Wednesday, March 13, 2019

Time Flies

My oldest had her last elementary sweetheart dance last Friday. This is probably the last dance she will attend where her daddy is her date...

Where did the time go?

So my youngest is in his last year of preschool. Boy, I was just thinking the other day that all the teachers probably can tell that he is my fourth and not my first . I am completely lost and so not on top of all things preschool related... it is embarrassing.

Good thing he is so on top of most things... "Mom - it's pajama day!"  "Mom - don't forget money for the eye screen!"

So we are in such a different phase of life with elementary school stuff... PTO events... school plays... district orchestra / band / choir etc. It is a fun stage and I wish I can just stop time for a bit. I'm not sure I'm ready for middle school yet.

This is a picture of my three older kids visiting me in the hospital when the youngest was born...

Tuesday, February 12, 2019

Dietary Supplements

So this is what I've been telling my patients who are on no prescription medications but a box full of "natural supplements"... there is really no one ensuring the quality of what is in those medicines... despite it being from a "reputable company"... and they usually cost quite a bit.  So I hope the FDA really does step up and start to oversee... 

Just saying... be careful... and my advice is always to have a conversation with your physician about whether or not anything you are taking is causing any harm...

This is from my AMA Morning Rounds newsletter: (American Medical Association)


FDA to increase oversight of dietary supplements

The Washington Post (2/11, McGinley) reports the Food and Drug Administration announced that it plans to increase oversight of the dietary supplements industry due to increased risks to customers, including “unlisted drug ingredients, and false and misleading claims about health benefits.” The FDA “underscored the need for greater oversight by announcing it had sent 12 warning letters and five advisory letters earlier this month to companies the FDA said are selling dozens of products that contain unapproved drugs or make illegal claims for treating Alzheimer’s and other serious diseases.”
The New York Times (2/11, B6, Kaplan) reports FDA Commissioner Scott Gottlieb, M.D., “suggested that Congress strengthen the FDA’s authority over” the supplements “industry, which sells as many as 80,000 kinds of powders and pills with little federal scrutiny.”

Friday, February 1, 2019


Hope your year is going smoother than mine so far! I've told this story numerous times now to different folks but I figured I'd also record it here... 

So I have spent the first month of 2019 basically recovering from a blow both physically and mentally. All because I was too cocky and did not listen to the sage advice of my nine year old. Picture this...

We were having one of those unusually warmer days during Winter Break, so we were outside. My second child was rollerblading. I thought I'd join her but soon got bored blading around the driveway. I figured I'd go around the neighborhood and get some real exercise.

"Don't go that way, mom!  It's really steep!" Having taken a spill on her bike heading that way before, my daughter warned me with concern in her eyes when she saw me going down towards our neighbors.

"Oh, don't worry. I know how to rollerblade!" I called out to her with a wave of my hand. So off I went and as I rolled past her, I gave her the thumbs up smiling from ear to ear. The next thing I knew, I was flying at lightning speed and before I could think I found myself slammed to the ground skidding down the sidewalk on my right hip and thigh.

Um. Ouch.

But I started to laugh because I realized how ridiculous I must have looked and how right my little girl was. I could not stop laughing but I also could not get up.

"Get daddy!" I shouted at my daughter. My husband who was doing who knows what around the garage finally sees me sitting on the ground halfway between our house and our neighbor's house.

"Take off your skates and walk back," he instructed me.

"Uh... I would if I could!" I hollered back.  Why would I be calling for him if I could do that? So he heads over.

"Why didn't you listen to Ashley?"

"I know... she was right... she was right..." I moaned and we both could not stop laughing. It must have been a sight because I really could not walk at the moment. My husband grabbed one of our kid's scooters and he was attempting to push me back up the hill while I balanced on it. Well it didn't work and I ended up half hobbling and half hopping on one foot to make it back into the house... I was in excruciating pain.

"Hey doesn't this remind you of that time you couldn't walk after jumping that wave?"  Where is the sympathy? Okay... maybe I deserve this one...

So you think I'd put some ice on my leg and lay low for a while. Nope. I think I was in denial. I was like "Hey Ashley, forget rollerblading but let's play some field hockey."

"I'm not sure that's such a good idea, " says my husband. Of course I did not listen to him.

"Oh, it'll only be for a few minutes. I'm fine."

Well... I was not fine because later that night I realized that I had developed a HUGE hematoma... and even now a whole month out, I'm still recovering!

What is a hematoma?

It is a collection of clotted blood within the tissues as a result of broken vessels.

What causes a hematoma?

If it appears on your leg, it is usually as a result of a fall or or a blow to the leg with a blunt object.

What are the symptoms of a hematoma?
  • pain
  • swelling
  • discoloration from the blood pooling under your skin

How do you treat a hematoma?
  • cold compress or ice pack for 20-30min following the injury to reduce swelling
  • rest
  • elevating the leg
  • light compression with a wrapped bandage
  • tylenol for pain
  • heat for 10min three times a day to help increase blood flow
When do you expect to recover from a hematoma?
Most hematomas improve on their own. However, if it is a large collection it can take months for the blood to fully absorb. Occasionally, further intervention such as draining or surgery is required. So if your hematoma does not heal in a couple of days, you should see your doctor to get further evaluated.

Doctors make the worse patients. I didn't do anything I was supposed to after my injury. Now in retrospect, I think I went through the five stages of grief. I was in total denial when it first happened. Then I was angry because I didn't heal immediately and I could not exercise as I had wanted when the new year started. That then sank me into depression when I realized that I am no longer in my twenties when I could fall and still get up and keep playing as if nothing had happened. There was a Saturday this month where I despondently sobbed the entire day with this truth sinking in. Finally, I think maybe I am now accepting the reality of my age and limitations. Oops... I skipped bargaining...  Oh well... my leg hematoma was the physical blow but this acknowledgement was the mental blow. 

All good... this has now given me renewed motivation to be more intentional in eating right, sleeping, and exercising. Here's to a trauma free 2019!

Friday, December 14, 2018

Blood Pressure Medicine Recalls

I have been meaning to write a quick summary of all the recent blood pressure medicine recalls. Especially with all the worried calls we've been getting in our office, I want to offer some reassurance and guidance.

Since late summer, there has been a lot of media about certain blood pressure medicines being recalled because they contain an impurity N-nitrosodimethylamine (NDMA) . 

The first FDA recall for this issue was around July 2018... but since then the list has been expanding with the most recent recall made on December 4, 2018. Here is a summary of the blood pressure medicines that are affected so far. This list is taken from FDA website:

12/04/2018Mylan  Valsartan-containing products  Detection of Trace Amounts of NDEA (N-Nitrosodiethylamine) Impurity Found in the Active Pharmaceutical IngredientMylan Pharmaceuticals
11/27/2018Teva Pharmaceuticals Amlodipine/Valsartan Combination Tables and Amlopidine/Valsartan/Hydrochlorothiazide Combination Tablets  Impurity N-nitroso-diethylamine (NDEA) in APITeva Pharmaceuticals
11/20/2018Mylan  Amlodipine and Valsartan Tablets; Valsartan Tablets; Valsartan and Hydrochlorothiazide Tablets  Contain trace amounts of an impurity, N-nitrosodiethylamine (NDEA)Mylan Pharmaceuticals
11/08/2018Losartan  Losartan Potassium Hydrochlorothiazide  Product contains NDEA impuritySandoz Inc
10/30/2018WP Westminster, more  Irbesartan Tablets, USP 75 mg, 150 mg, and 300 mg dosage forms  due to the presence of an impurity, N-nitrosodiethylamine (NDEA)ScieGen Pharmaceuticals, Inc
10/26/2018Aurobindo Pharma Limited  Irbesartan Drug  Due to the presence of an impurity, N-nitrosodiethylamine (NDEA)Aurobindo Pharma Limited
08/23/2018Torrent Pharmaceuticals Limited  Valsartan/Amlodipine/HCTZ; Valsartan/Amlodipine; and Valsartan tablets  Impurity detected in the API is N-nitrosodimethylamine (NDMA)Torrent Pharmaceuticals Limited
08/17/2018Torrent  Valsartan/Amlodipine/HCTZ Tablets  Impurity detected in the API is N-nitrosodimethylamine (NDMA)Torrent Pharmaceuticals
08/08/2018Camber Pharmaceuticals, Inc.  Valsartan Tablets, USP, 40mg, 80mg, 160mg and 320mg  Detection of trace amounts of N-Nitrosodimethylamine (NDMA)Camber Pharmaceuticals, Inc.
07/17/2018Actavis  Valsartan and Valsartan Hydrochlorothiazide Tablets  Impurity detected in the API is Nnitrosodimethylamine (NDMA)Teva Pharmaceuticals USA
07/17/2018Prinston Pharmaceutical Inc. dba Solco Healthcare LLC  Valsartan Tablets, 40 mg, 80mg, 160mg, and 320mg; and Valsartan-Hydrochlorothiazide Tablets, 80mg/12.5mg, 160mg/12.5mg, 160mg/25mg, 320mg/12.5mg, and 320mg/25mg  Detection of a Trace Amount of Unexpected Impurity, N- nitrosodimethylamine (NDMA)Prinston Pharmaceutical Inc. dba Solco Healthcare LLC
07/13/2018Major Pharmaceuticals Valsartan tablets, 80mg USP and 160 mg USP  may contain the probable carcinogen Nnitrosodimethylamine (NDMA)Major Pharmaceuticals
So what to do?

If your medication is on the recall list, you should have been contacted by your pharmacy. If you are not sure you can always call your pharmacy to find out.

The label on your medication bottle should tell you which company manufactured that medicine.

If your medicine is affected, speak with your physician for an alternative. This requires careful consultation because the type and dosage of medicine you can be switched to depends on your medical history and current health.

Also to note... the medicines on this list are all generics made by different manufacturing companies. So far there has been no recall on the actual brand name product.

Valsartan = generic for Diovan  (made by Novartis)
Losartan = generic for Cozaar (made by Merck)
Irbesartan = generic for Avapro (made by Sanofi)
Amlodipine = generic for Norvasc (made by Pfizer)

Brand name medicines cost a lot more than generics. However, with commercial insurance sometimes the company will offer coupons where the co-pay is lowered. Unfortunately, the coupons do not work with medicare patients. Again, consult with your physician about what is best for you.

Hope this helps!

Saturday, December 1, 2018


Happy December! Every year November is a bit of a crazy month for us with celebrating three of our four kids’ birthdays as well as Thanksgiving... and then there's Christmas looming around the corner. This year, my sister’s family again hosted Thanksgiving so I actually had a nice rest. Thanks, sis!

Here is a picture of these seven crazy cousins. What a treat to be able to live so close and grow up together!

We are actually in a nice stage where everyone is out of diapers, potty-trained, mostly self-sufficient, and occasionally even helpful. Ages 5, 7, 9, and 11, so our oldest is right at the edge but not quite fully plunged into the whole teenage world. Whew!

So lots to be thankful for... in addition to all the serious stuff here are a few random but significant things that come to mind...

• a lost sock missing for months suddenly shows up
• soccer game is cancelled due to inclement weather
• lunch bag returns home with all the food eaten
• dirty clothes makes it into the laundry bin
• extra minutes of sleep on weekends because kids can do the morning routine by themselves
• teachers who understand my child and goes the extra mile
• catching a glimpse of true sibling love
• tight hugs
• loud giggles
• sweet smiles

Hope you all had a wonderful Thanksgiving!

Sunday, November 18, 2018

Update on Probiotics

Winter came early this year! Here's a picture of my car as I was leaving work the other day... I was not prepared for the sudden storm!

So with the cold season comes an upsurge of sniffles, cough... sickness ranging from sinus infections, bronchitis, pneumonia to the flu. As antibiotics get prescribed, many take probiotics in hopes of warding off side effects such as diarrhea or yeast infections. While there is some evidence of promise that probiotics would help, one should consider carefully whether or not the benefit outweighs potential harm.

Here are a few things to consider and an update on this topic since my previous post in 2012.

First of all, what are probiotics?
- foods or supplements that contain live bacteria and yeast that are considered "good" bacteria and can alter the bacteria in the gut

How do probiotics work?
- your gut is full of bacteria but when "good" bacteria gets wiped out, for example during a course of antibiotics, this can cause GI issues like diarrhea
- the idea is probiotics replace these "good" bacteria to help restore gut function to normal or to prevent the imbalance in the first place

When are probiotics being used?
some common uses include the following:
- during antibiotic use to prevent diarrhea or yeast infections
- during late pregnancy and baby's first six months to prevent allergies / eczema
- in low birth weight infants to prevent NEC (necrotizing enterocolitis)
- in patients with diarrhea caused by viruses
- in patients with IBD (irritable bowel disease) to lessen symptoms
- in patients with IBS (irritable bowel syndrome)
- in patients trying to lose weight
- in patients with depression and/or anxiety

Does it really work?
- promising evidence that it can benefit antibiotic induced diarrhea in healthy persons
- not enough data to show prevention of allergies or NEC
- bottom line is more research needs to be done in all areas

What are the potential risks and down sides?
-  since there is no FDA regulating the over counter products, the amount of bacteria and type of bacteria in the different products can vary so much and may not match what the label is claiming
-  even if the labels match the content of the bottle, the different types of probiotics vary widely and how they may help certain conditions also vary widely so it is difficult to determine which would benefit someone in which situation
-  there is even question whether your stomach acid would make the probiotic ineffective by the time it reaches your gut, so it may not be effective at all
-  there is risk for an immunocompromised individual to become very sick from the active bacteria being introduced

So bottom line is there is not enough research and data studying all the different risks and potential side effects of taking these supplements. Best to discuss with your health care provider whether or not you would benefit and to proceed with caution.

Wednesday, October 3, 2018

Flu Shots Time

It's that time of year again to get your flu shots!

I read this on American Medical Association newsletter and thought I'd share...


Leading the News

U.S. saw most flu deaths in over a decade last winter

The New York Times (10/1, McNeil) reports that “more than 80,000 Americans died of the flu in the winter of 2017-2018, the highest number in over a decade, federal health officials said last week.” Although 90 percent of those deaths were in people over age 65, “the flu also killed 180 young children and teenagers, more than in any other year since the Centers for Disease Control and Prevention began using its current surveillance methods.”
The Cleveland Plain Dealer (10/1, Washinigton) mentions that last season’s flu vaccine “was about 40 percent effective, said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health,” adding that “there’s no way to predict if the upcoming flu season, which runs October through spring, will be better or worse, experts say.” The article says researchers are developing a universal flu shot in tandem with a seasonal vaccine, and “there’s also a new, fast-acting drug that appears to shorten the duration of flu symptoms” and is under FDA review with a decision expected soon.  
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