Eastside Family Health Center: April 2011

Saturday, April 30, 2011

Malignant Melanoma

What is melanoma? Melanoma is the deadliest skin cancer. The incidence of melanoma has more than tripled in the white population in the past twenty years and with this increase, the number of deaths. This truly can be a deadly disease and great diligence is needed to avoid it as well as to discover it early. The good news is that melanoma is uncommon in children ( but it does exist!)

Who is at risk of getting it? The risk factors for developing melanoma are both environmental as well as genetic. There is an interplay between these two factors. Males are more at risk; lower extremity lesions (skin abnormalities found on the legs and/or feet) were more common in non-white groups. There is overwhelming evidence of the association between melanoma rates and UV exposure (mainly associated with being in the sun). This is more true for exposed areas of the skin to the sun (sorry sun lovers!). The bad news is that bad sunburns even in childhood or adolescence increase the risk of melanoma. The data leans more toward intermittent intense sun exposure, in other words the occasional weekend sunburn from all day at the beach. Also, geography plays a role. The farther from the equator and the farther south increases the risk. If one has had a diagnosis of melanoma already, reducing the sun exposure recreationally really does help decrease the odds of getting a second melanoma.

As noted, it is interesting that the pattern of sun exposure is unique to the risk of getting melanoma. This tends to be associated with intense, intermittent sun exposure and frequently occur in areas exposed only sporadically such as the back in men or the legs in women. Melanomas of the head and neck are more common in outdoor workers. Parents, it is REALLY important to know that five or more severe sunburns in childhood give an estimated twofold greater risk of developing melanoma.

Most sunscreens with sun protective factor( SPF) will protect against UV-B and far less against UV-A. Unfortunately, there is no good data to prove sunscreens really protect against getting melanoma or any other skin cancer.

What about tanning beds? The hot topic is tanning beds. Technically, melanoma is more highly associated with UV-B but there is also strong data linking this cancer to UV-A which means patients using tanning beds and those treated with puva light therapy for psoriasis at an increased risk. The risk seems worse with the newer high speed, high intensity units. So, like a good doctor, I discourage the use of tanning beds, no matter what! If you want a tan, perhaps the best idea is the self-tanning lotions with DHA. It will help you look brown without the UV damage to your DNA.

What about moles? There are studies from Australia showing that the number of moles(or nevi) may be associated with increased risk. Someone with 50-100 moles is more strongly associated with melanoma risk ( up to 5% increase). It is very important to understand that if you’ve had a melanoma, you are greater risk of getting a second one. Thus, get your skin checked!

Be on the outlook for atypical moles. What is atypical? These are larger than the common mole(4-12MM); different colors( shades of tan or brown and pink or dark); some notched borders. Atypical moles have a higher risk of developing melanoma. If you have a funny looking mole, a dark mole, a new mole, a mole that has changed in its appearance, a lot of moles, or a family history of skin cancer, get a skin check up.

Even if these risk factors don’t apply, it is still a good idea just to get a skin check, period.

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Dr. Frank Marinkovich owns and operates Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.
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Thursday, April 28, 2011

High Cholesterol and Risk of Heart Disease

Hypercholesterolemia refers to increased levels of lipids (or fats) in the blood, which includes cholesterol and triglycerides. High cholesterol does not make you feel bad, but it can significantly increase your risk of developing heart disease, which is also called coronary heart disease. High cholesterol can lead to hardened arteries of the heart. These hardened arteries can be a cause of chest pain or heart attack or both. Because of the risk of this happening, treatment for high cholesterol or high triglycerides is usually recommended.

One type of cholesterol is LDL cholesterol, known as bad cholesterol, and it is the most accurate predictor of coronary disease, i.e. the higher the number, the more your risk of coronary disease. If you have had a heart attack or another significant vascular event, such as a stroke, your LDL goal should be less than 70. Otherwise anything less than 130 is optimal.

Other risk factors: Once you are aware of your cholesterol numbers, there are some other factors that also affect ones risk of coronary disease (heart disease). Other factors that can increase your risk for coronary disease include: cigarette smoking; high blood pressure; family history of heart disease( usually males younger than 55 or females than 65); males; and increasing age.

As well there are certain diseases that increase the risk of complications with coronary disease. Some of these are: Diabetes, type I and 2; symptomatic carotid artery disease—like stroke or TIA; peripheral artery disease; abdominal aortic aneurysm; and kidney disease.

Do I need treatment? The decision of who gets treatment for cholesterol and at what cholesterol number is treatment recommended is confusing at best for the public. This blog will give the ACP (American College of Physicians) guidelines and a table to determine your own level of risk. The ACP recommendations are based mostly upon the LDL cholesterol and the number of cardiac risk factors as noted above.

It is important to note that the ACP considers diabetes, carotid disease, aortic aneurysms and peripheral artery disease as heart disease equivalents (in other words equal to heart disease. The others such as smoking, high blood pressure and age are considered major risks, but not equivalents.

If two or more risk factors other than high LDL are present in a patient without heart disease (or an equivalent such as noted above), the ten year risk of developing heart disease is calculated by a risk table( see below).

NOTE: If you have 0-1 risk factors your 10 year risk is less than 10%.

Adapted from Adult Treatment Panel III at http://www.nhlbi.nih.gov/ The point total is determined in each category and the 10-year risk determined in the bottom row.

NOTE: These risk estimates for the development of coronary heart disease do not account for all important cardiovascular risk factors. Not included are diabetes mellitus (which is considered a CHD equivalent), family history of CHD, alcohol intake, and the serum C-reactive protein concentration.

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Estimate of 10-Year Risk for Coronary Heart Disease
Framingham Point Scores

Estimate of 10-Year Risk for Men

Framingham Point Scores by Age Group

Age	Points
20-34	-9
35-39	-4
40-44	0
45-49	3
50-54	6
55-59	8
60-64	10
65-69	11
70-74	12
75-79	13

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
<160	0	0	0	0	0
160-199	4	3	2	1	0
200-239	7	5	3	1	0
240-279	9	6	4	2	1
280+	11	8	5	3	1

Framingham Point Scores by Age and Smoking Status

	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
Nonsmoker	0	0	0	0	0
Smoker	8	5	3	1	1

Framingham Point Scores by HDL Level

HDL	Points
60+	-1
50-59	0
40-49	1
<40	2

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

Systolic BP	If Untreated	If Treated
<120	0	0
120-129	0	1
130-139	1	2
140-159	1	2
160+	2	3

10-Year Risk by Total Framingham Point Scores

Point Total	10-Year Risk
< 0	< 1%
0	1%
1	1%
2	1%
3	1%
4	1%
5	2%
6	2%
7	3%
8	4%
9	5%
10	6%
11	8%
12	10%
13	12%
14	16%
15	20%
16	25%
17 or more	30%

Estimate of 10-Year Risk for Women

Framingham Point Scores by Age Group

Age	Points
20-34	-7
35-39	-3
40-44	0
45-49	3
50-54	6
55-59	8
60-64	10
65-69	12
70-74	14
75-79	16

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
<160	0	0	0	0	0
160-199	4	3	2	1	1
200-239	8	6	4	2	1
240-279	11	8	5	3	2
280+	13	10	7	4	2

Framingham Point Scores by Age and Smoking Status

	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
Nonsmoker	0	0	0	0	0
Smoker	9	7	4	2	1

Framingham Point Scores by HDL Level

HDL	Points
60+	-1
50-59	0
40-49	1
<40	2

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

Systolic BP	If Untreated	If Treated
<120	0	0
120-129	1	3
130-139	2	4
140-159	3	5
160+	4	6

10-Year Risk by Total Framingham Point Scores

Point Total	10-Year Risk
< 9	< 1%
9	1%
10	1%
11	1%
12	1%
13	2%
14	2%
15	3%
16	4%
17	5%
18	6%
19	8%
20	11%
21	14%
22	17%
23	22%
24	27%
25 or more	30%

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Saturday, April 23, 2011

STROKE

Just recently at Eastside Family Health Center we diagnosed a previously healthy man in his mid-fifties with a stroke. This has been a life-changing event for him and for his family. I thought it would be good to review the topic of stroke on this blog.

Stroke is the term doctors use when a part of the brain dies because it goes without blood for too long. There are two main types of strokes: those caused by a blockage in a vessel in the brain and those caused by a bleeding in the brain or surrounding area.

In the USA there are about 700,000 strokes per year. Most of these are caused by a blockage in a blood vessel. Early treatment of stroke can reduce brain damage that occurs for this reason time is of the essence. Here, time equals brain lost or gained.

The symptoms of a stroke may begin suddenly or develop over hours or days. The damage from a stroke may be temporary or permanent.

Ischemic strokes are those caused by a blockage in one of the blood vessels that supply oxygen to the brain. If the blockage is not relieved after just a few minutes, the brain fed by that artery will become damaged.
Embolic strokes occurs when a blood clot travels from one part such as the heart to a smaller blood vessel in the brain. This is called an embolus. One of the most common causes of an embolus is an irregular heart rhythm called atrial fibrillation.

Intracerebral hemorrhage is bleeding in the brain. The blood is an irritant to the brain and puts pressure on the surrounding tissue. Some common causes of hemorrhage include: high blood pressure, injury, bleeding disorders, and deformities of blood vessels such as an aneurysm.

A subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures. The blood pools in the space between two layers of tissue covering the brain (the subarachnoid space). The most common symptom of a subarachnoid hemorrhage is a severe headache called a thunderclap headache or the worst headache of one’s life.

There are a number of risk factors for ischemic stroke: age older than 40, heart disease, high blood pressure (defined as any blood pressure higher than 110/60 ) , smoking, diabetes, high cholesterol, illegal drug use, recent childbirth, TIAs( stroke symptoms but with no evidence via CT or MRI that resolve with 24 hours), obesity, or past history of blood clots.

Risks for hemorrhagic stroke include: high blood pressure, smoking, cocaine use or use of blood thinners such as warfarin.

As high blood pressure is a common risk factor here is an interesting graph showing the relationships between increasing blood pressures and age to stroke risk. You can’t slow down your aging but we all can watch our BP’s!

Classic symptoms of stroke can be remembered by the acronym FAST:

Face—sudden weakness or droopiness of the face or visual problems
Arm--- sudden weakness or numbness of one or both arms
Speech—difficulty speaking, slurred speech, or garbled speech or inability to speak
Time—Time is critical, the sooner the intervention the better the outcome.

A stroke is a medical emergency! Call 911. If it is an ischemic stroke and caught within a window of three hours, a medicine may be used to dissolve the clot. A brain scan will be done in the ER to help differentiate what type of stroke it is.

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Wednesday, April 13, 2011

Gout...

Even though gout has gotten a lot of publicity in the recent years, it actually has been around a couple of thousand years. There are reports that mummies in Egypt had evidence of gout when dug up in the pyramids. In the past, it was called rich man’s disease, as it has been related to foods the supposed wealthy eat, such as steaks.

What is gout? Gout is a painful and often debilitating condition that develops in people that have a high blood substance called urate which is the breakdown product of protein. Not everyone with high levels of urate (also called uric acid) develops gout and up to two-thirds of those with high levels never get gout. We do not know why some do and some don’t.

Joints are the main areas of involvement of gout, classically the big toe. Other parts of the body can be affected as well such as the kidney or urinary tract causing kidney stones (uric acid stones cause 15% of stones).

A gout attack can cause a sudden intense pain in the joint. This is usually associated with redness, swelling, and tenderness of the joint. An attack usually is in one joint, but some people develop a few inflamed joints at the same time. The pain peaks within several hours but can resolve spontaneously after a few days. I believe an attack should be treated, as gout may destroy a joint. Anti- inflammatory medications are the mainstay of treatment.

What are characteristics that increase risk? Those would be obesity, high blood pressure, a recent trauma, fasting, consuming excessive amounts of alcohol especially beer or spirits but not wine, eating meat or seafood, and taking certain medications such as diuretics.

There are three phases of gout: Acute -with the above noted symptoms of redness, swelling, pain; Inter-critical period- a second attack of gout that typically occurs within two years; and chronic phase. People who have recurrent attacks may develop tophaceous gout which are large number of urate crystals that collect in joints, bones, and cartilage. These tophi can cause the joint to become damaged and even deformed.

Do you need to treat? Yes! First, for the pain which can be severe; second,to help prevent chronic gout which may threaten the joint; third, to help prevent uric acid stones; and fourthly,to decrease the overall load of uric acid in the body which may be a cardiovascular risk factor.

After the acute treatment, prophylactic therapy is usually done to prevent or reduce recurrences. The most common therapy is allopurinol which is a medication that decreases the formation of uric acid in the body. It may take weeks or months to lower the total amount of uric acid in the body. During this time, it is important to drink plenty of water and adjust the diet to more fruits and vegetables, less red meat, less seafood, less beer and hard liquor, less high fructose containing foods with corn syrup( some diet sodas). You are encouraged to eat and drink low fat dairy products, eat foods made with complex carbohydrates( whole grains, brown rice, oats, beans), a moderate amount of wine( 1-2 five ounce servings per day), coffee( this may actually decrease the risk of a gout attack), and vitamin C( 500 mg. per day) which increases the release of uric acid in the urine. Please note that a change in diet alone without the use of some preventive medication is not likely to work very well as diet alone lowers blood urate levels only by 15-20%.

Finally, do not be surprised if your doctor wants to aspirate the fluid in your involved joint. This is the best way to be sure of the diagnosis of gout. The fluid once tapped would then be sent for analysis of crystals.

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Tuesday, April 12, 2011

Gluten Free...Why?

You have probably seen the labels in the grocery store “Gluten Free”, but why? If you have heard the word gluten or wheat insensitivity, you are on the track of celiac disease. Celiac disease, like Vitamin D deficiency is coming into its own on the medical front lately. This disease indeed is not new at all but spans all the way back to the second century! It used to be thought of only as a bowel mal-absorption issue and not all that common but now has been linked to numerous other diseases.

During World War II during periods of food shortages, the symptoms of patients improved once bread was replaced by non-cereal containing foods. There was less diarrhea and abdominal cramping. A doctor by the name of Dicke found that wheat, barely, and rye all could trigger the abdominal pain and foul stool.

Later it was found that the primary problem occurred in the small intestine with inflammation and flattened villie (the fingers of the bowel that are responsible for absorption). There was found to be a genetic factor as well. Celiac disease is genetic disorder (Hla-DQ20) that is triggered by an environmental agent (gluten) in a predisposed individual. There is a strong association between the genetics of celiac disease and type I diabetes.

What are the symptoms? Some common symptoms of the disease include: bulky, foul smelling floating stools, a lot of gas, weight loss, anemia, deficiencies of vitamins such as vitamin D, osteoporosis. These are classic findings. Many, however, are without symptoms at diagnosis.

How do you know if you have it? The best way to make the diagnosis is a biopsy of your small bowel. There are blood tests also that are available. Ask your doctor for an endomyseal antibody test. There is an antibody called IgA that is especially associated with Celiacs.

This disease as noted is much more common than once thought. It was originally thought to be only related to mal-absorption of the bowels. It may be as high as one person in 250 affected. The question arises should everyone be tested even if no symptoms? Possibly.

So, should you be tested? There are four reasons to consider it: 1) the danger of cancer—the risk of cancer associated with Celiacs is not fully known but there is some association 2) the presence of unsuspected nutritional deficiencies (i.e. body not able to absorb nutrients) 3) to association with low-birth weight babies 4) the occurrence of autoimmune diseases such as diabetes and thyroid diseases.

As well, there is a ton data coming in now for associations with this disease with other things such as: arthritis (osteo), iron deficiency (high association), osteopenia/osteoporosis( due to vitamin D and calcium deficiency), kidney disease, risk of cancer-this is under active study, rash:, liver disease including hepatitis, menstrual issues, and perhaps even heart disease.

It is amazing to see the possible links of this disease with all the above! What is just as amazing is to think that all or most of it is treated or even avoided by simply a strict adherence to a gluten-free diet! Even the rash goes away with this diet! That is why I think you should ask your doctor if it makes sense for you to be screened for this disease.

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Saturday, April 30, 2011

Thursday, April 28, 2011

Estimate of 10-Year Risk for Coronary Heart Disease Framingham Point Scores

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

Saturday, April 23, 2011

Wednesday, April 13, 2011

Tuesday, April 12, 2011

Estimate of 10-Year Risk for Coronary Heart Disease
Framingham Point Scores