Thursday, August 28, 2008

Hypothyroid Update: Common Sense Triumphs over Bureaucratic Boobs

As you know, I was recently diagnosed with Hashimoto's Thyroiditis and subclinical hypothyroidism. I dug deep into this condition as a cause for my recent increase in lipoprotein(a) and homocysteine (it seems both are affected). Dissatisified with the first two Endocrinologists I saw I did some research and found the best local endo I could. I used the following criteria.

1. I wanted someone on the staff of a research and teaching hospital. I figured these were the types who saw the most varied and largest patient load and had an interest in the unusual as opposed to the "crank turners" who follow standard procedure.

2. I wanted someone who had graduated no less than 10 years ago and no more than 15 years ago. I wanted someone who was experienced yet was exposed to modern concepts and not yet set in their ways.

3. I wanted someone with an expressed interest in lipids, not just diabetes as most are.

4. It would be nice if the doc was in my insurance plan!

Well I found my guy at the Medical College of Wisconsin where they are actually doing research on the endocrine system's effect on lipids. It took some arm twisting and a little rule bending but I not only got in to see the doc I wanted but lucked into a cancelled appointment the following week (instead of having to wait 6 weeks).

The doc was excellent. He told me things the other two endos never covered.

1. My TPO and TG antibodies are indeed above the reference range but nowhere near what they see in bad cases and, most importantly, far below what they see for those suffering polyglandular auto-immune disease. That little tidbit was never mentioned before and would have been nice to know earlier.

2. He will treat me based on my symptoms not just my TSH level. How about that for forward thinking.

3. He was not opposed to Armour Thyroid although he did specify a preference for T4 only therapy. That is what is known as "open-minded."

4. My thyroid is actually small for my height and weight and is consistent for mild Hashimoto's Thyroiditis and subclinical hypothyroidism. Another little tidbit never mentioned.

5. He understood the difficulty in adjusting for sporadic hyperthyroid hormone spikes as my thyroid deteriorates and explained how we will ignore the "noise" inherent in any feedback system and focus on the trendline. Not much you can do about it but at least we had the discussion and I felt secure that the doc understood and appreciated my predicament.

Wow, I finally found the thyroid equivalent of a Track Your Plaque doc like Bill Davis! But it gets even better on the non-technical end.

Seems the Medical College has all kinds of strict rules about who the bureacratic "gate keepers" will allow in to see the docs even with an appointment. Seems the computers would not acknowledge my existence even though they had a record of me from 30 years ago when I was in for migraine headaches (those actually cleared up years later). Apparently, their auditors had not yet verified my new insurance. I was told I would not be allowed to see the doctor until I was "in the system." Just then a nurse appeared to tell the recalcitrant clerk, "The doctor wants to see this patient." When the clerk refused she gave a stern look and said, "I am taking this patient!" After additional objections from the clerk the nurse leaned in and in a forceful tone repeated, "I am taking this patient!" I thought it might come to blows.

Wow again. The nurse took me (minds out of the gutter please), the doctor saw me, and after being interrupted several times by a bevy of disturbed bureaucrats the computer gods were placated. Thank God there are still doctors and nurses who are not only competent but caring enough to put people over procedure. Outside the staff at Track Your Plaque, I was beginning to think the breed was nearly extinct!



Sunday, August 24, 2008

Another Reason to Lose Weight - YIKES!

Like many of you, I read a tremendous volume of online medical journals trying to keep abreast of the latest advances and atrocities in heart medicine. In yet another classic, "I don't know whether to laugh or cry" moment I stumbled across this report:

Extremely obese a cath lab problem: Some turned away because of weight restrictions on tables

In what has to be the one of the most incredulous statements ever uttered by a doctor, lead investigator Dr. Thomas Vanhecke (William Beaumont Hospital, Royal Oak, MI) offered, "It is a paradox. New research is showing us that patients are dying younger with more cardiovascular disease, and yet there are no cath lab guidelines for how to treat those who are morbidly or massively obese."

Is the good doctor worried about people getting fat and having heart attacks at an alarming rate at progressively earlier ages? No, he dithers over the fact there are no guidelines on how to treat morbidly obese patients. Hell, wouldn't want to smush any of that shiny new cath lab equipment or have the guy topple over on you! Where was the good doctor when these folks were shoving their faces full of cream pie? Here's a paradox for you doc, if not utter irony. Can you imagine being so overweight that when the inevitable angina or heart attack comes the hospital might turn you away because they fear you will break the cath lab table?!

Vanhecke also said that when faced with obese patients they are typically told to exercise and diet before they can undergo the procedure. Huh?! I'm having a heart attack and you want me to go exercise for six months then come back? Yowza!

Now, I hate to go off the deep end (not really) but if you link to the actual article you will see the quotes I lifted are not radically out of context. I've had my fun at the doctor's expense over some (ahem) rather dubious statements and it is time to get serious. These types of pronouncements speak loudly about the mindset of traditional medicine whose position appears to be "let people get morbidly ill while we invest in better "guidelines" and technologies to fix them." This might give you an inkling as to why medicine is becoming so expensive.

At the risk of being accused of using bad puns, what ever happened to the old axiom, "an ounce of prevention is worth a pound of cure?" Perhaps 500 pounds in some cases.

Excuse me while I finish my Diet Coke!


Tuesday, August 12, 2008

OMG! Vitamin D Lowers Death Risk? No Kidding!

Heh, slowly but surely the traditional medical community is beginning to realize what Track Your Plaque observed almost two years ago, low Vitamin D levels increase mortality risk. Now, I must admit, even I was slow to come around but when the overwhelming evidence of plaque reduction and Vitamin D poured in to Dr. Davis' practice I had to believe the data.

Now, years later, another study has found that that low levels of Vitamin D lead to an increased risk of death. The big difference here is that it was a rather large (13,331 persons) study that followed participants and average of 8 years (see Arch Intern Med. 2008;168(15):1629-1637).

There was one interesting fluke to this study for the numbers geeks like me. The study population statistics were striking. If you were in the lowest quartile (25%) of Vitamin D levels your morality risk was 1.26 (26% higher) within a 95% confidence interval (CI) where the CI was 1.08 - 1.46. Stats geeks realize that what this means is that if you ran this same test 100 times you would find the calculated mortality risk somewhere between 1.08 and 1.46 in 95 of the tests (but always higher than 1). The other 5 times the risk would be less than or greater than the CI range meaning you might actually find the risk to be LOWER (>1). This is enough to statistically link Vitamin D to reduced all-cause death but the similar analysis for CVD and cancer mortality only, while higher, did not meet this stringent statistical standard. I am just going to hedge my bets and keep taking Vitamin D armed with just the all-cause mortality results which this study proves and the overwhelming clinical practice experience of Dr. Davis. Melamed also offered sound advice when suggesting people should know their Vitamin D levels before pounding down supplements.

Of course, Dr. Melamed had to go and ruin everything by going off the deep end with the opinion that the most sensible advice for those wanting to ensure their levels remain optimal is to "spend 10 to 15 minutes per day in the sun and to eat vitamin-D-fortified foods, such as milk and oily fish." DOH! That, my friends, is down right malpractice in my opinion. Let me count the ways!

1. Sunlight to vitamin D conversion varies from person to person.
2. Sunlight to vitamin D conversion decreases with age.
3. Sunlight to vitamin D conversion varies with clothing, sunscreens, etc.
4. Sunlight to vitamin D conversion varies by latitude and season.
5. Sunlight to vitamin D conversion varies by race.
6. Most milk is fortified with D2 not D3 which is the more active form and what the good doctor ACTUALLY STUDIED! DOH! 25(OH)D (the study variable) is produced in the liver from the metabolism of vitamin D3.
7. Dietary sources of any kind generally will not provide enough D3 to signficanly raise blood levels.

Here is my personal regimen. Get my blood tested and take an oil-based D3 supplement. Repeat the cycle until I achieve 60ng/mL! I am now at 62ng/mL but it took a dose of 10,000IU a day. That's a lot of milk and oily fish, LOL!

It is so darn easy. What do they make it so hard?!



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