Ask Dr. Chung

Subject: Introduction

How do I find your answers to past questions?

You can use either the search/find functions of your browser or you can go to the INDEX. This is a large file so be sure to let it load completely before searching.

If you do not find the answers you seek, please know that I try to respond to requests for medical information (not advice) when they appear to be genuine. The only requirement is a minimum $35.00 donation to Doctors Without Borders which is the organization that won a Nobel Prize in 1999 for freely helping people with urgent medical needs around the world. Simply click on this link and fill out the form with as the second donor. They will send you an email confirmation which you should forward to me along with your question to Alternatively, a $35.00 on-line donation to the Wellness Foundation is also acceptable if the email confirmation is included with your question. Replies will usually be sent out within 24 hours except on weekends, holidays, or when I am away attending conferences. Please know that I literally receive hundreds of emails daily so that if you desire a more timely response or want to ensure that I answer your query, you should also call my office to inform me of your need.

Of course, you may want to consider visiting me in person at my office to have me answer your questions and to give you specific medical advice about your heart. Many people have found this to be the preferable route after visiting here. I am available for office consultation Monday through Friday by appointment only. You can make this appointment by calling my office.

Subject: Helpful Question Asking Pointers

Can you provide some tips on how to get a more meaningful email response?

Certainly, here you go.


(1) When asking a question, clearly state the subject.

Reason: I tend to group delete email with ambiguous subjects.

(2) When asking a question, make the narrative as brief and succinct as possible and clearly frame the question.

Reason: After scrolling through several pages, patience can become short (and the chances will be pretty good that I will be interrupted by my beeper before I get to the question). Also, with no obvious question, there can be no obvious answer.

(3) Try to be clear about what happened when the primary physician was consulted.

Reason: I get nervous when people are asking me questions without any intention of seeing a doctor who will actually physically examine and take care of them.


(1) Don't use me as a substitute to seeing your primary physician. My helping you should only serve as an adjunct.

(2) If you feel acutely ill, call 911. Have your family log you off and turn off your computer.

(3) Please don't even think about being your own doctor.

Subject: Nonadherence to medical treatment

I've received the advice: "don't take any drug unless you are in a life threatening situation." Is this good advice?

No. Physicians prescribe medications to prevent sequelae more often than to treat life threatening conditions. This advice is dangerous for the millions of individuals with hypertension, diabetes, and heart disease. Moreover, vaccinations are also medications and are given *before* someone is stricken. This advice would counsel someone against vaccinating their children against mumps, measles, rubella, diptheria, polio, tetanus, varicella et cetera.

Sure, side effects are always a concern and seem to be especially serious when they strike close to home but when medications are prescribed, your physician weighed the benefits against risk of possible side effects. He/she is not paid extra for your purchasing and taking the prescribed medications and assumes full responsibility for any bad outcome.

Subject: Free Medical Advice

Any pointers on how to stay healthy?

Here you go:

(1) Everything in moderation (even too much water can kill you).
(2) Safe Sex (or notarized complete sexual history from your partner... yeah right).
(3) See your primary physician and primary dentist at least once a year (your car gets a tune-up, oil change and/or emissions check as or more often than that).

I'll get off my soapbox now ;-).


Top or Index

Subject: Cancer

What causes cancer?

Things that damage DNA or impair the ability of one's cells to repair damaged DNA.

Some examples:

(1) Chemical carcinogens.
(2) UV radiation.
(3) gamma radiation.
(4) genetic predisposition usually traced to a defect in DNA repair mechanisms.
(5) certain viral pathogens especially retroviruses.
(6) aging.

Subject: colon cancer

Is colon cancer inherited?

The susceptibility to colon cancer can be inherited. See your primary physician about scheduling special colon cancer surveillance (i.e. colonoscopy) if you have first degree relatives with colon cancer.

Subject: hypercoagulability

Why do some people have a tendency to clot internally?

a short list of causes of hypercoagulability:

(1) elevated serum homocysteine
(2) protein C deficiency
(3) protein S deficiency
(4) antiphospholipid antibody
(5) antithrombin III deficiency
(6) leiden mutation (factor V defect)
(7) polycythemia vera
(8) malignancy.

Subject: Serum Protein Electrophoresis

Why do doctors order this test?

Serum protein electrophoresis is a test to detect abnormally high levels of specific proteins (i.e. paraproteins, kappa light chains, etc) which can suggest the diagnosis of multiple myeloma (a condition known for severe bone pain among other things). An abnormal test would be an indication for a bone marrow biopsy in order to secure this diagnosis.

Subject: Bone Scan

What is a bone scan?

a radiographic imaging technique

How is it done?

A labelled substance for which bone cells have an affinity is given by vein and a scintillation imaging system spatially maps where the uptake occurs.

and what can they tell from it?

Areas of higher than background uptake indicates areas of increased bone-forming activity. These areas would be suspect for either recent injury or disease process.


Top or Index

Subject: Stroke

What is a stroke?

This is a condition where part of the brain is injured from not getting enough blood. Some liken it to a heart attack of the brain or a "brain" attack. There are two kinds of stroke. The first arises from a blockage typically made up of clot that keep blood from getting to an area of the brain. This is known as an ischemic or embolic stroke. The second kind is caused by internal bleeding and is known as a hemorrhagic or a "bleeding" stroke

Subject: Stroke

What does a stroke feel like?

Typically, the stroke victim feels no discomfort. Classically, the victim finds that s/he is suddenly no longer to move one side of his/her body. There may also be slurring of speech.

Subject: Stroke

How is it treated?

Time is of the essence with any treatment because brains cells depend heavily on oxygen carried by the blood and die rapidly when there is a lack of oxygen. There is at most two hours after which brain cells become permanently lost so that administered treatment would no longer be effective. An ischemic stroke responds well to "clot-busters" when administered in a timely fashion. Surgical intervention for a bleeding stroke is problematic.


Top or Index

Subject: What is Hypertension?

I have been having elevated blood pressures with the lower number in the mid-100s. Some people in this newsgroup say that I will need 5 different readings on five different days before I can say I have hypertension. Is this true???

An accurate reading of diastolic pressures in the mid-100's is cause for concern even during just a single office visit. Sure, multiple reading (from only two different days *not* five) are required to diagnose essential hypertension but hypertensive *urgency* (SBP>220 and/or DBP>120) should receive immediate treatment with medication to lower BP in a timely fashion. If there is evidence of end-organ damage (AMS, papilloedema, retinal hemorrhaging, heart failure, chest pain, hematuria etc) then such elevated blood pressures should be classified as hypertensive *crisis* and warrants immediate hospitalization..

Subject: calcium channel blockers

If you start using this medication(approximately 3 months or less) will you pressure automatically be elevated above the level you started if you stop?


Can you ever stop using this medicine and replace it will natural therapies?


How can I wean off of it safely?

By the daily monitoring of your blood pressure, you can make changes that lower your pressure enough to allow you to no longer require the CCB.

My top pressure was 180 one day when I was > upset.

This means you may not be there yet as far as consideration for coming off the CCB safely.

At what pressure do you get headaches??

This will vary with each individual.

Subject: Cardizem CD

How can you wean away from this drug if you take a 120mg capsule daily for six months?

How long will I need to taper it off?

This drug is a calcium channel blocker rather than a beta blocker which could cause "rebound" hypertensive crisis with abrupt cessation. You should be able to switch from cardizem to another class abruptly w/o any untoward effects provided you aren't needing it for rate control. At any rate, you need to have your doctor involved in any changes you might make.

Subject: Hypertension

When does one accept the diagnosis of essential hypertension?

About 95% of all newly diagnosed hypertension are primary (aka essential) which means that there are no secondary causes. For this reason, an extensive and costly workup is usually not undertaken. Plus, routine blood tests that show values within the normal range probably rules out a few secondary causes such as Conn's syndrome, polycythemia, renal insufficiency, etc. The physical exam and heart investigations usually rule out rare things like coarctation of the descending aorta above the level of the renal arteries. However, there are a few secondary causes that would still be missed by these routine investigations and these include pheochromocytoma and unilateral renal artery stenosis.

If your hypertension is refractory to the usual measures of weight control, low sodium diet, abstinence from alcohol, exercise, and reasonable amounts of antihypertensive medications, no one would fault your physician for taking the expense of more extensive testing to look for a secondary cause for your hypertension..

Subject: How to stop beta blocker?

I need to stop taking it. I am half asleep at work, and that's not fair to my employer. I am in between doctors.

How long will I need to taper it off?

Changing doctors to find one that is receptive to ones needs/concerns is fine. In the interim, if your are taking yourself off the beta blocker (even if done gradually), you'll need to add something else to keep your blood pressure under control. Thus, I would suggest you find another doctor before tapering.

Subject: Immediate Symptoms of Elevated Blood Pressure

My blood pressure has been bouncing around since coming off medications and has gone as high as 180/120! I notice a sort of tightness all over my body but especially my face and head, sort of like all my muscles are contracting very hard but my muscles are not tensing at all. I also feel like I have a weight on my chest - making it hard to breath in deeply. Can high blood pressure cause these symptoms???

Yes, symptoms can appear when one's blood pressure gets too high. Especially worrisome is the chest-tightness you have just described. If you are having these symptoms now, please call 911. Otherwise, contact your doctor for an urgent evaluation.

Subject: hypertension

What is the normal variation of the blood pressure at rest during day time?

Higher in the mornings especially on awakening (especially when the alarm goes off ;-) Lower in the evening/night.

What is a normal increase of blood pressure under light/medium/strong exercise?

Typically about +60 mmHg systolic and +20 mmHg diastolic (for exercise that reach a target heart rate of 155 bpm)

Source: Majahalme et al., AJH 1997;10:106-116.

Blood pressure at rest should be measured after at least five minutes of rest. How is this condition fulfilled in a 24 hour test? And if it is not fulfilled, how can the results be interpreted in a meaningful way?

It's not. Why should it be when you have the entire BP curve to look at? You'll be able to see when the patient's BP is elevated from exertion or stress. The bottomline is that with 24 hr ambulatory monitoring, you can determine with 100% certainty whether a person's BP is sustained at a high level and thereby rule out "whitecoat" hypertension. Also there has recently been norms established for young adults that expand the utility of 24hr ambulatory BP measurements.

Source: Chase et al., AJH, 1997;10:18-23.

Subject: Blood Pressure

Want to buy a blood pressure monitor. There are wrist types, Arm Types and Finger types.(Omron). Please advise on which is the most accurate one. Appreciate recommendations with model number and if possible approximate price.

Most accurate is a properly sized manual arm cuff and a stethoscope. Your doctor should be able to show you how to measure your BP.

Subject: Hypertension

I recently had an allergic reaction to lisinopril (an ACE inhibitor). Aside from beta blockers, calcium channel blockers and diuretics, what other antihypertensive medications are there?

Here are some other classes of antihypertensive medications:

alpha blockers
central acting agents (ie clonidine)
direct vasodilatory agents (minoxidil, hydralazine, etc)
long-acting nitrates (ie NitroDur patch, Imdur, etc) although generally not prescribed solely for hypertension.

The working assumption is that your physician has ruled out secondary causes of hypertension.

Subject: hypertension

What is an auscultatory gap?

The auscultory gap happens when the first Korotkoff sound fades out for about 20-50 mmHg only to return. This can cause an undermeasurement of the systolic BP when the cuff is inflated to a pressure within the "gap". One just have to be certain that the cuff is inflated to a higher pressure to get a more accurate systolic reading and ignore the "gap" to get a true diastolic reading. This phenomenon when present is suggestive of arteriosclerosis..

Subject: Impotence and Hypertension

Are there any anti-hypertensive medications without sexual side effects?

Your primary physician would know to avoid beta blockers which have the most impact on male sexual functioning. That leaves plenty of other medications that may work for you.

Subject: Hypertension

Why is there a warning about hypertension on the labels of OTC sinus medications?

The concern is that many over-the-counter cold medications contain a nasal decongestant such as pseudoephedrine which will raise blood pressure.

Subject: Epistaxis and Hypertension

Why do some people experience nose bleeds when their BP rises?

They likely have thin-walled branches of the superior labial branch of the facial artery.

At what reading would this occur?

This would be subject to individual variation.

What can be done (apart from trying to lower the BP) to try and prevent this?

An ENT specialist could cauterize them but if the nosebleed warns someone that his/her blood pressure is high, left alone it may someday save that person's life.

Subject: Wide pulse pressure

Care to comment on the following reference?

TITL: Pulse pressure: a predictor of long-term cardiovascular mortality in a French male population.

AUTH: Benetos A; Safar M; Rudnichi A; Smulyan H; Richard JL; Ducimetieer e P; Guize L

CITE: Hypertension 1997 Dec; 30 (6): 1410-5

The hypothesis presented by these French investigators that in the >40 yo males that they followed longitudinally, the ones observed with wide pulse pressure (consistent SBP-DBP > 65 mmHg over a 19 year period) likely had preexisting underlying aortic pathology (stiffening of the aorta from arterioslerosis) is a good one. It is well known that people who die from coronary occlusive disease will typically present with a severely arteriosclerotic aorta (the aorta is very stiff, noncompliant, and "shaggy" from all the cholesterol build-up). So these observations and the hypothesis proposed by these investigators were not really surprising.

What does this hypothesis mean if true?

(1) In *some* males who are older than 40 years old, a wide pulse pressure may indicate arteriosclerosis of the aorta which will also yield a statistical association with coronary athersclerotic disease. A word of caution here, physiologically a wide pulse pressure can be caused by rapid dissipation of the systolic pressure by healthy large vascular beds in highly conditioned individuals (champion marathon runners often have pulse pressures >65 mmHg) and also in chronic disease states not associated with vascular occlusive disease (hyperthyroidism, pernicious anemia, congenital valvular disease, and AV malformations).

(2) A wide pulse pressure in a person with multiple risk factors (two or more) for coronary disease should raise the index of suspicion for *pre-existing* disease of the aorta. The clinical utility of this clinical finding will therefore depend on the rest of a patient's history and physical exam.

The bottomline: Only your doctor will be able to accurately determine whether further diagnostic testing and/or treatment is indicated if you have a wider than usual pulse pressure. For most people reading this newsgroup, a wider than usual pulse pressure probably adds little to what their doctor already knows about them.

Heart Attack or Chest Pain

Top or Index

Subject: stress EKG test

Speaking of stress EKG test questions, I have one: The day after I passed a stress test (with only one ambiguous reading. The MD was not worried), I was at the mall and passed by a treadmill booth. The MD had suggested I get a treadmill, so I played with one, revving up the speed fairly quickly and chatting with the salesman while walking briskly. Within hours I experienced chest pain and a little shortness of breath. Is it possible I just did too much too fast? Is that normal when you hit 50? Or should I pursue that little ambiguous reading with my doctor?

I would suggest you pursue it. Exercise induced chest pain is not normal at any age.

Subject: Heart Attack - What Really Happens?

Can someone have a heart attack without having risk factors?

The answer is that a person can have a heart attack without having any "known" risk factors. I've seen it but the way I would explain it is that we don't know all the risk factors.

Subject: LAD

Hospital angiogram records state that the "LAD is wrapped around apex". This is accompanied by a drawing. Is there something about this which is significant and/or would be something I might want to know about?

It means that this LAD is an extra important blood vessel that supplies both the front and underside of the heart and if it were to close off completely in the heart attack, it is unlikely to be compatible with life.

Subject: Q Wave positive

Could you explain to me what Q Wave positive and no ST elevation would signify in layman terms?

Possible heart attack in the past but nothing going on presently.

Subject: Left Ventricle Question

What does a hypokenetic left ventricle means? I had a MI 1 1/2 years ago, and a stress echo turned up this result and I was wondering what it meant. BTW: They attributed my MI to a vasospasm because my cath was clear, the only other problem they found was a slow heart rate (~45 resting).

It means that your left ventricle (the main chamber of your heart) is weak.

Subject: Left-axis EKG abnormality

I was diagnosed with this, about eighteen months ago. I had a wonderful doctor at that time, who took it into consideration along with my costochondritis, and put me on BuSpar, to reduce stress effects, and commended my three-mile a day walking routine, and kept an eye on me. Then he left his practice, and I got the Worried Doctor of the Universe, who immediately scheduled me for a Thallium stress test. Big mistake, a s I am claustrophobic, so I ended up not having that test. Now, I am in limbo, as I need to get to a new doctor--I just want the first one back! :-( --and am really wondering: Why? If blood tests never have shown a heart attack, if I am walking, if I am keeping my weight under control, and feel okay, why pursue this? Please, if anyone answers, I don't need to be frightened into doing anything, I just need some sensible reasoning.

I wouldn't second-guess your doctor especially since s/he seems to be trying not to miss anything. The mere fact that you've had tests to rule out a heart attack sends up red flags for me. There are other alternatives to a stress thallium that may suit you better. Ask your current doctor.

Subject: Heart attack; low cholesterol (70)

A good friend just had a severe heart attack. 32, female, slim, cholesterol=70 (!?), stopped smoking 6 months ago; 90+ % blockage of a major artery. I'd like to read about possible causes, but my websearch has turned up empty.

Any opinions as to cause?

Checking cholesterol within a few days of a heart attack can give a falsely low reading. A recheck in a few weeks may reveal that high cholesterol is a contributing factor.

Subject: Chest Pain

My father has been having chest pain. What could this mean?

If the pain is sharp and tearing, it could be something life threatening like aortic dissection, where the large blood vessel from the heart is splitting apart because of being weakened by atheroslerosis.

If the pain is relieved with a nitroglycerin pill under the tongue, it could be angina pectoris. Sometimes pain from a hiatal hernia or other esophageal problems can also be relieved with nitroglycerin.

Of course, there is always concern that chest pain is from a heart attack.

However, instead of guessing what it could be, it would be wiser if you redouble your efforts toward getting your father to his doctor.

Subject: Angiogram it worth the risk in my case?

I have been experiencing angina-like symptoms for almost 7 months. It started with pain/tightness in the middle of my chest (exertion wasn't necessary for it to occur). I am also experiencing 10-15 episodes of left arm pain accompanied by tightness in the left side of my neck and pain in jaw.

I have had several tests to determine whether or not the pain is heart related:
-stress test
-stress echo
-holter monitor
-several ECGs
-blood work in emergency
-GI scope

Everything has come back negative with the exception of the GI scope. It appears I have a small hiatal hernia and GERD II. Since I am only 30 years old, my cardiologist originally told me to forget about the heart angle and concentrate on my GI problems as the probable cause.

Now that Pantoloc has had absolutely no effect (in fact, the symptoms are worsening), my cardiologist has suggested that I make an appointment for an angiogram. To be honest, I am very afraid of this test. However, my quality of life has been severely impaired and if the angiogram will help him diagnose the problem I might be willing to take the risk.

I am looking for some personal opinions. Given my medical history, is it worth the risk or is there another less intrusive test I should be asking for first?

In skilled hands, a coronary angiogram can be perfomed safely with less than 0.5% chance of complications. It remains the "gold" standard for diagnosing occlusive coronary disease. It remains the only way to be 100% certain that your symptoms are not from blockages in your coronary arteries. Is this kind of information worth the risk ? Only you can decide (hopefully with the help of your cardiologist). Hope this information helps. Answers to related questions can be found on my web site.

Subject: Occlusive Coronary Disease

When is either bypass surgery or angioplasty needed in the setting of stable angina pectoris?

This is a hot topic from and I would direct your attention to the following reference:

"Bypass Surgery for Chronic Stable Angina: Predictors of Survival Benefit and Strategy for Patient Selection" Annals of Internal Medicine. 1991; 114:1035-1049.

The point here is that revascularization is not for everyone but knowing the anatomy can help determine the best treatment. It is true that medical treatment has gotten better with the advent of better lipid-lowering medications but one would fully expect that the benefits from these advancements would extend to revascularized patients who are supposed to continue receiving medical follow-up (though some are lulled into thinking their surgery or angioplasty is a cure that gives them the green light to continue with their old lifestyle ways until the next procedure).

Subject: Heart Attack

Over the last week or so I have been having some chest pains but I think they are more due to a pulled muscle in my left pec muscle. I was thinking of going to the doctor but don't have any *real* health insurance that would pay for any tests. Is there a blood test that can detect a heart attack. I figure this would be a good start and let me know if I need to proceed with other tests?

See an internist for a history and physical exam. These are the best initial tests for determining whether you have had or are at risk for having a heart attack. The internist will work with you on what further diagnostic tests are indicated. It will save you money because unnecessary blood tests are as expensive as diagnostic ones and who knows, seeing an internist may also save your life. A good maxim to live by: "A person who is his/her own doctor has a fool for a patient."

Subject: Angina Pectoris

How does one know one has it?

Your primary physician is the person you will need to rely on to make the diagnosis.

How do doctors determine this diagnosis?

By taking a careful history and physical exam, you doctor will get an impression about the probability that your symptoms may be related to ischemic heart disease (ie angina). Based on whether this probability is significant, s/he may order other tests whose results may confirm or refute the diagnosis of angina pectoris.

And what is done about it once a diagnosis is made?

Specific recommendations for lifestyle changes, medications or other interventions will be prescribed to lower the risk of sudden death from a heart attack.

Subject: Angiogram it worth the risk in my case?

I have been experiencing angina-like symptoms for almost 7 months. It started with pain/tightness in the middle of my chest (exertion wasn't necessary for it to occur). I am also experiencing 10-15 episodes of left arm pain accompanied by tightness in the left side of my neck and pain in jaw.

I have had several tests to determine whether or not the pain is heart related:
-stress test
-stress echo
-holter monitor
-several ECGs
-blood work in emergency
-GI scope

Everything has come back negative with the exception of the GI scope. It appears I have a small hiatal hernia and GERD II. Since I am only 30 years old, my cardiologist originally told me to forget about the heart angle and concentrate on my GI problems as the probable cause.

Now that Pantoloc has had absolutely no effect (in fact, the symptoms are worsening), my cardiologist has suggested that I make an appointment for an angiogram. To be honest, I am very afraid of this test. However, my quality of life has been severely impaired and if the angiogram will help him diagnose the problem I might be willing to take the risk.

I am looking for some personal opinions. Given my medical history, is it worth the risk or is there another less intrusive test I should be asking for first?

In skilled hands, a coronary angiogram can be perfomed safely with less than 0.5% chance of complications. It remains the "gold" standard for diagnosing occlusive coronary disease. It remains the only way to be 100% certain that your symptoms are not from blockages in your coronary arteries. Is this kind of information worth the risk ? Only you can decide (hopefully with the help of your cardiologist). Hope this information helps. Answers to related questions can be found on my web site.

Subject: NitroDur

What can I do about headaches I get with wearing a nitroglycerin patch?

Some people just don't tolerate nitroglycerin. The headaches are notoriously resistant to analgesics. Nitroglycerin can cause a reflex tachycardia when it lowers blood pressure especially in sensitive individuals (or when it causes a headache). Consider consultation with the primary physician about tapering off the NitroDur and covering with sublingual nitrostat as needed. If there is room for titrating up the betablocker, this may obviate the need for frequent nitrates.

Subject: Restenosis

After having gone through successful angioplasty, I am worried about having to go through it again. What are some of the latest developments to prevent this?

One of the latest medical developments in this area is angioplasty with intraluminal irradiation (brachytherapy) to arrest vascular smooth muscle proliferation (preventing restenosis). Trials have shown its efficacy.

Meanwhile, medical treatment with lifestyle changes to reduce risk factors should slow (and perhaps even halt) the progression of your disease in the rest of your coronary blood vessels.

Subject: Exercise Treadmill Test

I am scheduled for a treadmill test for a peace officer job next week. This is the only place I could think of to come for information. I would be most grateful if someone could tell me what the test is designed to measure.

The purpose is to determine whether a person likely has coronary heart disease.

What does it entail?

This test consists of walking on a treadmill that is ramped up every 3 minutes while vitals signs and EKG are continuously monitored. The test is stopped when there is chest pain, shortness of breath, nausea, worrisome changes on the EKG or when target heart rate is reached (85% of max which is calculated by subtracting age from 220 and then multiplying by 0.85).

How do you pass?

You pass it by reaching the target heart rate without symptoms or EKG changes (specifically ST segment depression of at least 0.1mV in two contiguous leads).

Subject: 95 percent LAD Occlusion

It is quite unclear to me how such a severe clogged artery did not show any signs in EKG or other tests performed to a 77 years old lady not having any pathological history until now.

Resting EKGs are not very sensitive for picking up stable coronary occlusive disease. Typically the abnormal changes on the EKG that we look for can occur when there is either old injury from previous heart attacks or when there is active ischemia as the coronary artery is closing up. A stable blockage of 95% can easily have no impact on the EKG or other cardiac tests if they are done only at rest when the 0.25% flow (plus collateral flow) is adequate for the energy requirements of the heart when there is no exertion.

Subject: Flunked Thallium Stress Test

Would appreciate having some opinions that will shed light on the problem. Would an angiogram be worthwhile for the sake of knowledge alone?

If you are still adamantly opposed to any intervention such as angioplasty or bypass surgery, the risks (>0%) outweigh any potential benefit (zero) from additional information that may guide therapy. Basically, your choice is conservative medical management which may be best handled by a good non-invasive cardiologist.

Subject: Patency of Bypass Grafts

More specifically, after 10 years or so, do the vein grafts plug up with cholesterol?

Yes, if not sooner.

Do they collapse from fatigue?

No. They close up by the same process that affected your native coronary vessels.

Does this mean probably angina or heart attack?

Yes, sooner rather than later, if you don't adhere to your doctor's recommendations for improving those aspects of your health that s/he feels contributed to the early occlusion of native coronary arteries.

How will I know?

If the chest pain (angina) returns.

Can medications then be in order?

Yes, if needed to treat contributory medical conditions such as dyslipidemia (cholesterol), hypertension (high blood pressure), diabetes, and/or hyperhomocysteinemia.

Is another bypass inevitable?

No. With good adherence to a good medical regimen, there is an excellent chance that the grafts may outlast everything else.

Subject: Severe Coronary Artery Disease

I am wondering if anyone has successfully treated a severe coronary artery disease (multivesesel) case without bypass surgery. My father is 48 years old and suffering from this problem. Are there any alternatives to bypass surgery? 2 doctors already said that it would be the best thing for him because the vessels are so clogged that they couldn't even use balloon angioplasty. Any suggestions? Thank you.

There's always aggressive medical management. This would entail a low fat/cholesterol diet, regular exercise as tolerated, good control of other medical problems that would accelerate progression of coronary occlusive disease, and medications to lower serum cholesterol and improve heart function.

Subject: Coronary spasm

I am 36F healthy and unfortunately a smoker. For some months now I have had central chest pain either waking me from sleep or first thing in the morning. I sometimes have referred pain to my jaw and left arm. I may go days or even weeks without an attack. Pain seems to respond to NTG spray. Is this likely to be coronary artery spasm?

Cigarette smoke has been shown to cause endothelial dysfunction leading to coronary spasm. So you are at risk while you still smoke. For the sake of your health, please stop.

Subject: Totalled LAD

I just had a catherization and my cardiologist is recommending a double by-pass (Blocked LAD and partial obtuse marginal branch). He said he couldn't tell how long the LAD was blocked off and wasn't recommending using the ballon with a stent. Is open heart my only alternative if I want to lead an active lifestyle?

As you probably already know, your options are medical treatment, angioplasty of the obtuse marginal (if there is a greater than 70% blockage), or bypass surgery. To determine the best approach, information about how much heart muscle (if any) is behind the LAD blockage that might benefit from a bypass graft is needed. If there isn't going to be any significant benefit, the surgery is not worth the risk. It is usually wise to get a second opinion when you are contemplating elective surgery.

Subject: Coronary disease

Is there a way to clear blood vessel blockage using beta particles?

I think you are referring to intraluminal post-angioplasty irradiation to prevent long-term post-procedure restenosis.

Subject: Slight Chest Pain

I have a slight pain in the left side of my chest. It started a couple of months ago and was very infrequent. But it has now started to happen more often. It is not a crushing pain but more a discomfort. I also sometimes feel a tingle in my left arm by the tricep and wrist. I am 32 yrs old. Any idea what this is and if I should see a cardiologist?

You should see a board-certified internist first who would refer you to a cardiologist if indicated. See my web site if you need help finding an internist.

Subject: Angina

I have just ben diagnosed as having angina, im 39,After the cardiologist told me that it was angina, everything he said after that has sort of been forgotten, Im due to go for something in the next two weeks, they are going to insert a tube into the groin and then put dye in to check the heart.Im not sure what to do now, im really scared as my mother died 25 years ago with heart problems.This has really freaked me out.
I live in the uk

A heart catheterization is a routine procedure that is relatively safe (less than 0.5% of complications) in the hands of a well-trained cardiologist.

As you start to get over your fears and start having questions, some of them can probably be answered by what you can find on my web site.

Subject: why do hearts get clogged up

I suppose others have asked this question in the past, but I would very much like to know the answer.

It seems strange that the heart arteries get clogged up with deposits, yet the very fine arteries and veins seem largely immune.

I did ask a cardiologist and a heart surgeon about this - both said they didn't know. It would seem to me that this should be a major area of research - if we can find out why they get clogged up then maybe something can be done to help avoid it - apart from the usual stuff done now.

There is the entire field of vascular biology devoted to this topic. Because of higher oxygen tension and physicial shear forces on the arteries, the environment is "harsher" compared to veins. This "oxidative stress" invokes oxyradicals, oxidized lipids, cytokines, and other inflammatory mediators in bringing about atherosclerosis. You can try the pubmed links on my web site to learn more if you like.

Heart Failure

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Subject: Congestive Heart Failure

He has a sonogram scheduled this morning. What would be the purpose of that test?

To determine the kind of congestive heart failure: systolic versus diastolic left heart failure.

This will help in optimizing treatment and determining whether further testing is needed.

Subject: Enlarged Heart

Should a person with an enlarged heart participate in vigorous exercise?

The main reason for being concerned about an enlarged heart is the risk for sudden death from an abnormal heart rhythm. Without symptoms and with a relatively normal physicial exam, this risk of sudden death is probably very small. To be safe, it may be a good idea to forego strenuous exercise until seen by a cardiologist.

Subject: Cardiomyopathy

What are the different types of cardiomyopathy?

Cardiomyopathy is a blanket term for disorders of heart (cardio) muscle (myopathy). They come in all flavors such as dilated (thinning of the myocardium), hypertrophic (thickening of the myocardium), ischemic (some people don't like this term), infiltrative (sarcoid, lymphoma, amyloid etc) et cetera.

Subject: Heart Failure

I've been led to understand that heart failure can be subdivided into diastolic and systolic dysfunction. What is the distinction between these 2 forms of dysfunction?

Diastolic dysfunction is an impairment of the relaxation phase of the cardiac cycle. This leads to elevation of end-diastolic pressures (LVEDP) with preserved ejection fraction. Pulmonary edema results as the pressure backs up and floods the lungs (aka pulmonary edema).

Systolic dysfunction is an impairment of the contraction phase of the cardiac cycle resulting in loss of cardiac output which in turn leads to hypotension. Because of the decreased forward blood flow, volume is backed up into the lungs causing pulmonary edema indistinguishable from that which can be caused by diastolic dysfunction.

Can diastolic dysfunction occur without systolic dysfunction and vice versa?

Yes but not vice versa.

Which is the most common form of dysfunction?
The estimated 50 million Americans with essential hypertension will have some degree of diastolic dysfunction although most are asymptomatic. this would make diastolic dysfunction very common. However if one were looking at people being admitted with congestive heart failure, systolic dysfunction is usually more common.

Should people with diastolic dysfunction be treated differently to those with systolic dysfunction?

Yes, people with systolic dysfunction should be given medications that reduce the workload of the heart (i.e. diuretics, nitrates, and ACE inhibitors) and enhance the strength of the heart muscle (i.e. dobutamine acutely or digoxin maintenance). On the other hand, treatment of isolated diastolic dysfunction though with similar use of diuretics in acute congestive heart failure differ in that there is an emphasis on increasing the duration of diastole and avoiding medications that enhance the strength of heart contraction.

Subject: Congestive Heart Failure

My father-in-law is in the hospital with congestive heart failure. He is 80 years old. What questions should I ask of the doctors, and what can I expect to happen?

You should ask whether the failure is systolic (from loss of squeezing strength) or diastolic (from stiffness). There will be tests conducted such as an echocardiogram. Expect improvement with the right medications for his type of heart failure.


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Subject: Implanted Defibrillator

I just had the defib implanted and was wondering what the shock was like. If someone with experience could give me an analogy I would appreciate it.?

Some of my patients liken it to a sharp punch to the chest.

Subject: Atrial fibrillation

I was recently diagnosed with A Fib. I worked at a hazardous waste processing facility for about 5 years. I was wandering if exposure to any chemicals could have caused A-Fib. I ask this because a friend of mine that works there has just been diagnosed with the same thing. And a few years prior another man that worked there was also diagnosed.

It's conceivable since one known cause is ethanol which is also a chemical solvent.

Subject: Hypokalemia and atrial fibrillation

Can low blood levels of potassium cause atrial fibrillation?

Can trigger it.

Once the potassium deficit is corrected, how long before the rhythm normalizes?

Will vary. May not ever unless cardioversion is performed.

How much potassium should one get every day when taking a diuretic?

Depends on the diuretic, the dosage, and kidney function.

Subject: atrial fibrillation and potassium loss

Could an oversupply of one negatively charged electrolyte like bicarbonate cause possitively charged potassium to be too low? I use regular baking soda as a deodorant spreading it under my arms. Baking soda is bicarbonate. Can it be absorbed through the skin and by doing so disturb my potassium balance and cause atrial fibrillation?

No, you can't absorb enough baking soda through the skin to disturb your potassium balance.

The most common cause of both low magnesium and low potassium resulting in atrial fibrillation is chronic alcohol abuse. Another common cause is the use (or abuse) of diuretics.

Subject: Ventricular Tachycardia

Because of the 4 beats of VT during the 1st 24hr holter I'm told that I am at an unacceptable risk from developing incapacitating heart rythm disturbances. Over the 4 Holters, I had 385000 heart beats, of which 16 were ectopics, ie: a lot less than 1%. Can anyone confirm that on the face of the above, I either have or haven't got a problem?

It would depend on the rest of your history. If there is suspicion that you've had *sustained* symptomatic VT and all this testing is for that, then I would suggest electrophysiological (EP) testing rather than continued holter testing.

Subject: AFib/Alcohol

Can alcohol consumption cause atrial fibrillation?

Yes. Atrial fibrillation (Afib) is an irregularly irregular heart beat rhythm. It arises from a problem with the natural "pacemaker" system of the heart. Alcohol is toxic to the cells of the heart and chronic alcohol use causes damage that can lead to Afib and even heart failure.

Subject: WPW

What is WPW?
WPW stands for Wolf-Parkinson-White syndrome, which is a problem arising from a physical defect in the conduction system of the heart that predisposes the affected person with a tendency to have potentially life-threatening rapid heart rates. For more details, see a small article I have written on this topic.

Subject: Pacemaker

Can my son exercise after pacemaker placement?

Yes, your son can. Having a pacemaker does not restrict physical activity. The newer pacemakers even "sense" increased physical activity and will increase heart rate accordingly.

Subject: pacemaker problem

My aunt ask me to post this. She had a pacemaker install in November, and she want to ask what kind of allergic responses anyone out there have to pacemakers (i.e., sudden leaps in blood pressure, flushing).
Is there any way you can test for allergy and it be accurate?
Are there any pacemakers on the market that, to replace it, a battery can be install instead of replace the whole thing? A doctor tell her that only the battery needed replace, but not the whole thing.

The pacemaker is one hermetically sealed piece containing both the battery and electronics. What you describe does not sound like an allergy.

Subject: Arrythmia and pacemaker

I would appreciate understanding in which cases the implantation of a pacemaker (by pacemaker I mean any type of cardiac stimulator, including defibrillators) is NOT advisable for a bradicardiac patient affected by paroxysmal flutter/fibrillation detected some six years ago.

Depends on the mechanism behind the bradycardia and whether you are symptomatic when you are bradycardic. If the bradycardia occurs when you have your atrial dysrhythmia, it would be better to keep you in normal sinus rhythm rather than implant a PM. If the bradycardia occurs when you are in sinus rhythm (presumably because of the medications you are taking to keep you in sinus) then it may be wiser to back off on some of the medications. If this is a catch-22 situation where keeping you in sinus causes bradycardia and backing off on meds causes you to have more afib/flutter, then it certainly may be time for a PM.

Subject: Pacemaker Recovery

My husband had a pacemaker installed two weeks ago for atrial fibrillation, and he feels worse than he did before. He's utterly exhausted. Is there a recovery time after the surgery? Some friends of friends have said it took them 18 to 24 months before the doctor coordinated their pacemaker rate and drugs correctly. What could be going on?

Sounds like there may be something wrong. You should check your husband's pulse to make sure he has a regular rhythm and a normal rate (between 60-90). If this isn't the case, your husband needs to see his cardiologist as soon as possible.

Subject: EP study?

Today, my husband went to his cardiologist and he is going to be scheduled for an EP study. The doctor mentioned ablation therapy and pacemaker? Can anyone tell me is this two different things or will both of these procedures be done?

Two different things usually done on the same day. Pacemaker first followed by ablation.

Subject: Conduction delay

I am a well-conditioned athlete who has been told his EKG shows a conduction delay. What does this mean?

It is not uncommon for aerobically fit individuals to have an AV nodal conduction delay resulting in a prolonged PR interval. Often there is also an associated resting bradycardia (heart rate less than 60 at rest). This condition is harmless.

Subject: Cardioversion

What is cardioversion?

Cardioversion is the process of restoring the heart to a normal sinus rhythm. The pathological rhythm is most commonly atrial fibrillation but it can also be supraventricular tachycardia, reentry tachycardia, or ventricular tachycardia. When the rhythm is ventricular fibrillation, then the term used is defibrillation.

Subject: Electrical Cardioversion

1. Is this a conventional treatment for chronic a-fib?

It's worth a try at least once medications are on board that may help maintain a sinus rhythm. Also anticoagulation is a good idea to prevent clots that may cause stroke or MI.

2. At what point in the EKG line is the shock sent?

On the R wave.

3. What power is minimal and how much can it be upped in, say, one session?

50-100J could be upped in 50J increments to 200-300J.

4. Mortality?

If anticoagulated and in a hospital setting with a cardiologist around, practically nil (<1%).

Subject: Pacemaker

Where can I find specific on-line information about pacemaker models?

See my links to cardiovascular resources.

Subject: Pacemaker

My father-in-law is 85 years old and is going to have pacemaker surgery. I would appreciate any information on the procedure, recovery period, hospital stay, etc. for a patient of this age.

His advanced age will not be a big factor for this procedure which is commonly done in elderly individuals. Losing one's natural pacemaker can be part of one's normal aging process.

The procedure entails passing a wire through a vein into one of the chambers of the heart until the tips of the wires burrow slightly into the wall of that chamber allowing the conduction of electricity so that pacing signals from the pacemaker unit "captures." Once this is achieved, the cardiologist will then tunnel the wires below the skin to where the pacemaker will be situated (also below the skin typically at the left upper chest). In women, there is the option to locate the pacemaker in breast tissue to avoid the bra strap.

Recovery period is one day in the hospital. Risk is minimal for a cardiologist who has been doing these routinely (less than 1% complication rate).

Hope this allays any fears.

Subject: PVCs

What causes these?

Premature Ventricular Contractions (aka PVCs) are caused by at least one cardiac muscle cell located in the ventricle that has decided it wants to " march to the beat of a different drummer." The cure is for a highly trained cardiovascular disease subspecialist (EP cardiologist) to find the solitary muscle cell(s) and kill them (radiofrequency ablation). The risks may outweigh the benefits but you may be the only one that really knows how badly this " benign" problem affects your life.

Subject: Atrial Fibrillation

Can drinking alcohol bring this about?


Ref: Koskinen, P., Kupari, M., Leinonen, H., and Luomanmaki, K. Alcohol and new onset atrial fibrillation: a case-control study of a current series. British Heart Journal. 57(5):468-73, 1987 May.

Subject: Left Bundle Branch Block (LBBB)

Could someone please describe this disorder? Also is there medication to help it?

The heart has its own natural pacemaker and electrical system. In very simplistic terms, the electrical system has two branches, a main one (left) and a back-up (right). The left one is now gone (or was never there) but the right one is still there. If the right one goes, the heart will no longer beat properly and we would fix this by implanting an artificial pacemaker and electrical system (leads). More commonly, the right bundle will last the rest of one's lifetime.

Subject: Irregular heart beats

I am trying to find as much information on my condition as possible. Basically I have days of irregular heart beats, skipped beats. I dont know what the medical term or name for this effect. I see the word a - fib mentioned. I would like to know is this the same as skipped beats. What are the rasons or the causes of this effect. Also is it dangerous!?

It sounds like you may have paroxysmal atrial fibrillation. You'll need to see your doctor about this possibility because it can be associated with increased risk of stroke which is dangerous. Atrial fibrillation (a-fib) is not the same as skipped beats (either PACs or PVCs).

Subject: Left Anterior Hemiblock

Can someone or ones explain in a layman's terms what a left anterior hemiblock is and how serious it may or may not be?

Think of it is a partial left bundle branch block. If it is an incidental EKG finding, it isn't worrisome. If it occurs suddenly in the setting of chest pain, it could be a sign of acute ischemic injury from a heart attack.

Subject: PVC's

What will be the effect of PVC's on exercise, and vice versa?

You should find that the PVC's become less frequent with regular exercise.

I've started walking a bit more, and want to check out a couple of wellness centres here. What should I be looking for there?

Motivation for regular exercise.

Stress test (will they do them if they know you have PVC's?)

They should.

Will weight loss affect PVC's, i.e. less weight to carry around?

Weight loss should reduce the frequency of PVCs.

Will lowering cholesterol and triglycerides affect frequency and numbers of PVC's?

not really.

Do stress reduction and relaxation techniques work?

They should help. Wouldn't hurt.

Subject: WPW

I am a 23 yo male with WPW. I discovered that I had WPW while I was in the military and running 10-15 miles per week. I went in for an examination because I was having fainting spells while running (on some occasions). During one of these spells my heart would start to pound erratically, sometimes I could feel this starting to happen and could control my breathing and it would go away. Other times it would start so fast that I would get faint and my limbs would start to tingle and I would have to stop running or pass out.

Is this typical for someone with WPW?

Yes, this is typical for someone with symptomatic WPW. When your heart races like that, there is a risk of sudden cardiac death if the rhythm degenerates to ventricular fibrillation. For this reason, most physicians (myself included) would not hesitate referring you to an EP specialist (a cardiologist with electrophysiology subspecialty training) for radiofrequency ablation to *cure* your WPW. I am surprised you did not receive this recommendation earlier when you were first diagnosed with WPW.

Medication Side Effects

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Subject: side effects of cholesterol lowering drugs

What are the side effects for cholesterol lowering drugs?

The likelihood of potential side effects of lipid lowering medications depends on the medication and what other medical problems you have. For example, the commonly prescribed HMG-CoA reductase inhibitors such as lovastatin, pravastatin, fluvastatin, and simvastatin all carry a small risk of hepatitis for which your doctor may be periodically ordering screening bloodtests. Other common reasons for stopping this class of cholesterol lowering medication would be for muscle weakness/pain. Other cholesterol lowering medications include high-dose niacin (flushing, abdominal cramps, and also hepatitis) and cholestyramine (bowel irregularities and fat soluble vitamin deficiencies).

Subject: Pharmacists

Is it a good idea to see a phamacist rather than a physician for common ailments?

A pharmacist is trained to fill prescriptions, advise on drug-drug interactions, and pharmacokinetics. IMHO, treating an ailment even with non-prescription medication should be left to a physician trained in physical diagnosis unless the pharmacist wants to be 100% accountable for any bad outcomes (i.e. carry malpractice insurance).

Subject: Statin and Cataracts

Can anyone give a reference regarding the increased incidence of cataracts among statin users?

1999 PDR page 1925 middle column:

The following effects have been reported for drugs in this class (statins)...

Eye: progression of cataracts

Subject: warfarin and aspirin

When does a physician use either aspirin or warfarin or both?

(1) coumadin is commonly used in stroke prophylaxis especially in the setting of atrial fibrillation.
(2) it can be used together with aspirin at the discretion of the primary physician particularly when there is proven coronary ischemic disease but usually, one would opt for one or the other but not both because of increased risk for hemorrhaging.
(3) aspirin is not used for "thinning" the blood in someone with high blood pressure. It irreversibly acetylates cycloxygenase, an enzyme in platelets that function in blood clotting. The indication for this is stroke and MI prevention not isolated hypertension.

Subject: Statins and CPK

Others have often posted on the importance of checking CPK when taking statins like Lipitor. Physicians here in Southwest Virginia seem to always order a lipid panel and a liver panel, but never a CPK. The liver panel does not include a CPK. Should we also be getting a CPK? Apparently the HMOs don't think it necessary. I have been unable to determine if the soreness in my hands is the beginning of rhabdomyolysis or the beginning of some form of arthritis.

Checking CPK should not be done routinely for someone on statins. However, IMO, CPK should be checked whenever there is *new* musculoskeletal pain in someone on statins.

An annual cataract screening exam is probably also a good idea.

Subject: Long term coumadin

Do you have any idea about any new findings, or the effect of 20 years of taking Coumadin?

There are no known adverse reactions specifically associated with chronic long-term use of coumadin.

Subject: Iron Supplements

Should men take multivitamins that contain iron?

In general, males and postmenopausal women should *not* take nutritional supplements that contain iron. Doing so can lead to excessive amounts of iron building up in the body. This can lead to problems with both the liver and the heart. However, if you are having or have recently had active bleeding with significant blood loss, your physician may prescribe iron for you. You would be wise to follow your physician's instructions in this case.

Subject: Tylenol and Alcohol

I've been taking 12-16 extra strength tylenol tablets a day for several months for headaches from drinking alcohol and am worried about my liver. How can I convince the emergency room doctors to check my liver?

There has been a lot of publicity in the form of TV and newspaper ads about tylenol hurting the liver and this has caused a lot of alarm in people like yourself.

It is inappropriate to engage in potentially harmful behavior with full awareness of risks and then expect to convince others that you are worried of the outcome.

The proper channel is for you to see your primary physician about your chronic headaches and your concerns about your liver. If your doctor feels that your may have liver injury then he/she might order the appropriate tests.

Subject: Microbial Drug Resistance

Where can I find information about how bacteria become resistant to antibiotics?

There are plenty of textbooks in most libraries about drug resistance genes carried on DNA plasmids, which are extrachromosomal circular pieces of DNA that are easily taken up cross-species.

Subject: Flushing when drinking wine

Why does this happen?

You likely lack one of the enzymes (aldehyde dehydrogenase) for metabolizing alcohol. This is common among people of asian ancestry. This is not an allergy.

Subject: Pharmacology Website

Is there a web site describing various medications?

try or any of the others under general medicine resources in this web site.

Subject: Drugs Affecting INR Tests

If a person is on Coumadin, Ticlid, Aspirin, and occasional Tylenol, are the effects of all reflected in the INR result? I know that they all affect blood clotting time but have previously gotten conflicting answers to the above question.

Mainly just the coumadin. The INR does not reflect platelet function which would altered by both ticlid and aspirin. Tylenol does not usually have a predictable anticoagulant effect but can raise INR by decreasing hepatic production of clotting factors whose activity are reflected in the INR.

Subject: Viagra & nitrates

Specifically, these are some of our concerns. After the PO use of Viagra, how much time must elapse before it is reasonably safe to give nitrates? Is this time period dose-dependent? Is the range of possible reactions realistically as great as described in the literature (i.e., from transient postural hypotension to intractable cardiac arrest)? Is IV access sufficient precaution against these potential side effects? Should we be modifying our protocols on the use of nitrates in the field?

These are all good questions for which good answers won't be known until discovered firsthand by those out there in the field because of limited experience with this new drug. What I would suggest, in the interim, is vigilence toward possible Viagra use in the cardiac patient and to avoid nitrates when there is a high index of suspicion (the setting should provide good clues) expecially if the patient's blood pressure is low to low-normal. Aspirin and Oxygen should remain mainstay initial treatment and morphine could serve as a substitute for nitrates in relieving dyspnea and chest pain in someone on Viagra.


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Subject: generalized lymphadenopathy

What can cause swollen lymph nodes everywhere?

Viral infection (CMV, EBV, HIV to name a few), tuberculosis, bacterial infection, parasites, sarcoidosis, or cancer. If you have this, you should see you primary physician about finding out what is causing this because there may be a serious underlying problem.

Subject: Hepatitis

What does a SGOT of 86 and a SGPT of 502 mean in someone with no symptoms?

Sounds like hepatitis. Because of the AST/ALT ratio, it is unlikely due to alcohol. If there really are no symptoms, could be something chronic. However, sometimes epigastric symptoms attributed to such things as heartburn or indigestion may mask liver symptoms.

The first things to think about are medications such as cholesterol lowering drugs such as simvastatin, lovastatin, or niacin. Then there are certain herbal medications that have been known to cause low-grade hepatitis. Of course, one has to rule out infectious causes of hepatitis too.

Subject: common cold

When is the common cold contagious?

About six hours after onset of symptoms and for the next 3 days afterward.

Subject: Immunization Websites

Where can I find information about vaccinations on the Internet?

The CDC webpages are a good place to start.

Subject: Chicken Pox

Can someone get Chicken Pox twice?

Yes, a person can have recurrence of chicken pox and this is known as "shingles." The varicella virus after causing chicken pox enters into a state of dormancy in nerve cells but when the immune system is compromised by age, medications, stress, infection, etc shingles can happen. See your primary internist because there may be something else going on especially if your shingles was particularly severe which can suggest significant immunocompromise.

Subject: Chicken Pox in Adults

I am a 25 year old female who has not ever gotten Chicken Pox and who recently came in contact with a child stricken with Chicken Pox. How bad can it be?

Chicken Pox (aka varicella infection) can be pretty bad for adults to the point of life threatening pulmonary and neurological complications. Moreover, this infection can hurt a fetus so if there is any chance that you may be pregnant, see your physician right away. Otherwise, I would recommend that you see your physician as soon as symptoms start (if they start - sometimes people forget that they have actually already had Chicken Pox) so that antiviral medications can be started immediately.

Subject: Tuberculosis

How much time is required to go by from the time of exposure 'til the time that a positive reading is possible?

Takes a minimum of two weeks. In the hospital, we start checking our clinical staff about two weeks after they have had significant unprotected exposure to a patient who has been shown to have active tuberculosis. This is on top of routine PPD skin tests every 6 months.

Is it really as simple as someone coughing on someone to create this condition?

Yes. But usually it requires a prolonged period of exposure over hours to days. However, PPD conversion with simply being "coughed on" would be more likely to occur if there is any immunocompromise going on.

Subject: Pneumonia in the elderly

Isn't it possible to prevent pneumonia in the elderly?

One way is to administer a vaccine (good for 10 years) against pneumococcal pneumonia and an annual one against influenza. Another is to make sure problems with swallowing do not increase risk of aspiration.

Subject: Tuberculosis

We have just heard that someone at our children's school has come down with active tuberculosis and we are scared for our children. What is tuberculosis?

I have put together an online resource about tuberculosis at Hopefully you will find it useful.

Subject: Shingles

Why do older people get shingles?

Older people tend to get shingles because their immune system weakens with aging (younger people who become immunocompromised also tend to get shingles). Shingles is actually a reactivation of the chickenpox virus infection most of us have had as children. We give systemic acyclovir to limit the duration (and hopefully minimize the severity of post-herpetic neuralgia which persists in some people).

Subject: Tuberculosis

How do doctors treat active tuberculosis?

Four drugs for two months until culture sensitivities are known:

(1) INH + B6
(2) PZA
(3) Ethambutol
(4) Rifampin

If susceptible strain then could knock off PZA and Ethambutol and treat for 4 more months (1 year is highly recommended if immunocompromised or if strain is INH resistant).

Subject: Chicken Pox

Is there a way to find out if one has had this before? I think I have but I am not sure.

Yes. Your doctor could order serological testing to see if you have antibodies against the varicella virus which causes Chicken Pox.

Subject: Chicken Pox and Pregnancy

How is Chicken Pox treated in a pregnant woman?

Acyclovir is the antiviral of choice but varicella (the virus that causes Chicken Pox) is a bad thing in adults especially pregnant ones. Best thing *would* have been the vaccine *before* pregnancy.

Subject: Shingles

How long is Shingles contagious?

As long as there is a vesicular rash (i.e. blisters).

My mom has been on Zovirax for 11 days, but she still has some patchy rash on her face. Is this still potentially a problem for those around her?


Is it contagious even after the lesions have cleared up?


Subject: Hepatitis Vaccine Allergy

A few years ago my employer gave us free Hepatitis B Vaccines. On the second dose I developed Bells Palsy and was told to not take anymore, of course. I now have a question as to this; Since most vaccines are a dead virus then if I was to develop Hepatitis B, what would happen to me?

The vaccine you received for HepB was recombinant which means that it is virtually impossible to get HepB from this vaccine because it never contained anything close to an intact virus either dead or alive.

Subject: Hepatitis B Transmission

Has this type of transmission (shared meal or fomites) ever been documented for Hep B? I'm not aware of any studies or even case reports to this effect.

It has been documented among dentists.


Status of viral hepatitis in the world community: its incidence among dentists and other dental personnel. Mori M. International Dental Journal. 34(2):115-21, 1984 Jun.

And components of HBV (HBsAg and HBeAg) that suggest the presence of intact infectious virions are detectable in the saliva of people with chronic HBV infection:

Salivary sampling for hepatitis B surface antigen carriage: a sensitive technique suitable for epidemiological studies. Chaita TM. Graham Annals of Tropical Paediatrics. 15(2):135-9, 1995 Jun.

The following recent paper concludes that horizontal transmission in infected families was "significantly associated with sharing of personal and household articles."

Prevention and control of hepatitis B virus infection in Singapore. Goh KT. Annals of the Academy of Medicine, Singapore. 26(5):671-81, 1997 Sep.

So putting two and two together, I think a case can be made for under-emphasis.

If I am not mistaken, hepatocellular carcinoma (which occurs at a very high rate among those who have previously been infected with HBV) is the number one malignancy causing deaths worldwide.

Subject: Hepatitis A after immunization

After hepatitis A immunization, what serology would be found if the patient developed acute hepatitis A with failed immunization?

From the CDC website:

Hepatitis A (see Chapter 3)

The diagnosis of acute hepatitis due to hepatitis A virus (HAV) is confirmed during the acute or early convalescent phase of infection by the presence of IgM anti-HAV in serum.

Serum for IgM anti-HAV testing should be drawn as soon as possible after onset of symptoms, as IgM anti-HAV generally disappears within 6 months after onset of symptoms.

During the convalescent phase of infection, IgG anti-HAV appears, and remains in serum for the lifetime of the person conferring enduring protection against disease.

The antibody test for total anti-HAV measures both IgG anti-HAV and IgM anti-HAV.

Persons who are total anti-HAV positive and IgM anti-HAV negative have serologic markers indicating immunity consistent with either past infection or vaccination.

Choosing a Doctor

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Subject: Medical Directory to research HMO doctor choices

Where can I go on the Internet to find out more about HMO doctors before making a choice?

Look under physician profiles in these webpages.

Subject: Physician Credentials

Where on the Internet can I check a doctor's credentials?

You can try the links under physician profiles in these webpages.

Subject: Healthy Rule of Thumb

What kind of doctor should one choose as one's primary physician?

A good rule of thumb is to see a primary physician for a routine exam. If you are concerned about adult problems, you should find a board-certified internist. If you go to a plastic surgeon for a routine annual exam or executive physical, don't complain about what happens to you.

Subject: Primary Physician

What is the difference between internists, family and general practitioners?

The differences arise in the postgraduate training (training after graduating from medical school with an M.D. degree). Family amd general practitioners train for 2-3 years while internists train for a minimum of 3 years. Aside from the time difference, the focus is different with internists getting more adult medical subspecialty training such as cardiology, gastroenterology, oncology, rheumatology, nephrology, pulmonology, etc. General and family practitioners get more pediatrics and obstetrics.

Bottomline: Internists are the doctors that are trained to handle health problems in adults.

Subject: Managed Healthcare

My father recently had a heart attack and his HMO transferred him to three different hospitals for the best negotiated price on each invasive procedure that was required. What are doctors and nurses doing about this crisis and what can patients do to help?

I recommend you visit the following websites:

Subject: Managed Health Care

Do you agree with the direction of changes in American Health Care?

I do not agree with the primary motivations for changing healthcare delivery which are described as "health care costs too much, and those who pay for care (business and government) have too little control over the process, while those who choose the care (the patients) often do not pay for it." If these are the primary motivations then the ultimate end-result will be that business and government will completely control the process. I would prefer that patients keep their autonomy so that they have the choice for holding on to those physicians who they trust as their advocates. Perhaps the solution lies in empowering people who choose their care to also pay for it directly. I think the public has more sense than either business or government give them credit.

Subject: Request for info about annual medical checkups

I plan to have my "annual" medical checkup because my previous one was a long time ago. Is there any web site which lists all the routine exams included in such visits?

I want to prepare myself for all the medical terminology and make sure nothing will be omitted during my checkup.

I would appreciate any info/hints/pointers including how to select a good physician and what to ask for. I am a male in mid-30s, in good health?

Here's what I do for a complete history and physical exam:


(1) Review any active/chronic illnesses
(2) Review current medications/supplements/OTC
(3) Review family history (IMHO, very important)
(4) Review social history
(5) Review of systems: (a) Constitutional (b) HEENT (c) pulmonary (d) cardiovascular (e) gastrointestinal (f) genitourinary (f) skin/breast (g) joints (h) neurological (i) immunological
(6) Review past medical history including immunizations
(7) Review of risky behavior such as seat belt disuse, illicit drug use, cigarette use, alcohol use, and unprotected sex.

Physical exam:

(1) General appearance (noting any skin abnormalities) and vital signs
(2) HEENT (includes a fundoscopic exam)
(3) Thyroid exam
(4) Lymph nodes
(5) Chest/Breast exam
(6) Pulmonary exam (ausculation, percussion, and sound transmission)
(7) Cardiovascular exam (venous and carotid waveform, PMI, ectopic impulses, heart sounds, peripheral pulses, peripheral bruits)
(8) Abdominal exam
(9) Extremity exam
(10) Neurological exam
(11) Rectal/prostate/genitourinary exam
(12) EKG
(13) Chest Xray
(14) Mammogram (option depends on sex and age)
(15) Lab tests: Chem19, CBC, and urinalysis and any additional tests as indicated by results of rest of H&P.

How to select a physician:

(1) Seek referrals.
(a) From friends and family (preferred)
(b) From acquaintenances or hospital referral services
(c) From insurance lists
(d) From physician referral services on the Internet

(2) Do some homework.
(a) Check out the credentials of prospective physicians.
(i) Use on-line physician profile services, many are free (you are welcome to check out those that I list in my webpages).
(ii) Look for those who are board-certified and who have received residency training from universities that you respect.
(b) Visit the physician for a brief in-office consultation before deciding on a long-term doctor-patient relationship with that physician.

Subject: Strokes and Heart Disease

My neurologist told me two weeks ago that my brain MRI shows I've had two small strokes. He put me on Plavix to prevent further strokes. He also wants me to take Trental (to increase circulation to the brain, eyes, and ears) and Paxil (for depression).

He mentioned nothing about a low-fat, low-sodium diet nor exercise nor did he mention anything about going to a cardiologist.

Wouldn't it be important for me to see a cardiologist to have my heart checked?

I would prefer that you follow-up with a good board-certified Internist who would be fully qualified to check out your heart along with the rest of your body.


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Subject: Definitions

Will someone please clarify the meaning of the following terms? It would appear that some of these are interchangeable. If some are not, in what way are they different?

irregular heartbeat
heart murmur
PVC's and PAC's
extra systoles

Palpitations - "sensing" one's heart beating (might be fast, strong, or irregular in rhythm)
tachycardia - rapid heart rate (>100bpm)
arrhythmia - abnormal heart rhythm
irregular heartbeat - irregular heart rhythm (a kind of arrhythmia)
heart murmur - an extra heart sound made by blood flowing through the valves or other parts of the heart
PVC's and PAC's - premature (early) heart beats of either ventricular or atrial origin respectively
extra systoles - same as PVC/PACs

Subject: EF

What is the average EF of a healthy adult heart in normal sinus rhythm?


Subject: Aortic Stenosis

Is there a website about the Ross Procedure?


There was one at but this site was down last time I checked. This is a surgical procedure where a defective aortic valve is replaced with the patient's own pulmonic valve.

Subject: MUGA

What does MUGA stand for?

MUlti-Gated Acquisition.

Subject: Bicuspid Aortic Valve Abnormality

How common is this problem?

Actually 2 percent have this congenital abnormality.

Subject: Cholesterol

What is Type 4 Hyperlipidemia?

It is present when a person has elevated serum triglycerides and VLDL. There is an association with increased risk of pancreatitis (inflammation of the pancreas, an organ involved in digestion). It can run in families in an autosomal dominant fashion. Typically one parent is affected along with half of the siblings. There usually is no indication for treatment unless symptomatic. See your primary physician about treatment.

Subject: Neurocardiogenic syncope

Any suggestions to people with this problem?

(1) Keeping well hydrated with liberal use of salt in one's diet.
(2) Avoid prolonged periods of standing at attention.
(3) Recognize your symptoms when they forewarn you of the syncope and immediately lie down.

Subject: Orthopnea

What can cause orthopnea and shortness of breath?

Lots of things. Here's a few:

(1) Idiopathic (familial) dilated cardiomyopathy
(2) Holiday Heart
(3) Hypo/hyperthyroidism
(4) Rheumatic heart disease
(5) ASD
(6) VSD
(7) Sarcoidosis
(8) chronically recurring SVTs
(9) chronic PEs
(10) malignancy
(11) collagen-vascular disease
(12) HIV infection
(13) atrial fibrillation with rapid VR
(14) anemia
(15) A-V malformations
(16) Chaga's dz
(17) Heavy metal poisoning
(18) Hypertension
(19) Crack cocaine abuse
(20) hemachromatosis
(21) renal failure
(22) hypoparathyroidism

This simply belabors the oft-reiterated point that clinical diagnostic acumen requires as much experience as textbook knowledge. A physician is more than just his/her medical school education.

Subject: Cholesterol

I am wondering if I should be on cholesterol reducing medication? I am a 30 yr old male with the following cholesterol profile:

ldl - 95 mg/dl
hdl - 20
total chol - 150
trigylcerides - 175

There is a family history of early m.i (before age 50). I presently do not have any symptoms of heart disease.

The only thing in your lipid profile that would place you at higher risk for developing coronary atherosclerosis would be the low HDL. Your internist probably has already recommended exercising regularly to see if it'll come up (plus other lifestyle changes such as smoking cessation and possibly a glass of wine daily). I would forego the cholesterol reducing medication for now since that really isn't your problem at the moment. There are other things to check before targeting the low HDL as only risk factor you may have inherited (homocysteine and lp(a) would be examples of some others).

Subject: Good Cholesterol

I've been on a low-fat diet and have been exercising 6 days a week. As a result, I have lost 50 lbs and have reduced my bad cholesterol quite a bit since the same time last year. My good cholesterol also went down a bit from a year ago and it was already in the unsafe range. What are some ways I can raise my good cholesterol?

(1) Continued aerobic exercise on a regular basis
(2) Daily glass of wine
(3) Medication.

Subject: Exercise and Heart Disease Prevention

I am doing a project for school relating to heart disease and prevention. I would really appriciate it if you could send me some information on heart disease/ prevention relating to fitness.

How being physically fit prevents heart disease:

(1) Reduces stress.
(2) Lowers resting blood pressure.
(3) Lowers resting heart rate.
(4) Lowers bad cholesterol and raises good cholesterol.
(5) Keeps you away from cigarette smoking.
(6) Lowers percentage body fat.
(7) Improves regulation of blood sugar.
(8) Improves lung function.
(9) Prevents sleep apnea.
(10) Improves circulatory function (grow vessels if needed).

Subject: Balloon in Leg

A friend of mine's mother, age 82, just had a double bypass, originally they said they were going to do a triple. They then said they had some trouble and needed to put a 'balloon in her leg' and keep an eye on it to make sure of getting enough blood to the leg, I assume risk of gangrene to the leg. They also said this would help her heart pump better during the immediate recovery period. What is going on here? What is the balloon in her leg used for???

You are referring to an intraortic balloon pump. It goes in at the groin but the balloon is actually placed in the aorta. It helps the failing heart work less.

Subject: Low cholesterol

Can cholesterol be too low???

Low cholesterol is a possible marker for problems involving liver and/or nutrition. By itself, low cholesterol is like low blood pressure in someone without symptoms. Basically, if everything else checks out, it is meaningless.

Subject: Stroke after valve replacement

An otherwise healthy woman in her fifties, who had rheumatic fever as a child, had a stroke a couple of months after a valve replacement.

Is there any possible correlation????

Yes, if we are sure that the stroke was of a thromboembolic rather than hemorrhagic pattern. Typically, management of people with metal heart valves include coumadin anticoagulation which usually prevents emboli originating from the valve. Another possibility is mechanical valve failure with parts of the valve breaking off in a shower of emboli.

Subject: High Cholesterol

Is there a nutritional supplement that reduces "bad" cholesterol or improves the ratio of bad to good? My family has a history of highcholesterol and no amount of dieting or exercise seems to improve our counts. My son just finished running a marathon, eats very wisely, loves seafood, and his count is 220.

Because you added the comment about your son loving seafood, some would suggest trying a little harder to stick to a low fat/cholesterol diet. Increasing dietary fiber should also help. If multiple additional risk factors for developing coronary occlusive disease are present, I would recommend biting the bullet and following your family doctor's suggestions concerning lipid lowering medications for primary prevention.

Subject: high cholesterol

I don't really care for taking "medications" and was wondering if there was a more natural way, in addition to diet and exercise, that I could use, i.e vitamins, minerals, or herbs.

Increasing dietary fiber and high dose niacin (a vitamin) under the supervision of your doctor can lower your cholesterol.

Subject: Stress test

My Dr. is sending me to Deborah Heart Hosp. for a stress test. I am very allergic to iodine and am wondering what the name of the test is that no iodine dye is used and how it is done.

Basically, you would be allergic to iodine-containing radio-opaque contrast dyes. Such dyes are *not* used for cardiac stress tests so you need not worry about having an allergic reaction from the test you have scheduled.

Subject: Cholesterol Advice Request

Care to comment on:
Gaziano JM, et al., Fasting triglycerides, high-density lipoprotein, and risk of myocardial infarction. Circulation. 1997 Oct 21; 96(8): 2520-2525.?

There are serious problems with the methodology:

"Patients with the diagnosis of confirmed MI, based on clinical history, who had an increase in creatine kinase and were discharged alive were enrolled in the study if they were willing and able to participate and if informed consent could be obtained from the patient and the admitting physician."

"All cases and control subjects were interviewed in their homes. Case patients were interviewed [nearly =] 8 weeks after their MI."

In other words, this is a restrospective study conducted 8 weeks after a person has survived an MI. This would be after 8 weeks of diet and medical therapy for secondary prevention of a repeat MI. See any problems with this methodology?

Here are the problems:

(1) These are MI survivors so the elevated triglycerides are also associated with *survival* as well as MI !!!

(2) A reduced fat diet ( < 20% ) raises triglycerides, so that what has been observed may be an artifact of dietary treatment rather than a true association with either MI or survival. In other words, it is very likely what has been observed is a spurious association.

The above illustrates the pitfalls of interpreting medical research if you lack the training..

Subject: Cholesterol Advice

What is the conversion factor for triglycerides(I live in Canada where different numbers are being used. My "trigs" are 1.61 - I happen to know that the conversion factor for the other lipids is 38.7)?

Multiply by 88.7. Your serum triglyceride works out to be 143 mg/dL.

Subject: Tricuspid Regurgitation and Primary Pulmonary Hypertension

An echo I had about 1 year ago for HTN was ok but after taking phen/fen and the big scare(against my MD) I went back to my cardiologist to have it all checked out. This echo said that I now have TR. My MD's concern is since this is not secondary to a Mitro (sp) valve problem and no Hx of Rheumatic fever. I also have had c/o palpitation and tachycardia. During a stress test (at rest) 135-140. But, I did well with the stress test just many outbursts of tachycardia. I was on the PHEN/FEN for 5 Months so is PPH a real concern?

New moderate to severe TR (2-4 on a scale of 1-4) after 5 months of PHEN/FEN with a normal baseline echocardiogram down within a year prior to PHEN/FEN treatment sounds very suspicious for primary pulmonary hypertension (PPH). Your history is also consistent with PPH. I am sorry to confirm the import of this news.

Subject: Fluid retention after heart valve replacement

Could someone please tell me what is the connection between heart disease and fluid retention?

The heart is basically a muscular pump. This is best illustrated by the simple analogy that when the sump pump in your basement fails during heavy rains, your basement starts to retain fluids.

What are the issues involved in the choice between bedridden inactivity and an attempt at living a normal lifestyle?

These days we rarely recommend bedrest if someone is ambulatory. The attempt should be made to attain a normal lifestyle with very few exceptions.

Subject: Coronary Risk Factors

My LDL-C levels and homocysteine levels are normal but there is a strong family history. Is there anything else that should be checked?

You might consider having your liporotein Lp(a) level checked. If high, maybe this is the trait that could be running through your family.

For a recent review:

Lipoprotein Lp(a) excess and coronary heart disease
Stein JH. Rosenson RS.
Archives of Internal Medicine. 157(11):1170-6, 1997 Jun 9.

Subject: RBBB

I had a medical checkup recently doctor told me that I am normal except RBBB. What is RBBB?

It stands for right bundle branch block. In simple terms, the electrical system of the heart consists of a pacemaker in one of the upper two chambers of the heart (right atrium) and the pacing signal is carried to the bottom two chambers (right and left ventricle) by two sets of wires (right and left bundles) to tell the two chambers when to beat. You lost (or have never had) the wire to the right ventricle but that's OK because when the left ventricle gets its signal, it tells the right ventricle to also beat.

He told me that it is normal in most human being, nothing to be worried about, I won't die from it. That I was born this way. Is that true?

Given your young age, you probably were this way since birth.

I am becoming a pilot, will this RBBB affect me in the long run?
What are the symptoms??

Subject: coronary arteritis

Where I might find information about coronary arteritis, or the symptoms, treatment and prognosis of this condition?

Try the Merck manual link in my webpages. A more specific term to try would be Kawasaki's Disease.


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Subject: Genetics Questions

What does it mean when a disease is caused by a recessive gene?

When a trait or disease is recessive, it means that one has to have both alleles (in most cases, one has two copies or alleles of any given gene) being of the disease-type. Usually, one copy comes from the mother and one from the father. Exceptions apply for genes that are sex-linked, mitochondrial, or subject to imprinting (ie Angelman's or Prader Willi). If one knows that a disease is autosomal recessive (i.e. Mendelian inheritance), and the disease is present in an individual, one can assume that both parents are at the very least carriers because the trait came from both parents. As far as the severity of the disease, this will vary from individual to individual because of variability in the inheritance of other genes +/- environment.

Subject: Blood type genetics

Could someone please explain how a father with type B-pos. blood and a mother with A-neg. blood could produce a child with O-pos. blood type. I know the child belongs to the two parents because I am the mother. My other two children have A-pos. and A-neg. blood types.

Here's how:

the father's genotype is B/O +/- and your genotype is A/O -/-.

The O-pos child's genotype would then be O/O +/-

and child#2 would be A/O +/- and child #3 would be A/O -/-

Subject: Celiac Sprue

Does anyone know about the genetics of Celiac Sprue? I have two daughters with the disease and a son who does not have it (he has ADHD instead!). They have both had diagnosis by blood tests and small bowel biopsies. I have had the blood test which shows that I am genetically predisposed to the disease. My husband is totally negative as is my son.

Celiac disease is inherited in an autosomal dominant fashion (linked to HLA DR3) with incomplete penetrance. This means that half of your offspring will be susceptible like you but not all who are susceptible will develop the disease.

Subject: Genetics of Blood Type

Can a woman with B- blood type have a son with A+ blood type?

Yes. The son phenotypically is A+ but genotypically he could be A/A;+/+, A/O;+/+, A/O;+/-, or A/A;+/-

If the mother is phenotypically B-, genotypically she could be either B/B;-/- or B/O;-/- based on phenotype but based on her son's possible genotype she must be B/O;-/- because if she were B/B;-/- then the son would have to carry a B allele somewhere and we already listed all the genetic permutations above and none include a B allele.

So the long and short of it is *YES*, the woman could have a son with A+ blood if her genotype is B/O;-/- *AND* the son's genotype is A/O;+/-.

Subject: Hereditary Angioedema

What tests for this and how is it treated?

The test for this is C1 inhibitor levels and the treatment to prevent further attacks would be androgenic steroids.

Subject: Intelligence

Where does intelligence come from?

It has been known for several years that the most common form of inherited mental retardation occurs when there is a disruption of the FMR (familial mental retardation) gene by expansion of repetitive DNA (deoxyribonucleic acid) elements. The phenotype is known as fragile X syndrome. The FMR locus is currently one candidate gene for intelligence. And yes, in males, the X chromosome does come exclusively from the mother.

Subject: MERRF

What is this?

MERRF stands for mitochondrial encephalopathy with ragged-red fibers.

It is caused by a mutation(s) in the DNA that are in mitochondria which are the ATP-producing organelles present in our cells.

These mutations have been identified. Researchers in the U.S. are characterizing their effects on the cell. Understanding the hows&whys may lead to effective treatment.

Subject: Genetics of Eye Color

How are green eyes produced genetically? Can a brown eyed person and a green eyed person produce a blue eyed baby?

Brown eyes are encoded by a dominant gene (for a higher amount of iridial melanin). All other colors are created by varying amounts of less melanin. A blue-eyed baby may become green-eyed or even brown-eyed as s/he grows older as pigment accumulates. Eye color typically becomes more stable after 6 years of age in most if not all children.


Archives of Ophthalmology. 115(5):659-63, 1997 May.


European Journal of Human Genetics. 4(4):237-41, 1996.

Miscellaneous Medical Questions

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Subject: Information about PEUTZ-JEGHERS Sindrome

I need information on diagnosis and therapy for PEUTZ-JEGHERS Sindrome.

Diagnosis (for those with strong family history):

(1) HOBT q year
(2) Flex sig q 2 yrs.
(3) Colonoscopy for those with two or more affected 1st degree relatives (or one that was affected at a young age such as below 40)
(4) AC-BE
(5) Panoramic jaw x-rays to pick up familial adenomatous polyposis
(6) Upper GI series
(7) Genetic screen for loss of heterozygosity at q21.


(1) Close monitoring for primary tumors
(2) Reduce/eliminate meat, alcohol, fat intake and increase dietary fiber
(3) Consider prophylactic colectomy as situation or clinical picture warrants.

Subject: carbon dioxide in blood

A recent blood test of mine showed pretty much all normal results execept that CO2 level was somewhat about normal. The doctor didn't comment but I'm wondering what could cause that. Does the fact I didn't eat for about 18 hours previously have anything to do with it? Or could it be the effect of some medicines?

Taking baking soda (sodium bicarbonate) can increase serum bicarbonate levels. However, the most likely explanation in you case is being a bit dehydrated from not taking anything in for 18 hours.

Subject: Allergies and Nursing

I am a nursing mother of a 15 month old. I am suffering from horrible pollen and mold allergies. Before getting pregnant I was on Allegra and loved it. Now I find that it is not compatible with breast feeding. Does any one have any suggestions of either over the counter or prescription drugs for allergies, preferably one that wont make me drowsy. My lactation consultant said that the doctors have been prescribing Claritin, even though there have been warnings, she said no one has complained. I am concerned about long term effects on my daughter.

I would suggest a passive electrostatic filter for your central ventilation system plus active HEPA air filtration in the rooms you frequent in your home. Then stay indoors and stay well-hydrated until the pollen count goes down.

Subject: Lacking Antithrombin III and taking Coumadin

Do you know what the implications are to having a deficiency of ATIII and whether taking Coumatin for 20 years might have severe side effects?

The implications are that you will require lifelong anticoagulation to prevent sudden death from a large pulmonary embolus (clot that goes to the lung).

Coumadin is a safe longterm means of anticoagulation.

Subject: Pituitary Gland
What symptoms are associated with problems involving the anterior pituitary gland?

The anterior pituitary gland makes several peptide hormones and they are:
(1) Corticotropin (aka ACTH)
(2) Thyrotropin (aka TSH)
(3) Prolactin
(4) Growth Hormone
(5) Follicle Stimulating Hormone
(6) Luteinizing Hormone

Symptoms from problems with the anterior pituitary may be explained by either a deficiency or surplus of one or more of the above hormones. Because of the number of hormones involved, these symptoms can be quite variable. When the anterior pituitary has globally decreased function there can be low blood pressure, low body temperature, dry skin, fatigue, memory problems, growth retardation (in children), loss of postpartum lactation, loss of menstruation, breast atrophy, testicular atrophy, and loss of libido. If a tumor is present, there can be a partial loss of vision from impingement upon the optic chiasma. There can be small secreting pituitary adenomas that produce an unregulated excess of any one of the above hormones. The symptoms would depend on the hormone in excess.

Subject: surgery

Why is using a cell saver during surgery better than transfusions?

The cell saver would theoretically save hospital days by avoiding complications of blood transfusion such as viral infection, fever, and GVHD (very rare except in immunosuppressed or coincidental partial sharing of HLA antigens). The downside is higher initial costs and lack of availability.

Subject: Pancreatitis

What is pancreatitis?

Inflammation of the pancreas, an organ that has both endocrine (insulin, glucagon, etc) and exocrine (amylase, lipase, etc) functions.

What are the symptoms, treatments, causes?

Symptoms include pain, nausea, vomiting acutely. Treatment is supportive with rehydration, pain medications, and nothing by mouth. It can be caused by alcohol (most common), biliary obstruction, cystic fibrosis, trauma, infection, malignancy, medications etc.

Subject: Hashimoto's Disease

What is Hashimoto's Disease?

This is an autoimmune disease afflicting the thyroid gland that acutely can cause hyperthyroidism but over time usually leads to hypothyroidism. Not to be confused with Grave's which is also autoimmune but involve antibodies that stimulate thyroid gland hypertrophy and hyperfunction leading to goiter. These antibodies also have the interesting property of causing exopthalmos (protrusion of the eyeballs).

Subject: Gallstones

What is a HIDA scan?

It's like a xray. It does take a while to perform but is not painful. It will show your doctor how the bile flows in and out of the plumbing connected to your gallbladder. This will help him answer the question of whether there is a stone blocking things up.

Subject: Blood Chemistry

What are electrolytes?

Electrolytes are the dissolved salts in the blood that give it the property of being able to conduct electricity. Hence the term *electro*lytes. They also make blood salty and most of the electrolytes consist of the cation Sodium and anion Chloride (aka dissolved salt) but there is also Potassium and Bicarbonate. The body usually regulates the level of each electrolytic component very tightly because large changes can cause electrical problems in the body such as seizures and heart malfunction.

Why does a person with liver problems also have problems with electrolytes?

A person with end-stage liver disease is at risk for sudden changes in electrolytes because of the shifting of fluids out of blood into the abdomen and legs and the medicines used to treat the swelling caused by the fluid shifts.

Subject: caduceus

What is caduceus?

from Stedman's medical dictionary:
caduceus - a staff wuth two oppositely twined serpents and surmounted by two wings; emblem of the U.S. Army Medical Corps.
See also staff of Aesculapius

staff of Aesculapius - a rod with only one serpent encircling it and without wings; correct symbol of medicine and emblem of the American Medical Association.

Subject: Marfan's syndrome

What is cystic medial necrosis?

Cystic Medial Necrosis (Erdheim) is more a pathological finding than a true disease entity. It has been associated with dissecting aortic aneurysms in people with Marfan's syndrome.

Subject: Continuing Medical Education

Where can I find on-line CME credits?

I list them here within this web site.

Subject: Amenorrhea

What can cause this?

consult your physician about *why* you are amenorrheic.

some things it could be:
(1) pregnancy
(2) anorexia
(3) malnutrition
(4) menopause
(5) other endocrine problems
(6) premature ovarian failure

Subject: Ganglion Cysts

How can I make these go away without surgery?

Usually what I recommend is to apply gentle circular pressure (with finger tips or palm of hand) often for a few minutes at a time (while commercials are on TV would be a good time or you could make it a nervous habit) and it stands a good chance of eventually shrinking and disappearing altogether.

Subject: Hippocratic Oath

Anyone have the text for this?

To address this FAQ, I have added a page to my collection with the text of the *Hippocratic* oath.

Subject: Dieting

What is the maximum sustained weight loss a fat and healthy person safely can have per week?

My rule of thumb is not more that 5% body mass per month which would work out to 1-2% per week. Think of it this way: 1 kg (or 2.2 lbs) of fat is equivalent to 12,000 kCal. Imagine a 12,000 kCal deficit per week for someone modestly overweight at 180 lbs (5'10") who is losing about 2 lbs per week. Such a person has probably halved his pre-dieting caloric intake from 3000 kCal/day to 1500 kCal/day. Even if he were fasting, the most one would expect is 4 lbs per week for such an individual.

Subject: TIAs

Can anyone tell me a bit more about TIA's?

TIA stands for Transient Ischemic Attack. It is taken as a warning of impending stroke.

What are the symptoms?

Like a stroke but lasting less than 24 hours.

How is it diagnosed?

By the symptoms and abnormal neurological exam. Often these include focal paralysis and parasthesias. Sometimes there may be slurring or loss of speech.

What is the treatment?

Call 911 immediately. It is a stroke until proven otherwise.

Subject: Diabetes Insipidus

What causes this?

It is caused by pituitary insufficiency - specifically the lack of vasopressin, a hormone released from the posterior pituitary gland. Treatment is vasopressin replacement.

Subject: B12 and Folate Deficiency

In light of all the media attention to homocysteine problems, how do we avoid deficiencies in folate and vitamin B12?

Folic acid deficiency is easily corrected with a daily multi-vit that typically has 1 mg of folate per tablet. Better would be just good nutrition while moderating ethanol intake (the most common cause of folate deficiency).

Vitamin B12 deficiency takes years to develop because normal well-nourished people have large stores of it. There are usually serious problems underlying vitamin B12 deficiency that occurs in the absence of chronic alcohol abuse. When there is vitamin B12 deficiency, there is the possibility that a person has a problem with absorbing it (a Schilling test would be needed to diagnose this problem). Here, the only way to correct the deficiency is to give B12 parenterally or intramuscularly.

The neurological problems arising from B12 deficiency may not completely reverse with correcting the B12 deficiency. Typically, either folate or B12 deficiency will present with megaloblastic anemia. The reason for caution with just giving folate in this situation is that the anemia will respond even if the real problem is low B12, thereby masking the B12 deficiency while neurological problems continue to worse. Excessive folate is not associated with neurological problems.

Subject: Skin

What is the branch of medicine the diagnoses and treats diseases of the skin?


Subject: Asthma

How do you reliably distinguish chronic bronchitis from asthma anyway?

The reason for your confusion is that there is a lot of overlap between those who have asthma (aka reactive airway disease) and those who have chronic bronchitis. In many instances no clear distinction is ever really made. Typically, the classic asthma diagnosis is reserved for children and adolescents with the classic findings of exercise/cold air induced dyspnea with wheezing. In older individuals particularly those without wheezing, we tend to diagnose as chronic bronchitis (aka chronic obstuctive pilmonary disease or COPD). This distinction is arbitrary and some may even argue inaccurate because there is often a component of chronic airway inflammation (bronchitis) in people with the classic asthma diagosis and a component of airway hyper-reactivity in those with the chronic bronchitis diagnosis.

The bottomline is that treatment is very similar for either asthma or chronic bronchitis obviating the need for a clearcut diagnosis:

(1) Bronchodilator Inhalers (both)
(2) Aerosolized anti-inflammatory agents (both)
(3) Aerosolized anti-cholinergic agents (more for chronic bronchitis with increased mucus).
(4) Theophylline (typically reserved for severe COPD).

The key to treatment is some form of objective measurement of response to medications. Periodic pulmonary function testing and home peak flow measurements are highly recommended and proven to be helpful in reaching optimal treatment and therapeutic goals.

Subject: Medline

What is medline?

It's a medical literature database.
There are places on the Internet where it is free.
Some of those places are listed under general medical resources in these webpages.

Subject: Non-Steroidal

I've been using a steroidal drug for my asthma (Azmacort) and been happy with it. I was told there are no side effects. Now I'm hearing that there are non-steroidal anti-inflammatory drugs...which makes me wonder why? Why did someone deem it important enough to create a NSAID when the steroidal ones seem to work just fine?

First, the distinction must be made between inhaled and systemic steroid use. Azmacort is inhaled. A typical ingested (systemic) steroid would be something like prednisone. Systemic steroids have great anti-inflammatory properties and you may have even have been given prednisone or received an injected form when your asthma really acted up but their chronic use can lead to a lot of bad things like acne, obesity, diabetes, heart disease, hypertension, and osteoporosis. These bad things don't really happen with inhaled steroidal medications nor with the NSAIDs. However, NSAIDs have their limitations and can make some inflammatory conditions, such as your asthma, worse.

Subject: Fibroids

My sister (without access to the Internet) has fibroids on her uterus. She is 34 and has two children, 7 and 4. I would like to know if anyone has this condition and what can be done about it, i.e. drugs, surgery, etc. Is this a very dangerous situation?

What can be done: no drugs. surgery - hysterectomy

Indications for surgery: significant symptoms and/or menstrual bleeding problems.

Dangerous situation? By themselves, no. Fibroids are benign smooth muscle tumors.

Subject: feel asleep during at work

i am getting this problem, feeling asleep at work, and can't get rid of it. Unless my friends who drink coffe, me i can't for sotmaache reasons, is there any way to feel more wake up. note that i sleep at most 6 hours, and the doctor tells me no need for tablets

so what do u suggest ? ( tea??)

Ask your doctor to consider sleep apnea. The test to determine this is known as a "sleep study".

New (to be filed)

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Subject: Cause for headaches?

Are berry aneurysms on the circle of Willis always detected by MRA, or is a vascular X-ray exam preferred?

MRI/MRA does miss things. A conventional cerebrovascular angiogram should be considered if there is a high index for suspicion.

Subject: Should I be concerned, my doctor has me scared?

Here's my story. About 3 years ago I weighed around 400lbs. At the time, I had a bad episode with GERD which scared me enough to send me to the hospital. When that happened I had the test done where they use the nuclear device and the dye to look at your heart. Plus I had numerous EKGs done. All turned out fine, according to them. Then through a gradual program of moving towards a vegetarian diet and cycling to work everyday, I'm now down to 247lbs. My blood pressure is great. My cholesterol is 125. There is no history of heart disease in my family.

Problem is, I've been worried about possibly having done permanent damage to my body. So I've been getting a battery of tests done to make sure I'm okay. A week ago I had an EKG Treadmill test. The test came back with a result that concerned my doctor at the high end. She said it looked like I could have some blockages. Tomorrow I'm going to see a cardiologist, but I guess I'd like to know (as I wait) what the odds are that this is just a false positive? Given the experience of some here, what are the chances that this was just a weird test, especially given that at 400lbs., 3 short years ago, the dye test was negative??

Let me first start by commending you for the weight loss. You were morbidly obese and were at risk for developing coronary and cerebrovascular disease. Now the risk is less for either development or progression.

It is possible that the "dye test" you had three years ago missed the detection of significant blockages. At 400 lbs, the test would have been less sensitive. Could you have had worsening of coronary disease over the past three years? The answer would again be "yes."

What are the chances that the treadmill EKG test is a false positive?

Given your history of having been morbidly obese (and male) balanced by being asymptomatic with good exercise tolerance (cycling everyday), I would estimate about 30%. I think it remains a good idea for you to see a cardiologist to go over all your risk factors and any physical exam findings that would weigh into a more accurate estimate of your likelihood of having significant coronary disease.

Subject: Prevention

The latest edition of Time magazine focuses on health and heart disease. I thought, finally, they broke it down simply. Chop out all the study information, confusing technical terms, and just tell us what to eat and do to prevent heart disease.

Unfortunately, just scanning through the mag revealed the same old story. Taking this "may" prevent, or this "might" help, or "could prevent". Please. Is there anything conclusive? Something that definitely "will" prevent heart disease? How do I really know if I am wasting money on garlic tablets?

Eat foods low in fat and cholesterol favoring fruits and vegetables. Avoid excess especially if you are overweight. Engage in regular exercise such as a brisk walk for more than 30 minutes at least three times per week. Time this exercise before the largest meal of the day to help curb appetite. An adult aspirin tablet a day for men over 35 yo and women after menopause will keep heart attacks away. If your cholesterol is high despite diet and exercise, consider medication. Definitely stop smoking. Instead of garlic tablets consider folic acid, B6 and B12. See your doctor about that annual check-up. All the above *will* prevent heart disease.

Subject: Why is HDL good?

Why is HDL good? Is it simply that in persons having lots of it, statistics show that their arteries do not clog up as much? Or is there a function which HDL does especially well?

It removes oxidized LDL (oxLDL) from the walls of arteries. The most proatherogenic component of cholesterol is oxLDL.

Subject: After effects of Exercise(stress) ECG?

Just wanted to ask for some advice about after effects of having an Exercise ECG.

I had one last week and was told my target pulse was 220- my age , I'm 27 so thats 193, I actually acheived about 185 Beats per Minute on the final stage (leevl-4 UK treadmill), the doc said it was great, no abnormal rythmns or breathlessness, just me and a lot of sweat!

My problems started about 36hrs after when I started to get sever Angina pain, I'd never had it before, after 3 days I saw the doc who said it was "Common" after what I had been through. I have Hypertrophic Cardiomyopathy, although my valves are clear and I have a 60% EF.

My Cardiologist never mentioned this might happen, the attacks are become less severe daily, now just over a week ago but I am not getting some minor pains in my wrists and neck that seem to be eminating from beneath the skin and not muscular. I've spoken with someone else who says it took them 3 weeks to recover as the body circulation restored to normal. Bearing in mind that the only exercise prior to this my doc allowed was brisk walking which took my pulse into the 90s is this to be expected, if so roughly for how long before I should start worrying? Also is there any risk of permanent damage from having an Exercise ECG?

Actually, 220 minus age is the theoretical maximum heart rate. Target is usually 85% of maximum. The symptoms you had 36 hours after the treadmill likely was unrelated to the test. Strenuous exercise causes permanent damage to the heart primarily when it triggers a heart attack.

Subject: Variation In Blood Pressure Readings

Very confused about my blood p readings.

I take 7.5mg Zestril every morning when I wake up around 7 AM. Then one or two cups of coffee. Then, around 8AM, I measure the p with a AND UA-702 monitor.

The systolic readings usually are all over the place. Typically varying on one day to a reading of 95, then on other days, perhaps 120.

diastolic varies from 55 to 75, day to day.

Unfortunately, I have no good way to calibrate the meter. Batteries are new, but who knows if it is truly calibrated.

Take it with you when you see your doctor and s/he will check if the readings are accurate.

Today, I measured my pressure at a pharmacy with one of the automated machines in mid afternoon, and it was 155 for systolic !

Those automated drug store machines are notorious for being inaccurate.

Can reading really vary this much throughout the day?

It can but more likely the variability is from inaccurate measuring devices.

How low is too low? I'm 65 yrs of age, 6' tall, and Not overweight.

Systolic pressure less than 100 mmHg *and* symptoms such as dizziness or profound weakness.

Subject: Variation In Blood Pressure Readings

What does diastolic have to do with heart rate? My understanding is ZILCH. I have done exercise until my rate is over 130 and I still measure 80 diastolic (my 30 day average is 83).

Blood pressure (MAP) is the product of cardiac output (CO) and systemic vascular resistance (SVR).

Cardiac output is the product of cardiac stroke volume (SV) and heart rate (HR).


And, MAP = (1/3)*SBP + (2/3)*DBP

The relationship is therefore not ZILCH but:

DBP = (3/2)*[SV*HR*SVR-(1/3)*SBP]

BTW, this should be the formula that BP machine manufacturers should be using to calculate DBP from SBP holding SV and SVR to predetermined (often inaccurate) constants.

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