June is for Fathers (and the Women who stand by them!) Seventieth Anniversary of D-Day Invasion!

Reflection: Dads' roles have changed for the better! Whereas it was once said that dads were mainly interested in providing for their families, modern dads know they have a far greater and challenging role to play and cannot succeed without a strong woman/partner at their side. I learned this from my dad, now 87 years old and a WWII veteran. Through thick and thin, he and my mom always did/do everything together: long hours of work, tough decisions, heated arguments, painful sorrows, quiet prayer, shopping and cooking, intimate dancing and outrageous rejoicing! "Together" is their MO. When couples come into my office, I am immediately reminded of my parents' "Fidelio" relationship.

If you will allow me another reflection on Father's Day, Rita and I recently had the (6:00 AM) pleasure of watching the Disney Classic, Little Mermaid, with our wonderful granddaughter, Alida, who is now two and a half years old and already a feminist. You may recall the scene where King Triton, the MerKing, reprimands his daughter and then sheepishly turns to his adviser (a crab named Sebastian) and asks, "Was I too hard on her?" This scene vividly captures the challenges faced by all dads: "How do I hold the line without inhibiting the development of my gifted child?" (If you know the answer, please send it in one hundred words or less to [email protected]!).

Happy Father's Day to all the great dads who fight/fought on the front lines, at home and abroad!

Men, your loved ones need you! Here are a few updates to assist you in your role as Grandfather, Father, Brother, Spouse, Uncle, and Best Friend!

John A. Schmidt, MD 

Where We Choose to Die

An article published in the New England Journal of Medicine on June 26 examines where we die and begins with the sentence, "Until well into the twentieth century, the appropriate place to die was a foregone conclusion: it was at home, surrounded by family and friends." Grieving is facilitated because people feel more comfortable expressing their feelings and emotions in the privacy of a home or homestead. With the introduction of technology, the rise of hospitals, sanitariums, intensive care units, and global wars, fewer Americans died at home. Even my grandmother, who was fond of saying she would never go to a hospital, died in a hospital. I find it moving how families struggle for years to bring the remains of their war dead home. The home is where we live and, under the best of circumstances, die. This realization has led to the home hospice movement. I work with Medicare Funded Hospice Agencies and families to help their loved ones die in dignity in their homes. The impact has been a recent rise in the percentage of Americans dying at home and fewer Americans dying in hospitals.

Paradoxically, the rate of ICU use in the last month of life has risen from 24percent in 2000 to about 29 percent in 2009, the main reason being that many families and their doctors wish to exhaust all modern medicine has to offer before accepting the inevitable death of a loved one. Completing the POLST (Physician Orders for Life Sustaining Treatment) form with your doctor is therefore very important because it tells caregivers and emergency workers if the patient wishes to go to the hospital or ICU in the event of a serious life threatening illness.  

Because the trend to more intensive care is not likely to change, another article in the same issue of the Journal reminds physicians that ICU care needs to be Dignity Conserving Care.   

Drug Safety in the Digital Age

My patients and I appropriately spend a lot of time discussing drug safety and I am constantly amazed by the amount of misinformation spread by newspapers, the Internet, and broadcast media. Such hype interferes with the appropriate use of life sustaining medications. An article published in the June 26 issue of the New England Journal of Medicine examines how patients choose to update their knowledge on drug safety and points out that Wikipedia is the most frequently consulted on-line health care resource because of its high ranking in Google search. Unfortunately, only 23 percent of Wikipedia pages were updated more than two weeks after a Food and Drug Administration (FDA) warning and more than 36 percent of pages remained unchanged more than one year later! Bottom line: go the authoritative source for drug safety, the FDA. Enter "Medwatch" into Google search to navigate to the FDA site on drug safety. Go to [email protected] for complete drug labels. Another option is to use WebMD because the FDA automatically feeds safety data to WebMD. Twitter users can follow FDA safety communications at @FDA_Drug_Info.  

Adverse Health Effects of Marijuana Use

An article published in the New England Journal of Medicine on June 5 shows that, "the popular notion that marijuana is a harmless pleasure" is misguided. About 12 percent of people 12 years of age or older report annual use with high rates of use among young people. Adverse effects include addiction, withdrawal, increased use of other illicit drugs ("gateway drug"), impaired brain development in adolescents, poor school performance, and impaired driving ability causing motor vehicle accidents and visits to the Emergency Department. The THC (tetrahydrocannabinol) content of marijuana as detected in confiscated samples has been steadily increasing from about three percent in the 1980's to 12 percent in 2012, raising concerns that adverse effects will worsen with time. My patients are often surprised to hear that cannabinoids (dronabinol and nabiximols) are already available by prescription and used in several clinical settings. Proponents of "medical marijuana" argue that these FDA-approved synthetic cannabinoids are not as effective as smoking pot based on largely anecdotal (uncontrolled) data. I am surprised at the willingness of tax-hungry governments to legalize marijuana. With the rise in narcotic related deaths and the known potential of marijuana to serve as a gateway drug, why burden society with yet another legal addiction? Cigarettes, alcohol, and gambling are quite enough! 

Monitoring Heart Rhythm in Cryptogenic Stroke/TIA

Strokes and Transient Ischemic Attacks (TIAs) are a common cause of death and disability. As I have discussed in previous newsletters, getting to the ER fast is essential. Figuring out the cause is also important as well because it affects the kind of therapy used to prevent recurrences. For example, if the cause is a ruptured atherosclerotic plaque, antiplatelet therapy (aspirin, clopidogrel) is essential. If the cause is an embolism, blood thinners (warfarin, Pradaxa�, Xarelto�, Apixaban�) are the preferred therapy. Sometimes the cause is unclear, i.e., cryptogenic. Two well-designed studies published on June 26 in the New England Journal of Medicine, show that intermittent (paroxysmal) atrial fibrillation is an underappreciated cause of cryptogenic stroke. To detect the arrhythmia, the investigators monitored patients for thirty days with an internal or external "loop recorder" which proved to be superior to conventional 24-48 hour Holter monitoring. The editorialist concluded that thirty day monitoring should now become standard of care in patients with unexplained stroke or TIA.

Valerie and I wish our patients a Happy Fourth of July and express our thanks to all the men and women who secured and preserved our independence, as well as the freedoms enunciated by FDR during his State of the Union address on January 6, 1941: Freedom of Speech, Freedom of Worship, Freedom from Want, and Freedom from Fear! God Bless America (and the US Soccer team!).