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Grand Rounds: Men's Health


Dr. Paul Nicolai
Bastyr grad, 2nd year taking Pathol
Montana and Oregon
undergrad in Math and Psych at Texas A&M
Men's & Women's health
he drinks coffee but will tell us to take caffeine away from your patients

relaxed speaker, no power point, off the cuff, invites discussion
friend of Josh Levitt, unruly hair
Lyle Lovett made him aware of this poem
"Some folks say there ain't no bears in Arkansas"
read out loud
he will post articles for us

HIS PRACTICE
"You don't get answers to questions you don't ask."
His initial appts are 2 hours
get a thorough history including med hx, doses too
if can't remember bring supps to 2nd appt
does physical exam on everybody
decides about labs
does iron studies on just about everybody
CBC, CMP, Chol, 25OHvitD
rarely prescribes ABX and gives probiotic with them
he likes to make people eat kale, make people afraid of simple carbs
takes people off coffee
he only uses salivary hormone testing for cortisol, not other hormones

BUSINESS TIPS
know who owns the charts: own them
know diff btw employee and independent contractor
have current drug book copy on desk
derm book on desk
merc or equivalent

MEN'S HEALTH
topic of lecture
hemochromatosis
"Men are generally too dumb to go to the doctor"
most men in his practice are because he's seeing the wife and she convinced him to go
Bruce Milliman in Seattle practices: "he doesn't do anything"

CONDITIONS

HEREDITARY HEMOCHROMATOSIS
prevalent among N eur caucasians 1/300
SCREENING is indicated, he finds lots of women who are iron deficient
starts screening men in their 30's, repeat in 40's
in 10 years of practice he has dxd hemochromatosis 10-20x
he hasn't seen screening dx breast ca, colon ca, crc, etc
a cause of MS?
HFE gene makes GI tract good at picking up iron
several genes, a new one too, C282Y, H63D
compound heterozygote = 1 copy of each gene

SX: none or unexpected
weak, fatigue, loss of libido, joint pain, rashes?
fe dep in liver, heart, testicles
-->dm, hypogoanidism, cvd, cirrhosis, osteopenia/porosis
64% of men with this dz have osteopenia
DX: iron study, tibc and ferritin and all
transferrin sat over 45-50, ferritin over 300, that's positive, then get genetic testing
he uses lab corps, he haggles with them because they charge too much for lab tests
get a "client price", got basic CBC down under $30
genetic test $120 but he says you may not need it
if LFTs abnormal then refer, consider liver bx

TX: don't take iron
avoid red meat and liver
avoid alc
avoid vit C with meals
drink tea with irony meals
TX: therapeutic phlebotomy, draw 300ml, lower ferritin 90? points
may have to do weekly cycles for a long time to get it down to normal
then repeat 2-4x/year

GET THERAPEUTIC PHLEBOTOMY
American Red Cross now using iron rich blood
used to throw it away
patients don't have to pay
**special collections phone 503-280-1443

ALLERGIES/LABS
he likes USbiotec allergy panel
he sent many samples of his own blood to two different lab companies
all 6 pts (labelled diff his blood) had same food allergies w/ US biotec

METABOLIC SYNDROME/INSULIN RESISTANCE
he says 85 is ideal fasting blood sugar for normal height x weight person
now 6.5+ HGB A1c is diagnostic if repeated
Sx: ED, obes
METABOLIC SYNDROME IS 3/5: high waist circumference, TGs over 250, HDL under 40, HTN systolic over 130 or diastolic over 85, fasting blood sugar over 100
Tx: diet and lifestyle (science backs that lifestyle change works better than drugs)
weight loss: he doesn't care what diet as long as patient is on board and can do
first personal diet on internet: people loose 15-30 pounds/month, smashes insulin resistance
http://www.1stpersonaldiet.com/ he's had pts use this
asks pts to bring their diets to him so he can check for dangers
asks pts to bring supps to him same reason

TESTOSTERONE
he almost never gives it to men
visceral obesity makes you turn all your T into estrogen
husband's est 2x his postmenopausal wife's: proving a point
give T to obese man he may get hot flashes
tx for low T: lose weight, exercise
HCTZ: thiazide diuretic for HTN may decrease T
tests T between 8-9am in both men and women, in serum, free and bound

HYPOTHYROIDISM
in men not as uncommon as you might think
find elevated TSH in routine screening
case: infertility, low libido in 35yo male
he uses naturethroid, 80%T4 20%T3

VITAMIN D
he tests all his pts
80% are low

PROSTATE CANCER SCREENING
USPSTF has guidelines for mammograms and 2008 prostate screening guidelines
mc cancer in men
#2 cancer cause of death in men
USPSTF guidelines:
current evidence insufficient for screening in men under 75yo
recommends against screening for men 75+
inadequate evidence that treatment post dx actually helps
but he does testing in all men over 50 and also digital rectal exam
this is "kind of the gold standard"
screening every 2-4 years mb as good as every year
Sx: prostatdynia
nocturia, urinary urgency, frequency
hesitancy, dribbling, decreased force of stream
infections, retention of urine
insomnia, nocturia
coffee drinking-->decr zinc absorption, incr symp tone
TX: kegels
pharm: alphablockers, etc
herbs: pt may be taking right herb wrong dose
sitz baths: alt hot/cold
stop coffee or limit to 1/day, it irritates smooth muscle and caff processing slows w/ age
2 cups at 8am may cause trouble at 2am

QUIT COFFEE
for 2-3 weeks
don't call me in 1st week
you will hate me, hate yourself, hate the world
after 2-3 weeks see if your sx change
you will have the info that you need
if it didn't work we'll try something else

PEYRONIE'S DZ
notes below this point from wikipedia:
Induratio penis plastica, CITA: Chronic Inflammation of Tunica Albuginea
CT disorder involving the growth of fibrous plaques in the soft tissue of the penis
1-4% of men
fibrosis of tunica albuginea in fibrous envelope surrounding corpora cavernosa
causes abnormal curvature of the penis
etio: trauma, calcium channel blockers, beta blockers
without tx 12-13% improve, 40-50% worsen, the rest stable
Tx:
combo of vit E and colchicine
meds?: potassium para-aminobenzoate (Potaba), acetyl L-carnitine, propionyl L-carnitine, L-arginine, sildenafil (acting through phosphodiesterase-5 inhibition) and pentoxifylline (acting through TGFβ1 inhibition)
Interferon-alpha-2b (new)
superoxide dismutase
also: injx to plaques with Verapamil!!? or iontophoresis with Verapamil and Dexamethasone???
surgery; Nesbit operation: last resort
penile prosthesis
European surgery: Leriche technique: 18 gauge needle used to lacerate the plaque

ERECTILE DYSFUNCTION
naturopathically: vital force
test: libido, erections at night and in morning?
"postage stamp test" lick stamp and stick on penis, if it pops off at night you got a woodie
most ED not dt hormones unless metabolic syndrome
most men with ED need normalization of height, weight
tx HTN, stop smoking
botanicals don't always work
case: man had multiple myeloma, caught because of high Calcium on initial screening test

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WOMEN'S HEALTH
always check T in postmenopausal women esp surgical menopause
many have very little-none

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