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Sarge,

The costs can be much higher than that, particularly if you are talking about emergency room or surgical emergencies. They operate under the "take ZERO" chances. So, tests are often ordered even though the likelihood of a positive study is nearly zero. A stupid example. A person walks into the ER with a cough that has a chest xray showing the patient has pneumonia, then the ED doc always orders a CT of the chest to rule out a clot in the pulmonary arteries. The chance of BOTH occurring is real but slim. The average pre-test positive predictive value in those cases is less than 4%...which means 96% of those studies are negative. Did I mention one of those tests costs 800 bucks? There is more to the discourse, but the gist is really we over order to CYA. In a courtroom nobody will fault you for over-ordering tests to rule out the possibility of everything. If you don't order that test, you may find your balls in a sling. So, undoubtedly, it significantly impacts care and the costs of care.

Seth, first off, the diagnosis of ADHD is really a clinical issue. If the person in question can function in a classroom or workplace competently but may be easily distractable, then you don't formally have a clinical diagnosis of ADHD. In order for a person to truly have it, it HAS to impact their daily function such that they aren't getting work done or are doing poorly at school. If those impediments are occurring, then a person ought to be treated after they have been appropriately diagnosed. I'm fairly distractable and I have some of the traits of ADHD but it has not impacted my academic or professional career except that I got a B in conduct in grade school routinely.

Thanks Jules.
I think most times Teachers just dont expect boys to be boys anymore. And the grades were all A's and B's so no issues, as i suspected.

Seth, I would council you to be sure that he isn't disrupting class routinely and the antics or distractions are minor. If they aren't, then an eval may be in order just to make sure there aren't any other issues. I would be very hesitant to give someone I care about any medication for the long term unless there truly wasn't any way around it. There are therapy sessions for helping kids adjust to classrooms and expected behaviors. But, then again, these are over the top if they are just that the kid "talks too much to his friend", "is not cooperative at times",....insidious things are issues where the child is withdrawn or is genuinely a risk to others or prevents the teacher from being able to teach. Those are larger issues. Could also be that the kid is too smart and is simply bored.

There is more to the discourse, but the gist is really we over order to CYA. In a courtroom nobody will fault you for over-ordering tests to rule out the possibility of everything. If you don't order that test, you may find your balls in a sling. So, undoubtedly, it significantly impacts care and the costs of care.

Jules,

Appreciate the info, but the question still remains on what was your take on Obama's speech to the AMA?

Sarge, hard for me to know what he means. He was vague, but talked about deterring frivolous law suits. There are litigious oriented patients who will sue for a bad outcome. Obama's comments really are welcome but hopefully not a platitude. In many cases, patients sue people because they feel like they were neglected even if they weren't. I do think part of that responsibility lie with us as physicians to take appropriate time to talk to our patients and know them, their expectations and needs. That is probably where this ought to start first. Ironically, as reimbursements go down, physicians see more patients to make expenses. That in turn feeds the cycle.

The notion of not addressing caps on awards was surprising. I do think there should be a cap on what lawyers make on those awards. I think that would be the single largest deterrent to frivolous or overstated cases. I also think there has to be reason injected into pain and suffering. Tort reform has generally helped regulate malpractice premiums from all I'd read.

The notion of not addressing caps on awards was surprising. I do think there should be a cap on what lawyers make on those awards. I think that would be the single largest deterrent to frivolous or overstated cases. I also think there has to be reason injected into pain and suffering. Tort reform has generally helped regulate malpractice premiums from all I'd read.

Exactly. I thought it was quite telling that Obama was all for reform, but when it came to the single most useful tool, IMO, for reform (malpractice caps), he said he wasn't for that. Seemed to me he's trying to say he's a reformer, while still keeping his trial lawyer buddies happy.

Okay Jules, I have a big one to throw at you...

I had my inguinal hernia repair surgery last Wednesday, recovery is going okay. Thanks for your advice on that.

During the surgery they knocked me out and while monitoring my heart they discovered an irregular heartbeat. They called in a cardiologist and he diagnosed it as an Atrial Fibrillation. They are concerned because this type of condition typically appears in people much older than me. I’m only 41, don’t smoke, not overweight, I’m very physically active and my diet is pretty solid. They did an Echocardiogram on the spot and found nothing more, at least nothing bad enough to keep me in the hospital any longer at that point.

I had a follow-up with that Cardiologist’s Nurse Practitioner today, my heart is back in normal rhythm... but, she said they noticed the walls of the lower chambers are slightly enlarged or thicker than normal. She said causes for this could be viral, genetics, low potassium, alcohol and one other factor I can’t recall right now. She said my blood work ruled out the other factors (except genetics of course). She’s really fixating on my alcohol consumption which is… 3-4 beers on a Friday night and 6-12 during the course of a Saturday afternoon into the night (obviously these totals vary based on the situation) but that is a pretty generous average – I don’t touch a drop the rest of the week. I told her that right before my hernia repair I was diagnosed with a swollen lymph node in my right groin, I thought it was a double hernia (the inguinal was on the left side), but the surgeon determined it was a swollen lymph node. He said a cause could be the body fighting infection, among other things and I should just leave it alone. The Nurse Practitioner said that my white blood cell count was elevated, but didn’t think that was the problem causing the enlarging of my heart.
I just had a physical at the end of 2007 (right before I turned 40), I had an EKG where a right bundle branch blockage was found, so I went for an exercise stress test and they basically laughed me out of the room because it took so long for them to get my heart rate up. After the stress test I had my first Echocardiogram and no problems were found. My cholesterol was fine and my blood pressure was good and has been fine since. My alcohol consumption, diet and exercise regimen was pretty much the same then, as it is now.

So my question to you is... Why would my heart suddenly be under siege from my alcohol consumption in less than 2 years time? It just doesn’t add up for me. What’s your opinion? Do you agree with the Nurse practitioner’s assessment? Should I seek a second opinion? Should I explore the swollen lymph node thing?

As always... your opinion is appreciated Doc.

wow, real quick before Doc makes his appearance, hope everything works out, and boy am I effed.

Hmm....lots to address there.

There are two separate issues. One the atrial fibrillation or a-fib. The second is the mild wall thickening of the lower heart chambers or ventricles.

Ventricles:

I'll start with the second. Ventricular wall thickening: First off, it could simply be from exercise. If you exercise as often as you do, then it would be reasonable for you to have mild ventricular wall thickening. This can be corroborated with your resting heart rate and is the MOST likely explanation for this. In the absence of known high blood pressure, valvular heart disease and no family risk of what's called hypertrophic cardiomyopathy, then there is very little likelihood it is from a medical problem but most likely related to exercise (good).

There are a few other outliers called non-ischemic cardiomyopathies (not related to clogged arteries but other cardiac diseases related to certain auto-immune disorders, viral infections, genetics, chronic illness etc). These are uncommon, you are not the right demographic. Highest risks, younger patients (<25), older patients with chronic illness (>65), Ashkenazi Jews (who have certain genetic glycogen storage disorders) and blacks. The latter can have problems similar to what they found with you that ultimately results in wall thinning (very bad) of the ventricle. You don't have the right demographics. Alcohol does NOT make the wall thicker to the best of my knowledge, however, it can result in a dilation of the cardiac chamber (known as an alcoholic induced cardiomyopathy). But that would fall under the significant consumption which you really don't have. Your greatest is on Saturday, and my off the cuff recommendation would be to curb it to closer to 3-6 rather than 6-12 drinks except on super special occassions.

Atrial fibrillation or a-fib:

This is difficult for me to answer. Some people have abnormal pacemakers and they compete with the normal one disrupting heart rhythms. There are SO many things that can account for this. If you had a single isolated episode that resolved without medication, then I'd say you probably need to be checked annually after they do a modestly annoying 72 hour Holter monitoring...that records any abnormal rhythm over 72 hours and reports them as events. The most likely explanation is too much coffee or any sort of stimulants (chocolate, cold medicine to relieve nasal congestion or allergy meds or meth) or a combination of lack of sleep AND lower amounts of stimulants. Or even poor sleep, allergy meds and alcohol (the latter lowers your threshold for abnormal pacing in the heart).

There are numerous other possibilities, but I'd start here by saying that I think this was circumstantial rather than deep rooted pathology. Not saying it is something to ignore, but saying it seems from what you say that it was a single, isolated episode and not recurring.

All in all, from the info you provided, I'd say your risk is negligible overall, but I'd go a little lighter on Saturday drinking and I'd have them investigate your heart more closely for the chamber wall thickening but I think it is exercise related.

Sorry...the lymph node...if it was firm to the touch, then yes I'd explore it. If it was tender or warm to touch, then it is most likely inflammatory and if they found it after surgery was probably related to that. Or an ingrown hair or something.

If YOU can feel it, and it is firm (feels like a rock or solid) and doesn't resolve in a few months, you can have it checked out. In an extreme case, it would be simple to remove it if the answer remains unclear.

In all seriousness now Jules, honestly, i am a smidge concerned here by the following:

Your greatest is on Saturday, and my off the cuff recommendation would be to curb it to closer to 3-6 rather than 6-12 drinks except on super special occassions.



I excercise very frequently -lifting as well as cardio, yet my 'off day' per wknd sees me easily tripply scotty's low end beer consumption. Meaning 18 beers is almost a done deal.

NOW -i should state that I drink "wussy" beer in that I drink MGD 64 and used to drink Mich Ultra.

The alchohol content on an MGD 64 isnt even listed on the bottle unlike all other beers, but this switch is a new thing for me (last few months).

I will freely admit to being a huge drinker in college and before marriage and the 1st few yrs (ex: Id bring a 30 pk of lite beer to a tailgate, go thru most before entering and not being slurred or falling down drunk (high tolerance coupled with being large>??) have a few inside and if we lit the grill up again after, finishin off that 30 pk.

I guess my question is two fold- Ive heard that if you stop smoking, you are less and less likely to show the effects of that bad habit as time passes. Is this true also of alchohol and its effects on our systems?

I dont drink like i once did and by all accts ive never been healthier. At 36 my blood pressure's great, blood sugar is great, per my Dr. ive been within my ideal weight (within 10 lbs on either side) the past 2 yrs now, i excercise at least 1x a day most wks, and ive curbed that binge drinking by a large margain.
Am I still at risk for the typical alchohol related illnesses? Is there anything I can do to lessen the chances if abuse's effects are cumilative ?

The 2nd question is only if your 1st answer is as i may fear it is: What tests would you recommend if any for someone in my shoes to determine the severity of any effects? Perhaps it takes a LOT to dammage our bodies from booze, and this is all for nothin (Id be fine with that) but what would you recommend.

Thanks.

Well, Seth, there isn't a specific threshold for alcohol related damage in terms of an absolute number of alcohol servings. If you stop drinking altogether you will almost certainly reverse any damage caused to your liver.

The problem is that things like alcohol and smoking affect too many different organ systems. The biggest risks for both are: cancer and heart related diseases.

Now, it takes a substantial amount of liver damage from drinking before it becomes irreversible which I believe is your question. The mitigating factors: size corrected for standard AND the amount of alcohol dehydrogenase your body has. It is present in lower amounts in Asians and that is why you will notice they have flush faces even after a few drinks.

In your case, you cannot count serving for serving your consumption to be equal to somebody 75% or 65% your size. Therefore, if your drinking is moderated (a nebulous range), then your risk is minimal since your liver can regenerate before you damage it beyond the point of no return. Alcohol related liver disease is uncommon in patients below age 45. It takes a substantial amount of drinking to bring it about. The major concerns are if you are taking medications like cholesterol lowering drugs, tylenol, pain meds like vicodin (which contains tylenol) and an assorted variety of other commonly prescribed meds, THEN the threshold is lowered since they cause low grade (but reversible) injury to the liver. The combination of these and alcohol are something to be cautious of.

I am sorry, I can't give you a specific number regarding what would be safe compared with dangerous, but the fewer the better. Not saying to go dry, but unfortunately that is the safest route.

MGD? I've truly become an elitist! Troeg's, IPA or any number of specialty brewers???? You used to go to Mad Mex, I imagine, yes? Love that place...they have a rotating schedule of specialty beers every few weeks. Then there is that Hofsbarhaus (franchise, admittedly) but has some good seasonal brews.

One other thing, Seth. I would never tell you that 14-18 brews in a day on weekends is ok. If it happened occasionally, I'd say it happens, but if it were something that were doing on a weekly basis, I'd encourage you to halve that amount even while realizing that the beer you have is relatively low in alcohol content.

Seth, when you come to visit again, you had better re-acquire a taste for Ultra. I have some leftover from your last visit and even the homeless won't take them!

Oh, and Jules, can you visit the "Eli Manning is the highest paid player in football" thread in the 'Bleeds?

Just addressed the missing link...er bitch.

Jules, long time listener, first time caller....

for the past few months, my wife has been battling a shoulder problem that her orthopedic diagnosed as 'frozen shoulder'....she did not have a previous shoulder injury or do anything specific to hurt it. for the past 3 to 4 months she has been going to physical therapy twice a week and doing some exercises at home. while it is slightly better, she has very limited range of motion (she can lift her arm straight out but cannot lift it above her shoulder). the doctor gave her the choice of PT or going in for a procedure where they would do a manual adjustment while she is "under". based on what she's read and heard from others (extremely painful and debilitating, plus additional PT), she decided she did not want to do that. but, the slow progress is very frustrating and at some point the insurance company is going to terminate the PT. she's really unsure what to do and is concerned she is going to have to live with this the rest of her life. just wondering what you would advise to do.

Regarding the above discussion, ... heart problem and alcohol consumption.

For what it's worth, ... following the heart attack in October my cardiologist informed me it was acceptable for me to consume 2 to 3 beers per day. (I don't but that is what I was told.)

I know, Dean....just trying to be realistic. He would recommend that for lots of reasons. I recommended what I did as a suggestion to moving towards moderation.

ED, frozen shoulders are related to inflammation of the capsule that surrounds it. The risk is that the longer her range of motion (ROM) is compromised, the higher the risk of developing scar tissue that will have a lasting impact on her ROM. Currently, being put through those ROM exercises breaks up scar tissue and allows preservation of motion. I'd get a second opinion and it would be painful if they forcibly break up the scar tissue even if they use anesthesia...cuz she will have to wake up.

Seth, not to be maudlin, but my wife's friend drank herself to death last year. She would drink wine, daily, to complete intoxication for a number of years. About this time last year, her liver failed and a month later she died.

I'm not saying this will happen to you; she had a number of other problems, but it's sort of related to the thread.

Hey seth,

Drinking 18 beers one day a week has a name. It is called binge drinking and it is very dangerous.

Doesn't count, only 2.8% beer

Girlie binge drinking?

Thanks Jules.

I am taking note of the information you put out here. I saw Munch's warning and I gotta say I drank like that quite often- usually 4 or 5 days a wk in college, a bottle of Silver Spiced rum before we'd go out and then maybe 7 to 10 beers at the bars (Mad Mex-meh, I was a CJ's guy Jules).


I think Ive wanted to lessen the amount i drink when i have given myself 'the green light' to drink for some time now.

When there's an 'event' etc- like say the Draft party- well its pretty much game on and the # can be way up there.

I think im goin to try to really watch what i put in the body more, i cant say that the 18 beer Sundays are history, but we will see. Goin to make the effort for sure. Dont feel like crappin out due to failing liver.

Thanks.

(Talon- I'll drink that Ultra, dont sweat it)

Well, Seth, there isn't a specific threshold for alcohol related damage in terms of an absolute number of alcohol servings

And that sums up what a scary game of Russian roulet this all is guys.

I know most of you think I am a on some sort of big book thumping alcohol is evil campaign. But let's talk realistically for a minute.

I've watched too many guys die from this. Guys that most of you would say didn't have a drinking problem. After all they never drank in the morning, had jobs and money and wives only drank on the weekends yadda yadda yadda.

I also talk to a few guys daily that have no business being alive at this point with the amounts they drank.

You can't quantify what is dangerous because it is different for everybody. I've known 250lb guys who's livers exploded while drinking half of what a 150 guy who still walks this earth did.

So go on believing I am some annoying crazed prohibitionist.

But don't delude yourselves into believing that you aren't drinking at dangerous levels if you are.

My posts on this subject might be treated like I am trolling.

But please know that they come from sincere concern.

[/rant]

Simplest thing is this, would you feel comfortable talking to your PCP about how much you drank on that single day? If the answer is no, then I think you already know/knew it was too much.

The reason people are vague about it are: 1) you won't get people to quit....think smoking and prohibition....2) nobody really knows since physiology differs from person to person.

In the end, I've said moderation is the best, and that is something that requires a safe for all comers....which is where two servings/day comes in (EXCEPT IF YOU ARE ON CERTAIN MEDICATIONS).

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