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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Friday, February 27, 2009
    "Snap" Isn't Good

    OK. What shall we talk about today?

    I know. Let's start with the telephone call I got yesterday from the ER. They were seeing a patient of mine, an elderly woman who's been bed bound for several years following a stroke. Yesterday while bathing her, the caregiver raised her (the patient's) arm so as to do a better job - and heard a loud SNAP.

    That's how bad osteoporosis can get. You snap someone's humerus in two, just by raising their arm.

    Granted, it usually isn't that bad. If you're immobile and non-weight bearing that really accelerates the process, and no, calcium supplement isn't going to be enough to fix that. Bone is like muscle in the sense of "Use it or lose it"; it reacts to being stressed by strengthening itself. Bones are active, not static; bone matrix is constantly being revised to respond to stress. This is why astronauts are at extra risk for osteoporosis. If you spend time in a zero gravity environment, bone strength decreases. Weight bearing exercise like walking, jogging, weights are all helpful in maintaining bone structure but swimming and stationary bicycling are not.

    I spend a lot of time trying to convince patients to take medication for osteoporosis. Most patients, at least in my experience, think that calcium alone is enough. It's not, not if you are on that slippery slope of bone loss. But you should take calcium, and these days I recommend calcium citrate with vitamin D. Calcium citrate is more easily absorbed than calcium carbonate (the kind you get in antacids). Also, you need stomach acid to absorb calcium properly. There is evidence that long-term PPI or H2 blocker use (i.e., meds like ranitidine or omeprazole) can be a risk factor for osteoporosis because it means that you're absorbing less calcium.

    We have lots of great new medications to treat bone loss now. Probably the most commonly used are the biphosphonates like alendronate and risedronate. (US brand names: Fosamax and Actonel.) These are the ones that can irritate the esophagus and have to be taken on an empty stomach, but they work the best. I also use raloxifene (Evista), mostly if someone can't tolerate a biphosphonate.

    Why do we treat? It turns out that fractures are much more of a health risk than you'd think. Here's an article about mortality risk associated with hip fractures: in this study, a cohort of 120 elderly patients were followed after sustaining a fracture. Six months out, 18% had died and another 29% were institutionalized. That's 47 percent - nearly half - who never made it home.

    Other risks for osteoporosis include being thin (hah), heavy caffeine intake, smoking and alcohol. Lifestyle does make a difference here, but the main risks are age and genetics. If osteoporosis runs in your family it means you have a higher risk of getting it.

    My patient isn't a candidate for surgery. She's too frail and her bone quality is so bad the surgeon wouldn't be able to pin the bone. So she's in an immobilizer and she's lost the use of her good arm (the other one is the stroke-affected arm).

    Take your calcium, exercise and cut back on the coffee.


    Thursday, February 26, 2009
    May I See the Wine List?

    V. just sent me a voicemail from one of the nursing homes where we often see patients. The charge nurse called to give V. a test result and then added: "The patient is requesting red wine with dinner. Please call us back."

    Requesting wine with dinner, at a nursing home?

    I voicemailed her back and suggested that the staff get some grape juice and pour rubbing alcohol in it - "He won't be able to tell the difference." Hmm. Chateau Geriatrique. Sounds catchy.

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    Monday, February 23, 2009

    As I watched the Oscars last night I thought back to a film I saw several months ago at an independent film festival. I meant to blog on it but somehow never got around to it. Independent films are a bit of a crapshoot; they can be either very good or very bad. You never quite know what you've let yourself in for, but I was eager to see this particular movie due to its star Gregory Itzin - you may know him better as President Logan from 24. The movie is called Float and is centered around the owner and employees of a Glendale ice cream parlor.

    As it turned out, Float was a very pleasant surprise. I'm a sucker for anything with multiple plotlines, and this is an ensemble film where each of the actors gets their own story, so I sat back happily and watched. Two of the actors (not Itzin) co-wrote the script. One is Filipino, the other Armenian, and one of the pleasures of the film is the glimpse it gives the audience of the Armenian community in Glendale.

    The plot is set in motion when Itzin's wife leaves him. He's playing Ray, a hardworking small business owner who clearly hasn't thought about anything but his job for years. When she leaves he's thrown for a loop and can't stand the thought of staying in his house alone. He camps out at the ice cream parlor but is discovered by his assistant manager, Gevorg. Gevorg is a fast-talking playboy type who's always running some sort of side business out of the ice cream parlor, but he's also kindhearted and takes Ray in to stay with him. Complicating matters is Ramon, a former employee who's been fired by Ray and is also staying with Gevorg.

    Gevorg is somewhat estranged from his traditional Armenian family, particularly his father, who's running for city council. He meets and falls for Ray's daughter Emily, who works for an environmental organization and is somewhat estranged from her father as well. Meanwhile, Ramon has fallen for Gevorg's cousin, who wants to stay in the U.S. and is looking to marry an American citizen... you get the idea. Lots of stuff happens.

    The film concludes with happy, or at least hopeful, endings all around. Greg Itzin does a very good job as Ray, the owner who rediscovers that there's more to life than work. He gets a tattoo, meets a nice woman and starts a new relationship.

    Sadly, due to the competitive nature of independent films, it does not look as though Float is coming to a theater near you anytime soon. The last I checked the director was trying to get a deal for distribution of the film. Should that happen or if it makes its way onto DVD, I'd recommend it. The screenplay is witty, the acting is good and the relationships among the characters make for entertaining viewing.


    Sunday, February 22, 2009
    Brief Early Oscar Review

    I did not think I would be big into watching the Academy Awards this year, but here goes. Heath Ledger won the Supporting Actor award this year for playing the Joker... dull surprise. And I relieved my feelings at Bill Maher by flipping him the bird the entire time he was onscreen. (F*** you, Bill Maher. I hate you. No specific reason, I just hate you. No hard feelings, 'kay?) But he was not nominated, which made me feel better.

    Updates as they happen.

    UPDATE: YES!! The sound team for "Slumdog Millionaire" won. They look so excited. I really think this movie is the underdog film that everyone is rooting for.

    ...and SM just won for film editing. Go, go, go, guys.

    AND AGAIN: Ah, gee whiz. So nice that Eddie Murphy is giving Jerry Lewis his props. The man has raised untold amounts of money for muscular dystrophy.

    ONE MORE: Best Original Song: After watching the talented cast of SM dance and dart across the stage, who could doubt that they would win? And they did not fail... SM did win.

    AGAIN: The Obligatory Salute to Those Who Have Gone Before Us is moving, due to the inclusion of Charlton Heston, Cyd Charisse and Paul Newman.

    AND ANOTHER: Wow, Danny Boyle as Best Director for SM. I think I spot a trend.

    HEY: Kate Winslet cops the little gold statue! Good for her!

    UPDATE: Dang, Anthony Hopkins is near 'bout as bald as Ben Kingsley. And we have the obligatory quip about Sean Penn and the paparazzi.

    ... and of the Brat Pack nominees, Sean Penn cops it. (Why was Mickey Rourke wearing sunglasses indoors at night??) Gee, thanks for the preachy acceptance speech, Sean.

    UPDATE: Best Picture montage was v.v.g.

    UPDATE: Slumdog Millionaire gets it!! Well done!

    FINAL UPDATE: Wait, wait. Where was my federally mandated George Clooney sighting in all of this? Did I miss him? Either I did or I was robbed. Robbed, I tell you!


    Monday, February 09, 2009
    Parenthood: The Real Story

    Sometimes, The Onion just tells it like it is. I thought this was hilarious. But then again, I don't have kids.


    Sunday, February 08, 2009
    Using Up Leftovers

    Sometimes I open the fridge and find myself confronted by something I bought that I need to use up. This time it was ricotta cheese. I had bought it on sale and made lasagna with some of it, but there was still a fair amount left. What to do with it?

    I thought of manicotti, but I had had my fill of Italian food for the moment just finishing the lasagna before it went bad. So I got on the Internet and started searching. (Some view the Internet as a bottomless well of news and politics; some see it as a warehouse for dirty pictures. For me it's the world's biggest cookbook.) Most of the recipes I found were for muffins. I picked the simplest recipe I could find, one that would not involve me having to purchase more ingredients just to use up the ricotta. It turned out to be Lemon Ricotta Muffins, and I liked them so much that I made them a second time and decided to post the recipe (with a minor alteration).

    The single most important thing about baking with ricotta, I have found, is to make sure your baking powder is fresh. The first time I made these they came out a little... dense. Actually they were plutonium-level dense, but they still tasted good. I knew I had had my baking powder for a while, so I checked the can and found that the expiration date on it was 1997. I now have a nice new can of baking powder, and the second batch of muffins came out as advertised. I also added a tablespoon of lemon juice to the batter, which was not in the original recipe. This both boosts the lemon flavor and adds some oomph to the leavening.

    So here is the recipe as I make it. Yields one dozen muffins.

    2 cups flour, sifted
    1/2 cup + 2 T. sugar
    2 1/2 t. baking powder (FRESH!)
    1/2 t. salt
    1 cup ricotta cheese (You can use skim or whole-fat ricotta here, it doesn't matter)
    1/3 cup milk
    6 T. melted and cooled butter
    2 eggs
    3 t. lemon peel, zested
    1 T. lemon juice

    Preheat the oven to 400 degrees and grease a muffin pan (or use liners).

    In a large bowl stir together the flour, 1/2 cup sugar, baking powder and salt. You are going to mix the batter in here, so make sure it is a large bowl. In a smaller bowl stir together the ricotta, milk, butter, eggs, lemon peel and lemon juice; when well combined pour this into the flour mixture and beat only until just combined. Do not overbeat; batter should be a little lumpy. Spoon into the prepared pan and sprinkle each muffin with 1/2 teaspoon of sugar (that's the additional two tablespoons mentioned above). Bake 20 to 22 minutes.

    These are really good and don't take that long to make. You can save time by mixing the dry ingredients together the night before. Zesting the lemon peel is made much faster if you have a Microplane grater; if you don't have one, get one. It is a marvelous invention.


    Saturday, February 07, 2009
    It's Been That Kind of Week

    funny pictures of cats with captions


    Friday, February 06, 2009
    It Has Come To This

    So there's this drug called Amitiza, used to treat severe chronic constipation. Most people don't need it; you put them on prunes or spinach and explain to them that they are supposed to eat five to seven fruits/vegetables per day and not per week, and they do fine.

    But some people do need it. I have one patient who does. Today I had to call his insurance company to get the drug re-authorized, and this is what ensued:

    Pharmacy Benefit Rep: "What is the frequency of the patient's bowel movements on the medication?"

    Me: "Whaa?"

    PBR: "How often is he having bowel movements?"

    Me: "He has not shared that information with me."

    PBR: "We need to know that before I can authorize the Amitiza."

    So now I have to call up my patient and ask him how frequently he, uh, goes. What a surreal conversation that's going to be.

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    Monday, February 02, 2009
    On Call: Rules of the Game

    As I sit at my desk facing another night on call, I thought perhaps I might do my good deed for the day by posting a few etiquette suggestions.
    • To the anxious relative calling from three thousand miles away: You are running up your phone bill for nothing. If you want to get your money's worth you should probably call during office hours so that you can talk to your parent's ACTUAL DOCTOR. I can guarantee you that if you talk to me we will both wind up frustrated. I can't read my partners' minds, and I can't tell you what Dr. X was thinking when he ordered Drug A instead of Drug B or why he sent your parent to Nursing Home Alpha Beta Gamma instead of Whiskey Tango Foxtrot.

    • Also, if you are a grumpy patient looking for ammunition to bolster your claim that Dr. X makes terrible clinical decisions you won't get it from me. Even if that is the case (which I am happy to say is highly unlikely, at least in my group) there's no way in hell I'd tell you that over the phone. That way lies madness, not to mention malpractice suits. If I have a real question about care I will raise it directly with the doctor himself/herself, and I will assure you of my intention to pursue it and then get back to you. Rarely do I need to do this, but it happens once or twice a year.

    • If you are sitting in the ER waiting to be seen, you have my sincere sympathy, but I do not run the triage department and I cannot get you seen any faster. Please do not call me.

    • If you are an elderly neurotic with a grudge against your family because they dared (how dare they!) to go away for the holidays without you, even though they made arrangements for you to get regular home care while they were gone, and you call me to ask if you should file a complaint with Adult Protective Services, I will make you sorry that you were ever born. I am not making this up - I actually got this call.

    • If it's likely that you will need a prescription, please have a pharmacy number in mind before you call me. If it's the middle of the night or a holiday, please make sure it is a 24-hour pharmacy. Do you want the prescription or not?

    Thank you.