While the exact cause of an AAA is unknown, there are certain factors that may predispose an individual to AAA development:

* Artherosclerosis
* >60 years old
* Male gender
* Immediate relatives with AAA
* Hypertension
* Smoking history (past or current)
* Chronic obstructive pulmonary disease
* Amputation above the knee
* Spinal cord injury

AAAs develop slowly over many years without symptoms. Patients do not know they have a problem until the aneurysm’ walls tear (“dissection”) or break (“rupture”). Either causes severe pain, often in the back or deep in the abdomen. If rupture occurs, blood hemorrhages into the abdomen and the patient usually collapses in shock.

The key to surviving an AAA is detecting it before it ruptures. When repaired before rupture, the survival rate is 95% and hospital time is a few days. When emergency surgery is required, the survival rate is less than 50% and the patient is often hospitalized for a month, recovering from shock and damage to most organs.

Obviously, the key is to operate before rupture or dissection creates a disaster – but when? Many people die in old age with small aneurysms that are found at autopsy. It would make no sense to operate on aneurysms that will not even rupture. Research has shown that there is almost no chance of rupture until an AAA is at least 5cm in diameter, which is about twice the size of a normal aorta.

Therefore, our strategy is to measure the AAA by a CT or Ultrasound every 6-12 months and refer to a surgeon if and when the diameter exceeds 5cm.

Sometimes the surgeon waits longer – until the AAA is 5.5 of 6cm, due to other considerations.

Formerly, treatment involved opening the abdomen, cross-clamping the aorta, cutting out the bad portion of the aorta, sewing in a replacement tube made out of tent material (Dacron), then unclamping the aorta and sewing the patient up.

Now a new technology avoids opening the patient at all. Via an artery in the groin, a replacement tube (collapsed) is floated up into the aneurysm (it is sized so it is longer than the aneurismal segment), attached to the aorta both above and below the aneurysm, and inflated. This “stent” provides a new, strong, and safe channel through the center of the aneurysm. The patient usually is home in 1-2 days with only a small scar in the groin.

Unfortunately, no drugs have been shown to slow the progression of AAA. However, rupture and dissection are less likely when blood pressure and cholesterol levels are lower.

Currently, there is no standard screening protocol for early detection of AAAs. Most of the AAAs that are detected early today are found by accident during a routine physical exam or through a test for some other issue (e.g. lumbar spine x-ray, gallbladder or kidney ultrasound, or CT colonography.)

While a full-time student in business school Alex concurrently garnered a job at Oregon Health Sciences University, continuing a passion for research initiated while an undergraduate. He has been working as a researcher in the Hematology Division for 3 years, where scientists attempt to find causes and cures for blood disorders like anemia, leukemia, and bleeding problems. He has worked within the same laboratories and with the same equipment, used by Dr. Brian Druker, who discovered the power of a small molecule now called Gleevec, which has revolutionized the treatment of chronic myelogenous leukemia (CML) and other cancers.

Finally, all this experience has congealed into a plan–to become a doctor. So, Alex spends every Wednesday here in Longview seeing patients with Dr. Kirkpatrick and PAs Matt Pyrch and Dave Kirkpatrick, learning how health care providers listen, examine, diagnose and treat patients with hundreds of different ailments, each with nuances of the patient’s life situation.

Alex has a quick and curious mind, and sees not only the implications of office visits for individual patients, but also the bigger picture of the “business” environment in which external forces like government, insurance companies, and advertising all challenge the traditional “Doctor-Patient” relationship.

Alex also brings a nice mix of city and rural thinking, to the office. Having grown up in Toutle, he can relate well to the challenges inherent in “country folks” managing their illnesses. After 8 years of living in the City, he also understands the urban perspective.

1. A day without sunshine is like night.
2. On the other hand, you have different fingers.
3. 42.7 percent of all statistics are made up on the spot.
4. 99 percent of lawyers give the rest a bad name.
5. Remember, half the people you know are below average.
6. He who laughs last, thinks slowest.
7. Depression is merely anger without enthusiasm.
8. The early bird may get the worm, but the second mouse gets the cheese in the trap.
9. Support bacteria. They’re the only culture most people have.
10. A clear conscience is usually the sign of a bad memory.
11. Change is inevitable, except from vending machines.
12. If you think nobody cares, try missing a couple of payments.
13. How many of you believe in psycho-kinesis? Raise my hand.
14. OK, so what’s the speed of dark?
15. When everything is coming your way, you’re in the wrong lane.
16. Hard work pays off in the future. Laziness pays off now.
17. How much deeper would the ocean be without sponges?
18. Eagles may soar, but weasels don’t get sucked into jet engines.
19. What happens if you get scared half to death, twice?
20. Why do psychics have to ask you your name?
21. Inside every older person is a younger person wondering, ‘What the heck happened?’
22. Just remember — if the world didn’t suck, we would all fall off.
23. Light travels faster than sound. That’s why some people appear bright until you hear them speak.
24. Life isn’t like a box of chocolates. It’s more like a jar of jalapenos. What you do today, might burn your butt tomorrow.

Unlike these thought-provoking phrases, most of what you hear about health care is designed to mislead.

The instruments, all cleaned, oiled and polished by Jessie Rawson, Christie Kirkpatrick and Scotty Kirkpatrick, were evaluated and repaired (when necessary) by retired Longview music educator Richard Uthmann, a certified National Instrument Repair Technician.

The horns will soon be used by students at a school on the Haitian island of Ile-a-Vache.

re: Dr. Kirkpatrick and his boyhood friend Steve Bailey of Los Angeles, combining their efforts to get two nearly new cellos to the orchestra program at Monticello Middle School.

The Daily News Link:
http://tdn.com/business/local/article_ec50f87e-ba7b-5b48-9dd4-ef4c6ca03b7d.html

Topics covered include:

1. Shooting fundamentals
2. Scoring without the ball
3. Free throw shooting
4. 12 types of layins and when to use them
5. Beating the halfcourt and fullcourt presses
6. Individual defensive positioning
7. Inside-outside game, getting the ball into and out of the post
8. Low Post Moves

These sessions are free to kids of both genders and all ages.

For more information:
Email: kirkpatrick[at]kalama.com
Re: Longview Wildcats Basketball Clinics.

Click on the image to download a flier about “Understanding the Disease known as Obesity.”

Reference: http://cme.medscape.com/viewarticle/702303?src=cmemp

Last month, pancreatic cancer took yet another former Longview resident, Dr. Karen Johnson Freeze. Karen was a very caring woman who created mission efforts in Czechoslovakia, wrote case studies for Harvard Business School, and was a professor in the Henry Jackson School of Government at University of Washington, specializing in Eastern Europe.

She was preceded in death by her father, former Reynolds Metals’ Longview mill manager, who also died of Pancreatic Cancer.

I can think of a dozen local people in my age group who have died from that deadly malignancy. I worry all the time that, if the City of Longview decides to feed it’s water supply system from wells under Reynolds/Fibre/Weyerhaeuser, even more locals might come down with the disease.

Medscape featured an article on May 5th about a study that projects risk for developing pancreatic cancer, based on a population study of over 450,416 people. The study’s 5-part index (participants scored 1 point for possessing each characteristic, with a total score of 0 being unhealthy and 5 being very healthy) included:

• Body Mass Index (BMI) between 18 and 25
• NonSmoker
• NonDrinker (alcohol)
• Following Mediterranean Diet
• Regular Physical Exercise

Only 7% of the 1,057 victims of Pancreatic Cancer had a score of 5. Smoking was the strongest predictor of pancreatic cancer. If none of the 450,000 patients smoked, statistics say that 14% of the patients who came down with cancer would have been spared.

We cannot control whether or not the City of Longview pumps Reynolds water into our homes. But we can avoid drinking and smoking. We can adopt the vegetables/fish/fruits diet and exercise regularly. And most of us can get the BMI up or down to the desired 18-25 range.

These lifestyle issues are common sense matters, which reduce the risk of many maladies, including heart attacks and strokes. Somehow, the successes our medical system has with cardiovascular disease, makes them not seem too ominous. But pancreatic cancer, with very, very few treatment options (which rarely succeed) should be a very strong motivator to “get your life in order.”

Some authorities believe that 50 million Americans have chronic pain that is poorly controlled. Obviously, it’s no big deal if you have a little stiffness in your hands, but on the other hand if you have chronic neck or spine pain, residual symptoms from a surgery or injury, or chronic pain after shingles or any other nerve damage…then pain can be a major problem for you.

Doctors are taught to ask people to state their pain level on a scale of 0 to 10, where 10 is the worst pain imaginable. Most people can function normally with pain in the 4-6 range unless activities aggravate it. On the other hand, with pain in the 7-8 level, patients have trouble sleeping or relaxing. And, a patient’s entire life literally goes on hold if they experience a pain level at 9 or 10.

Many things, such as lack of sleep, arthritis/inflammation, and depression, aggravate the pain, and focusing on them may be very helpful in lowering the pain intensity. Hence, we can often help by giving them sleep-aids (amitriptyline), anti-inflammatories, or anti-depressants (Effexor or Cymbalta).

Some patients find that they can minimize their awareness of pain on the surface by using ice or Lidoderm patches.

Also, many people feel less pain when they’re taking an anti-convulsant like gabapentin (Neurontin), pregabulin (Lyrica), or Lamictal, Trileptal, Tegretol, or Depakote. The problem here is that many insurers won’t pay for medications that are utilized for purposes that have not been endorsed by the FDA.

Now, if these measures are inadequate, we must use narcotics. Narcotics can be short- or long-acting drug, depending on the type. Most authorities prefer to focus on long-acting medications because blood levels and pain relief are steady/prolonged. Examples include Duragesic (or generic fentanyl) patches that last 2 to 3 days, Avinza or Kadian (morphine), or Ultram ER (tramadol) that have 24 hour duration, and twice/thrice daily narcotics like Oxycontin, Oxycodone CR, Morphine ER or SR, Tylox. Short acting medications include morphine IR, darvocet/propoxyphene APAP, hydrocodone (Vicodin, Norco, Lortab), oxycodone (Percocet, Roxicet), Atique or Fentaro (fentanyl), or Demerol. Generally, hydromorphone (Dilaudid) is reserved for near-death situations.

Generally speaking, we use long-acting medications and supplement with occasional short-timers if pain suddenly increases. If the pain worsens due to any number of factors, and the patient is using lots of short-acting medications, then we increase the dose of the long-lasting one, to re-establish control of the pain.

If things just aren’t working out, and we’re already using antidepressants, anti-inflammatories, sleep-aids, topicals, etc., then we may need to change to a different narcotic. Sometimes this is necessary because of side effects, too. Regardless, when we do that, we do not substitute 100% equivalent doses of the new drug. Why? Because people become accustomed to narcotics, resulting in a reduction in potency…when the patient takes a different drug totally new to them, the dose potency is usually much higher. So, many authorities recommend cutting to a dose ½ the potency of the old medication. Sometimes, we rotate every few months from one narcotic to another.

If all medications are failing, or if there are intolerable side effects (confusion, constipation or nausea are the most common), then we often refer for nerve blocks, spinal cord stimulators, epidurals, and other technical procedures.

For as long as I can remember, we doctors have had a major dilemma when it comes to treating chronic pain and it is spelled N-A-R-C-O-T-I-C-S.

The Federal Drug Enforcement Agency (DEA), almost every branch of law enforcement, and most Pharmacy Boards–in short, anybody who is responsible for monitoring pills (and especially diversion of prescription medications into the street market of illegal drugs), believes deep in their heart that “People with chronic pain should never be treated with narcotics or tranquilizers because of the risk of diversion or addiction.” When official regulations of the State of Washington’s Board of Pharmacy proclaim that, most doctors fear prosecution and loss of license.

The contrafoil is every professional medical group, members of which provide medical care for patients who have chronic pain. The American Pain Association, the AMA, the American College of Physicians and others all say that “chronic pain is tragically undertreated” and that “millions of Americans go to bed in pain every night.” Case law now states that doctors have been sued for malpractice because they undertreated patients’ pain.

Treat and you lose your license…Don’t treat and you get sued.

This conflict has not been resolved, and as the parties struggle to be tolerant of each other, most medical clinics have to decide whether or not they will take care of people with chronic pain, who need daily narcotics. Like others who have pledged to help patients who need aid, we face all sorts of increased surveillance and potential harm for doing it.

Like everybody else, we do not want to be manipulated by criminals posing as injured workers. We’re bothered when anonymous callers state “Mrs. Jones is selling her prescription pain pills.” But at the same time, we want to help those in need. So we have a variety of procedures to try to discourage people from illegal activity.

1. Every patient must sign an agreement every 3 to 6 months that outlines our rules.
2. At every monthly visit, they must fill out a two-page form that details where their pain is, how bad it is, etc.
3. We check the “drug hotline,” an informal system that detects people using multiple offices and pharmacies to obtain narcotics.
4. We require police reports in order to replace prescriptions that are lost or stolen; filing a false police report is a FELONY offense with stiff penalties.
5. We Xerox all narcotic prescriptions so we can tell if they are altered in any way.
6. We require periodic urine drug tests; the report tells us whether a patient is taking his/her drugs…or if NOT; it can also tell if people are taking some of their pills and selling the rest.
7. At every visit, we check all medications.
8. When people violate our signed agreement, we usually dismiss them from our practice.
9. We do not provide prescriptions for narcotics to patients who are taking illegal drugs.
10. Periodically various providers discuss cases; especially when suspicious behavior occurs.
11. Whenever professors hold seminars on “Pain Treatment,” we attend, ask questions, and share notes.

This takes time and effort and we are sorry to require so much paperwork and office visits that sometimes seem to have little value. But, if we don’t take major precautions, eventually the State or the DEA could restrict our prescription-writing privileges