which is correlated with the clinical presentation, i.e. what the patient states as symptoms or what is observed through the physical examination, imaging studies, other clinical studies, etc.

We use different types of medications to prevent certain types of diseases and/or illnesses, as well as to assist cellular function when there is a decline in cellular activity as due to cellular injury  or cellular death for example.  Because of the degree of natural repair and healing which is apart of homeostasis-created through appropriately functioning organ systems, cellular injury and/or cellular death may go unrecognized clinically until a specific disease is in advanced stages. In other words, disease or illness is further defined by the decline in homeostasis, or abnormally functioning organ systems limiting a balance in overall human function.  Thus, this is the basic indication for preventative healthcare or health-maintenance programs. While we can’t completely eliminate cellular injury and/or cellular death as this is apart of the natural aging process, cellular injury and/or cellular death can be detected early to slow its progression or at least maintain a level of acceptable functionality as in certain types of chronic diseases for example. And, this level of surveillance requires clinical laboratory testing for Hemoglobin A1c in diabetes for example, or BUN/Creatinine/Urine Analysis to assess Kidney function from diabetes or high blood pressure or primary kidney disease, as another example; or to assess HIV-Viral Load/CD4 counts for HIV/AIDS status for still another example.

During Part II of this discussion (ALL ON MY INSTAGRAM ACCOUNT-CLICK HERE TO JOIN DR. GATES ON INSTAGRAM), Dr. Gates selects certain types of diseases to give illustration as well as to demonstrate through selective medical literature, ” how therapy and management are selected” in terms of inhibiting, reversing, maintaining or slowing the progression of cellular disease.

 

MDC-Atlanta remains committed to keeping our patients informed for better quality health care.


The Informed HIV Positive Patient

http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/10

 HIV Treatment Goal Page 1HIV Treatment Goal Page 2

Click on the above image

 

Patients are living LONGER LIVES with HIV because of the effective antiviral medications that are currently available, with a RANGE OF CHOICES. INFECTIOUS DISEASE EXPERTS NATIONWIDE AND WORLD-WIDE HAVE SET GUIDELINES FOR PRIMARY CARE PROVIDERS TO FOLLOW IN THE TREATMENT AND MANAGEMENT OF THIS DISEASE. The United States Department of Health and Human Services now acknowledges that this disease is a manageable Chronic Disease.  But it requires patients to be vigilant about their care, i.e. knowing their CD-4 levels and HIV viral Load Levels, as these are the two key components to determine treatment and management. Genotypic Resistant Testing (GRT) may also prove helpful to know. Furthermore, diet and exercise become critical with this management as well as partnership with a health care provider and routine visits to doctor, to check for side-effects of medication and/or monitoring progress of the disease.

Ask questions and STAY VIGILANT, as there are large numbers of patients who are now approaching more than 25 years living with this disease, and whose viral loads have been near undetectable, with CD4 count levels ABOVE 1000, without significant liver and/or kidney disease, bone-marrow suppression, lipodystrophy, neuropathy, opportunistic infections, or other significant sequella from this disease.

MDC-Atlanta, Informing Patients for Better Quality Health Care!!


Second Opinion For The Informed Patient

Source: Patient Advocate Foundation:

Please click on image below:

Second Opinion Part I  Second Opinion Part II

The Mission of MDC-Atlanta Remains Keeping Our Patients Informed, and Saving Lives-One Patient at a Time!!


Plain Talk About High Blood Pressure and Diabetes

 

High Blood Pressure Therapy Page 1High Blood Pressure Therapy Page 2High Blood Pressure Therapy Page 3

Click on the above articles to review

Millions of Americans suffer from two major chronic diseases: Primary( Essential) High Blood Pressure (Hypertension) and Diabetes type II.  These two diseases are associated with significant morbidity and mortality. However, if treated  and managed appropriately, one could see a rapid decline in the incidence of acute heart attack, stroke, and kidney failure. Although typically asymptomatic during early stage of the disease, these two (2) most prevalent chronic diseases are often mismanaged by primary care providers leading to detrimental complications widely known by the general public and costing billions of dollars for overall medical care.

Even though there are appropriate guidelines which are established by experts in the field of cardiology, endocrinology, and nephrology, among other related medical fields, patients continue to be misguided with recommendation for therapy. And, so after evaluating literally hundreds of patients living with these two prevalent diseases, it became clear that patients continue to be misinformed.  Although the causes of these diseases are multifaceted including genetics, dietary habits, and other risk-prone life-styles, hampering the development of these two devastating diseases is most prominent in Preventative Care Maintenance Programs.  Rather than getting into the pathophysiology i.e. the origin, development, and manifestation of these two diseases, I would rather list what patients MUST know to take control of their health to assist their physicians in managing their high blood pressure and diabetes, reducing the notion of “CLINICAL INERTIA” as described by the above article, and given the fact of those currently on inappropriate medications.  Consider this basic concept as one review the list below: Knowing what ingredients are needed to prepare a dish has major influence on the outcome of the prepared meal. The taste is literally in the pudding, i.e. what you know about or put into your own health-care can have major outcomes in advancing and/or preventing major complicating medical events.

Primary (Essential) HIGH BLOOD PRESSURE:

1. Patients who are forty (40) years are older, either with a personal or family history of early heart disease and/or stroke, should start with an ACE (Angiotensin Converting Enzyme) inhibitor or ARB (Angiotensin II receptor blocker) plus or minus a diuretic. If patients do not achieve control with an ACE inhibitor or Angiotensin II receptor Blocker, a second class of antihypertensive medication is attempted starting with a calcium channel blocker, which after no control, a third class of antihypertensive medication such as a beta blocker is added.  If blood pressure control is not achieved at this point, patients are then referred to expert for further management of their blood pressure control.   ACE inhibitors and ARBs are protective against heart attacks and strokes. The old school of thought of grouping patients into treatment strategy based on two ethnic groupings, White and Black, is outdated (i.e. A-ACE inhibitor for Whites; B-Beta Blocker For Whites; C-Calcium Channel Blocker for Blacks; and D-Diuretic for Blacks).  Because of low expense, we typically start our patients who are above the age of 40 years old, regardless of ethnicity on a combination therapy which includes Lisinopril (an ACE inhibitor) and hydrochlorothiazide (a diuretic), if tolerable and if there are no contraindications for these medications. The goal is to achieve a blood pressure level between 130-140/70-90.

2. Patients who are younger than forty years old, are typically given a trial of a diuretic alone, such as hydrochlorothiazide and/or counsel regarding life-style changes, appropriate dietary habits, and exercise.

3. Patients who are older than sixty-five (65) years old, should be primarily evaluated by hypertension (high blood pressure) specialist(s), prior to being placed on medical therapy, given the complexities that come with age, and that may influence therapeutic and management decisions.  Typically the goal is to achieve a blood pressure level between 140-165/70-90, but again this may be greatly altered based on other underlying complicating diseases, i.e. advanced stages of cardiovascular disease, and/or kidney disease.

4. We recommend that patients monitor blood pressure on a routine basis, by purchasing an automatic blood pressure monitor.  That way, patients may share their numbers with their physician on follow up visits, to assess control.

Controlling Diabetes AlgorithmADA Diabetes Therapy Algorithm

DIABETES TYPE II

1. There are standard guidelines according to American Diabetes Association and the American  Association of Clinical Endocrinologists, both websites are readily available to the public. While there may be some slight differences in recommendations, some basic fundamental principles hold.

2. Patients should know their numbers:

a) Hemoglobin A1c; The ideal number should be less than 6; but aggressive therapy may be delayed until numbers are above 7.2-8.0, or 9.0 depending on which authority one may review.

b) Monitor Glucose level: ideal range should be 80-110, again depending on patients other medical conditions and/or other specific guidelines that patients should discuss with their physician.

3) Follow strict dietary guidelines according to the above indicated Associations, as well as considering appropriate life-style changes and/or exercise.

Lipid ControlLipid Control Page 2

4) Know your numbers for your lipid status:

a) Total cholesterol, recommended 200 or less; but not less than 180

b) High-density lipoproteins (HDL), (cardiac protective) recommended greater than 50; the higher the better, and can be increased by increasing fibers to diet, and exercise.

c) LOW-density lipoproteins (LDL), (Increases risk of cardiovascular disease), recommended less than 100 or less than 70 for those with personal or family history of early heart disease, stroke, and/or diabetes

d) Triglycerides (also known as stored dietary FAT),  recommended less than 180, again depends on patient’s other medical conditions.

Disclaimer: We recognize the revised recommendations from the recent ATP-III panel. However, we, at MDC-Atlanta, believe that certain basic targets, as originally indicated by the previous ATP-III panel, give a level of guidance for patients to achieve a basic control with respect to LDL-cholesterol.  LDL-cholesterol  is the chief component to the development of atherosclerotic cardiovascular disease,  and thus increases risk for early heart attacks and strokes.  Remember, vascular disease is also a natural process of aging, and while we can’t completely eliminate vascular disease, we can responsibly reduce risks of complications from EARLY vascular disease.  Because of side-effects with certain cholesterol lowering medications, such as Statins, our medical practice shall remain selective and vigilant with regards to prudent medical therapy for reducing our patient-population risks of early, and advanced cardiovascular disease.

In General, therapeutic and mangement decisions are made with a goal to reduce patients’ risks for cardiovascular and Cerebro-vascular events, as well as other complicating illnesses,  while maintaining a HEALTHY LIFE STYLE.

We at MDC are committed to KEEPING PATIENTS INFORMED FOR BETTER QUALITY HEALTH CARE, Through Patients Partnership with a DOCTOR!!


How is My Disease/Illness Diagnosed?

Often times, patients are confused as to how a health care provider may derive at an accurate diagnosis in order to render effective treatment, management, and give patients an idea regarding whether or not the patient will get better or not (prognosis).

Patients should remember this simple equation:

symptoms+/- risks +/- signs + evidential support (lab tests, imaging studies, etc)

= Wellness or Diagnosis of illness/disease

The principle goal of medical evaluation is to derive at an accurate diagnosis of disease and/or illness.
So, when a patient sits down to chat with the health care provider, an interview regarding the patient’s health ensues.

The History of Present Illness (Symptoms):

-The health care provider asks a series of questions pertaining to the present illness, often initiated by “Chief of Complaint,” ie. “what caused you to want to see the health care provider?”

-Time or sequence of events pertaining to the “chief complaint.” When did this problem start? Was there an initiating event that caused it? Do you think the problem is getting better or worse? What makes it better, or what makes it worse? Are there any other symptoms that you can associate with this problem, and if so, what makes those symptoms better or worse? Are you having any other conditions that may be associated with the symptoms? Are there other concerns regarding your health and your current condition that you would like to address?

Past Medical/Surgical History (Risks)):

-Previous Medical Evaluation/Diagnosis: Do you have any other medical conditions that have previously been diagnosed by a health care provider? What are they? Have you had any surgeries done before? What are those surgeries that you have had done in the past?

Medication List (Risks):

Are you currently taking medications for treatment of specific diseases? What are they?

Allergy List (Risks):

Are you allergic to certain medications? What are the names of those medications for which you are allergic? What sort of symptoms do you associate with the medication allergy?

Social History (Risks):

Do you smoke or use tobacco or alcohol, or any other illicit drugs? If so, how long have you used tobacco, or how much alcohol do you consume within a week, for example?

Family History (Risks):

Are your parents currently alive and well? Do they have any medical conditions for which they are being treated? If your parents are deceased, what was the cause of death?

Based on the answers to the above questions, the health care provider generally has an idea regarding potential diagnosis, or diagnoses, as this is known as “A differential Diagnosis.”  The next step is The Physical Examination.”

The Physical Examination (efforts to detect signs of disease):

A general physical examination would include an objective analysis of all the organ systems, starting from a general health assessment, i.e. age appearance, physical appearance, gait, presence or absence of acute distress, orientation to time, person, place or situation, etc.  This is followed by assessment of vital signs,i.e. weight, height, temperature, blood pressure, pulse rate, and respiration rate. A detailed physical evaluation of all organ systems is then initiated, starting from Head and Neck, to Chest, then Abdomen; then Pelvis, Extremities, and finally the Neurological Assessment (which is often included during the performance of other parts of the physical examination)

At this point, specific diagnosis or diagnoses can be determined preliminarily.  A plan of action is then discussed with the patient with regards to gathering supportive, confirmatory evidence for disease or illness based on the above clinical assessment.  This would include the following:

Clinical or Pathophysiological Evaluation (ASE) (Evidential Support for Illness/Disease):

collecting blood/body fluid/tissue/cellular samples for laboratory testing

Special Clinical Studies, i.e. cardiac stress, ECHO,  EKG, EMG, Pulmonary function test (PFT), Endoscopy/Colonoscopy, bronchoscopy, colposcopy, cystoscopy, etc

The Anatomic or Structural Evaluation for Disease (Evidential Support for Illness/Disease):

-ordering imaging studies like X-rays, CT scans, MRI, bone scans, Mammogram, Ultrasound, etc

-Procedures, such as skin biopsy, or Fine Needle Aspiration, or Pap smear, Peripheral Blood Smear Review, etc

Based on the findings from the above collective studies, A FINAL DIAGNOSIS AND/OR DIAGNOSES ARE DETERMINED, and the following takes place concluding the medical evaluation:

-Plan of care, i.e. medications or surgeries

-Instructions and recommendations for life-style changes as appropriate for healthy living, recovery from disease or illness, maintaining acceptable functional course with stable chronic disease/illness, or preparing the patient for end of life process.

-Instructions and reading materials for patients to become Informed about their diagnoses and CARE-PLAN (we recommend that our patients get information from websites such as: MayoClinic; WebMD; and Medscape, for example)

-Recommendation for referral regarding specialty medical care and SECOND OPINION.

-Opened Question/Answer Session between Patient and Doctor

Preventative Care and Healthy Care Maintenance:

Now imagine, if the patients come in already prepared to answer the above questions, then the medical interview could be as short as 10-15 minutes, and the patients could be on their way to an accurate diagnosis, treatment, and management.  More importantly, patients without symptoms, should seek medical diagnosis before symptoms develop, as in complications from diabetes, or high blood pressure, or heart disease, or stroke,or HIV, or cancer, etc.  Typically when a patient presents with symptoms, the diagnosis of certain types of diseases is usually  in the advanced stages and effective treatment becomes limited.  Thus, we at MDC stress PREVENTATIVE CARE AND MAINTENANCE HEALTHY CARE, to avoid expensive, typically ineffective/inefficient sick care.

Consider preventing diseases through routine healthy check, and not just through dieting and exercising which are helpful but at no means all inclusive in the PREVENTION of major diseases, particularly as it relates to genetic, congenital, infectious, and degenerative diseases, for example.

 

Empowering Patients for Better Health-Care!

The Pathologist, as the common expression among other physicians,  “The doctor that is knowledgeable about many diseases, performs many investigative diagnostic procedures, and a member of the treatment/management team, BUT TOO LATE.” We at MDC-Atlanta, are committed to performing the medical tasks BEFORE IT IS TOO LATE, by partnering and communicating with patients DIRECTLY, as well as providing treatment and management of certain illnesses and/or diseases!

 


Spinal Pain, The Real Truth

Millions of Americans suffer from Chronic Spinal Pain.  Many choose to accept the debilitating function that comes with this type of long lasting and consistent pain, often times interfering with daily functional activity and/or routine activity with family and friends.

The real question becomes what is spinal pain, and what is the accepted course to deal with it.

Our late, and beloved President John F. Kennedy is an example of an elite figure in our history who had to deal with chronic, debilitating spinal pain, choosing medication to do so, in order to carry out daily activity.

Spinal Pain, commonly known as chronic back and/or neck pain, is often caused by a degenerative process of the vertebral (spinal) bone.  The vertebral column, or spine, is comprised of thirty (30) bones located along the central, posterior portion of the neck, back, and tail. Often times due to trauma, as it relates to motor vehicle accident, traumatic fall, and/or injury on job, or simply due to the aging process due to shear weight-bearing stress on the spine, the bones of the spine or vertebrae become brittle and began to break down.  During the life-long, on-going repair of the degenerative bone, extra bone, known as osteophyte, as well as fibrous and obstructive connective tissue may replace the original boney matrix with entrapped nerves along the cortex of the bone causing intense and severe debilitating pain.  Imaging studies, such as CT-scan and MRI, are used to define the anatomy of the abnormal boney structures of the spine.  This allows the patient’s health care provider to define the patient’s illness as it relates to the cause of the chronic pain syndrome, as well as to make recommendation for therapy and/or management.  Although, many of the painful symptoms are caused by irritation of nerves along the cortex of the vertebral bone, as well as nerves encased in reparative connective tissues within the medullary matrix of the bone, there is also bone on bone articulation where the intervening cartilage becomes less functional or absent all-together, as in degenerative knee/hip pain (osteoarthritis).

Three options for medical care currently exist for patients who suffer from chronic debilitating pain syndrome.  Those options are surgery, nerve block (with injecting anesthetic agents), and oral medication.  Often times, patients find themselves limited to medication to treat ongoing chronic pain syndrome due to the expense or inconvenience and other limitations that come with surgery and/or nerve block. Certain types of oral medications used to treat pain are similar in action as to endorphins.

“Endorphins are among the brain chemicals known as neurotransmitters, which function to transmit electrical signals within the nervous system. At least 20 types of endorphins have been demonstrated in humans. Endorphins can be found in the pituitary gland, in other parts of the brain, or distributed throughout the nervous system.Stress and pain are the two most common factors leading to the release of endorphins. Endorphins interact with the opiate receptors in the brain to reduce our perception of pain and act similarly to drugs such as morphine and codeine. “

Most, responsible patients who partner with their physicians to do the right thing in managing their chronic pain syndrome do quite well on oral medication, which tends to be effective in allowing the patient to carry on daily functional activity. Surely oral medication tends to be more readily affordable for most patients as compared to the other two options.

THE BRAIN AND CHRONIC PAIN, READ

Responsible management becomes the most prominent position to address. Nationally respected panels of pain medicine experts have created guidelines and recommendations for patients and physicians to follow, given the fact, that more than 80% of physicians who manage patients for chronic pain are general practitioners and family medicine practitioners.  And, studies have shown this to be safe and effective when done under appropriate guidelines and recommendations.

(The Journal of Pain Volume 10, Issue 2 , Pages 113-130.e22, February 2009)

It becomes the patient’s responsibility to partner with a physician in choosing which course of management will be most effective for the patient.

Every patient May NOT be a candidate for out-patient based pain management, and licensed physicians who treat patients with certain medications for chronic pain syndrome should be held responsible in making this life-altering decision for patients (in keeping with FIRST DO NO HARM).  Certain high-risk patients for outpatient pain management include those who: 1) require more than 200 mg of morphine-equivalent opiates per day; 2) have been previously discharged from pain management clinics due to overdose, diversion, abuse, and/or addictive behavior; 3) patients who do not have evidential, imaging support of disease indicative of pain management.  The idea is to treat debilitating pain, and NOT pleasurable behavior.  Thus, my recommendation to patients who suffer from chronic debilitating pain syndrome, is to choose your physician and/or health care provider wisely by doing due diligence in reading, asking questions, and making sure the patient understands risk versus benefit in  long-term, oral medicinal/therapeutic management for pain. Moreover, patients who chose to “doctor shop,” visiting multiple doctors simultaneously for certain medications,  or “pharmacy shop,” visiting multiple pharmacies simultaneously for medication fillings, place their own lives at risk for serious complications related to certain type of medications. Physicians or other health care providers who treat patients for chronic pain syndrome with certain medications have ethical and legal obligations to discontinue care of such patients in keeping with the platform, “first do no harm.”  Furthermore, combination therapy, such as xanax, Klonopin, somas, should not be used while taking certain oral medications because of the risk of seizure, coma, and/or death. In our practice, our strategy regarding managing patients with certain types of medication is to follow National Guidelines and Recommendations (refer to above reference article in The Journal of Pain) with respect to: a) retard the development of rapid, high-dose medication tolerance through appropriate dosing of medication; b) monitor for side effects with oral medication(s);c) monitor behavior for abuse, diversion, and/or addiction; and d) appropriately make recommendation for detoxification with withdrawal protocols, and referral to board-certified MD-psychiatrist and/or addictionologist as clinically indicated.  HIGH RISK PAIN MANAGEMENT-A DIRECTION FOR PATIENTS

We, at MDC-Atlanta, have found that the best course of therapy for our patients is to base treatment strategy on the degree of MRI or other imaging findings, i.e. severe degenerative changes with canal and/or foraminal stenosis, nerve/spinal cord impingement, with or without osteophyte formation and/or bone on bone articulation.  The level of pain also helps decide treatment strategy.  Thus, the idea is to “start low and go slow” with chronic opiate therapy for NON-cancer related pain (COT), to maintain low risk potential for addiction, diversion, and abuse.  With this, we suggest oral treatment should only be taken when pain level exceeds level 8 out of 10, and to resist the notion of around the clock COT usage.  Typically, there is a relief of debilitating pain during tolerable therapy for 5-6 hours or more. By  the patient supplementing pain therapy with anti-inflammatory or topical analgesic type medication in between high level pain, this may also delay rapid development of high risk potential. For example, during tolerable oral medication therapy, if a patient takes a pain (analgesic) medication, a tolerable pain level should be achieved for 5-6 hours or longer. As patient begins to experience an incline in intensity of pain, then the patient should take an anti-inflammatory-type medication (i.e. ibuprofen, motrin, advil, aleve, etc) to retard the need for another stronger analgesic medication.  Thus, the time for next dosage could be around 8-10 hours or longer.  Therefore, typically 2-3 tablets of select analgesics (pain medication) (less than 100 mg dosage equivalence/day), each tablet separated in time by at least 6-8 hours,  over an 18 hour day, per day, may be all that is needed.  Keep in mind,  the chronic pain patient should also get appropriate sleep for at least 5-7 hours per day, given a therapeutic cycle of 12-18 hours over a 24 hour period, under appropriate prudence of oral analgesic (pain) medication usage.

It requires law-enforcement, pharmacist, and health-care practitioner communicating with one the other to keep patients safe.  One missing link in this communication effort may bring harm to patient.

MDC-Atlanta remains committed to keeping patients informed for better quality and safe health care!

 


Who Interprets Your Cellular or Tissue Sample?

 

Diagnostic Medicine at A GlanceAffordable Care Act-ACT and the VALUE of Point of Care Laboratory Testing

It has been estimated that more than 50 million biopsies are sent to American Medical Laboratories for Diagnostic Interpretation each year. Let’s take a look at this for a moment.  When you factor in cost for patient to travel to physician’s office or hospital, time off from work, and the professional expense by clinicians/hospitals/laboratories/etc, the average cost to patient for the biopsy could be estimated as much as $1500-$2000 per biopsy, i.e. 50 x 10(6) x ($1500 or $2000)= $75 to $100 billion dollars or more perhaps annual cost for those biopsies to the patient-public. And, that’s just a low estimate!!

The question becomes:

-Are those biopsies absolutely necessary?

-Are the additional specialized tests on the biopsies absolutely necessary?

-Is there appropriate communication between the patient’s clinician and the laboratory medicine physician who interprets the test sample?

-Can the patient’s physician personally identify which laboratory physician provided the final interpretative diagnostic result?

-Does the patient’s physician know what diagnostic criteria were used and/or if a second opinion/review was rendered?

-What references are available for the patient’s doctor or the patient to review for more clarity regarding the specific final diagnostic report?

-Does the patient’s physician have a financial incentive to send biopsies to certain independent-referenced laboratories or hospital-based laboratories?

-How can the patient directly participate in selecting which laboratory physician provides diagnostic service to patient?

Remember, prior to CLIA’88, physicians routinely performed supportive medical testing on-site in the physician’s office.  With the advent of increasingly CLIA waived clinical laboratory analyzed-testing, more tests are being done at the physician’s office, where patients can ask questions about the futility of the testing as well as cost upfront for testing, thus decreasing the number of unnecessary, additional medical laboratory testing sent out to referenced medical laboratories.  We at MDC are making an attempt to bring real accountability in diagnostic laboratory medical testing back to the physician’s office through our unique medical practice.

 

At MDC-Atlanta, we answer the above questions for our patients with transparency and accountability.

 


Classifying Human Diseases

FUNDAMENTAL CLASSIFICATION OF HUMAN DISEASES:

1. Genetic/Inheritable/Congenital: Related to chromosomal abnormality by the transferring of genes from parents to child; or abnormality related to embryonic/fetal development and/ or surrounding birth.

2. Degenerative and/or Metabolic Disease: Related to the aging process or wear and tear

3. Inflammatory, Infectious: Related to pathogens such as Bacteria, Fungi, Viruses, Parasites, etc

4. Inflammatory, Non-infectious: Related to autoimmunity,allergens, environmental pollutants, etc.

5. Neoplastic, Benign or Cancerous: Related to abnormal growth or division of cells.

6. Trauma: Related to chemical and/or physical destruction of cells or tissue

7. Psychiatric: Related to the alteration in mental status and/or perception

Organic Disease Classification could be summarized as Follows:

GENETIC VERSUS ACQUIRED

ACQUIRED DISEASES CAN BE GENERALLY CATERGORIZED AS: CONGENITAL/DEVELOPMENTAL VERSUS REACTIVE VERSUS NEOPLASTIC

REACTIVE DISEASES INCLUDE: INFECTIOUS VERSUS NON-INFECTIOUS (Allergens, Autoimmune, and Degenerative-related to the aging process)

     NEOPLASTIC DISEASES INCLUDE: BENIGN OR CANCEROUS (MALIGNANT) TUMOR-GROWTH 

DIAGNOSTIC CRITERIA FOR SPECIFIC ETIOLOGY OF DISEASE

(Usually established by World Health Organization-WHO, or other International Authority)

This is typically based on:

a) Clinical Presentation and Physical Examination/Evidence

b) Laboratory tests

c) Imaging studies

d) Clinical Studies

e) Research/Investigation by Scientific Methods, Peer-reviewed

TREATMENT AND MANAGEMENT OF SPECIFIC DISEASE

Typically under the auspice of National Standards and Guidelines, as established by Panels of Experts within Selective Fields of Specialty

National Guideliness For Medical Therapy and Management

PREVENTATIVE CARE AND MAINTENANCE CARE

Typically under the auspice of National Standards and Guidelines, as established by Panels of Experts within Selective Fields of Specialty

At the end of our medical evaluation at MDC-Atlanta, we want our patients to understand how we derive at an accurate diagnosis, as well as make recommendation for treatment and/or management; and we welcome the patients to ask the following questions:

1) Which category is my disease classified?

2) What is the specific diagnosis of my disease and/or illness, and what diagnostic criteria were used, as well as which national or world standards were used to derive at the specific diagnosis?

3) What references are available for the patient to access with regards to getting more clarifications regarding specific diagnosis, treatment, management and prognosis?

Thanks for visiting Medical Diagnostic Choices, MDC-Atlanta, as we are committed to empowering our patients to being INFORMED FOR BETTER QUALITY AND SAFE MEDICAL CARE!


Ten (10) Reasons Why Patients Visit the Doctor

Here are the top ten (10) reasons why patients visit the doctor as observed by MDC-Atlanta:

1. Headaches and debilitating musculo-skeletal Pain

2. Acute Injury due to trauma

3. Acute infection, i.e. cold, flu, bronchitis, sinusitis, pneumonia, gastroenteritis, urinary tract infection, sexually transmitted infections, etc

4) Abnormal skin lesion, i.e. rash, abnormal growth on skin, etc

5) Acute respiratory failure, i.e. difficulty breathing

6) Acute neurological failure, i.e. abnormal speech pattern, weakness, loss of sensation and/or movement, etc

7) Acute cardiac failure, i.e. heart attack, congestive heart failure, arrythmia, etc

8) Well-check, weight gain,pregnancy, birth control, screening exams, and health maintenance/monitoring of chronic diseases (diabetes, high blood pressure,high cholesterol, cancer, HIV, etc), requiring physical examination, imaging studies, EKG, Labs, colonoscopy, stress test,  and other clinical studies.

9) Changes in mental health status, i.e. dementia, delirium, depression, psychosis, neurosis, etc

10) Hypochondria

 

In our practice at MDC, while we treat some of the above illnesses, we attempt to encourage our patients to seek routine health maintenance to detect disease in early stage and/or to PREVENT some of the above organ-system failure resulting in EXPENSIVE SICK-CARE.

RECOMMENDATION for Preventative Care and Well-Care Maintenance:

1) Ages 21-39, baseline complete medical evaluation, followed by routine doctor visit every 2-3 years or sooner as clinically indicated

2) Ages 40 -60, routine doctor visit once a year, or sooner as clinically indicated, to include National Guidelines for recommended screening health exams

3) Ages above 60,  routine doctor visit as clinically indicated.

4) Ages above 75, only as clinically indicated.


Medical Diagnostic Choices-MDC Atlanta