News about Acetaminophen

When a patients picks up a prescription medication from the pharmacy, there is usually a detailed patient information sheet that includes warnings about the medication. And who hasn’t heard the television commercials for pharmaceuticals that list a number of dire possible outcomes? What patients often don’t realize is that over the counter medications can be even more toxic than prescription medications.

This week the FDA is issuing new regulations intended to reduce the risk of severe liver injury and allergic reactions associated with acetaminophen (Tylenol). Acetaminophen is one of the most commonly used drugs in the United States and between 1998 and 2003 it was the leading cause of acute liver failure in the country; half of the cases were accidental overdoses. Since acetaminophen is in so many different products, patients can inadvertently exceed the maximum daily adult dose of 4000 mg/day. The toxicity is markedly increased when combined with even a modest amount of alcohol.

When buying an over the counter medication, read the label carefully. Keep track of all medications, both over the counter and prescription, to lessen the risk of liver damage. And never combine alcohol with acetaminophen. 

Flu Activity, 2011 Week 2

Influenza-like illness activity remains minimal for Connecticut. Activity is moderate for New York City. There have not been any reported cases in Wilton. Westport/Weston has reported eight cases and Norwalk has reported 55 cases for this season (cumulative). 

Tell Me A Story ...

Many people find it hard to get regular exercise, follow a healthy diet and take their medications regularly. Even patients with chronic diseases, such as hypertension and diabetes, usually feel well so it’s hard to stay motivated. A study discussed in the Annals of Internal Medicine suggests that listening to the experiences (stories) of other people with hypertension can improve blood pressure control.

Research has shown that listeners may be influenced by a story if they identify themselves with the storyteller and picture themselves taking part in the action. At a clinic in Alabama, DVD’s of patients telling their stories in their own natural voices inspired positive health behavior changes. In contrast to entertainment education and testimonials, this success of this program may be due to homophily (perceived similarity between the character and the patient).

Physicians do not have a monopoly on wisdom: other patients with the same chronic illness can be a valuable resource. Social networks, such as Facebook and Twitter, may have an increasing role in patient education, medication compliance and motivation to stick with a diet and exercise plan. In this particular study, listening to the stories of other patients had a beneficial effect similar to that of increasing medication. More research is sure to follow.

Ann Intern Med. 2011;154:77-84

Flu Activity, 2011 Week 1

According to the Centers for Disease Control, influenza-like illness activity is minimal for Connecticut. Activity is moderate for New York City but minimal for the state of New York as a whole.

Picking Up the Pace

I took advantage of the snow day this week to watch “Joan Rivers: A Piece of Work,” the documentary that follows the comedienne as she turns 75. She looks terrific, thanks to the expert application of cosmetics and the perhaps overuse of plastic surgery. However, even as Joan appears to be wrinkle-free and youthfully coiffed, she betrays her age with her gait. Joan Rivers walks like an old lady.

One of my professors of pediatrics taught that if a three year old child can hop on one foot when asked, that child is probably neurologically intact. The evaluation is not so simple in the adult, and certainly not in an older patient. An article in JAMA considers if gait speed can be used to predict survival in the geriatric population. The conclusion: as the speed of walking increased, so did the remaining years of life for each sex and age group. The authors wrote, "Gait speed could be considered a simple and accessible summary indicator of vitality because it integrates known and unrecognized disturbances in multiple organ systems, many of which affect survival. In addition, decreasing mobility may induce a vicious cycle of reduced physical activity and deconditioning that has a direct effect on health and survival."  (JAMA. 2011:305(1):93-94.)

It’s not easy to take a walk when the ground is covered with two feet of snow – I would even caution my patients to stay inside to lessen the chance of falling on ice. However, spring is only nine weeks away and one can get in a lot of miles on the treadmill, up and down the supermarket aisles and at the mall. Shoulders back and pick up the pace!

Flu Activity, 2010 Week 52

According the Centers for Disease Control, influenza-like illness activity for Connecticut was "minimal" for the last week of the year. However, activity is "high" in nearby New York City.

Value

As the new year starts, many of my patients are scrambling to present their new insurance cards and understand any changes in their plans. It’s a given that premiums have gone up and the days of $10 co-pays are long gone. Many people are wondering if all that money is really buying what was intended. Michael Porter of the Harvard Business School presents an interesting perspective in the New England Journal of Medicine (N Engl J Med 363:26).

Professor Porter believes, “the failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices.”

How are we to measure quality? Here is one of the HEDIS 2010 measures: was the body mass index (BMI) recorded in the chart? That’s it. In other words, the physician who was foolish enough to waste time discussing nutrition, exercise or health maintenance will receive the same grade as the physician who recorded a weight but made no comment or recommendation. The second physician may even get extra points for efficiency.

I agree with Professor Porter – we need to achieve high value for patients. We need better ways to measure quality and results. We cannot lump all patients together: different populations need different bundles of services. We need to make sure that our health care dollars are spent wisely. 

Secondary Hypertension

In the United States, one in three adults has high blood pressure. In five to ten percent of these patients, there is an underlying, potentially correctable cause. This is secondary hypertension.

Many medications, both prescribed and over the counter, affect blood pressure as do substances such as alcohol, cocaine and amphetamines. Sometimes a trial period off the potentially offending medication is all that is needed to normalize blood pressure. Dietary causes of hypertension include excessive intake of sodium and licorice.

In young women, one of the more common (yet still rare) causes of secondary hypertension is fibromuscular dysplasia. For an unknown reason, the blood vessels to the kidneys become narrow, leading to less blood flow. As an act of self-preservation, the kidneys respond by sending messenger chemicals to raise blood pressure, hoping to increase blood flow. In older patients, blockage of the renal arteries may be due to atherosclerosis and will also result in systemic hypertension. In any suspected blockage of arteries to the kidneys, the initial diagnostic test is MRI.

Endocrine imbalances are extremely rare causes of secondary hypertension. These include pheochromocytoma, Cushing’s syndrome and hyperaldosteronism.  Much more common is thyroid dysfunction – both over and under active – which can cause hypertension.

When the blood pressure is high, one of the purposes of the physician’s assessment (history, physical examination, laboratory testing) is to exclude possible secondary causes. A patient’s response to medication must be monitored, since any patient with essential hypertension could develop secondary hypertension as well.

Am Fam Physician. 2010;82(12): 1471-1478.