Berlin for the second time

I took a cruise tour to Berlin for the day.  It was a long drive in the rain but I saw so many things I had heard about such as Point Charlie.

This time on the Bus tour coming up we will be in Berlin for 5 days.

Berlin, Germany link

Budapest, Hungary for the second time

Budapest Lonely Planet link

Eat, Drink & Be Magyar

There's a lot more to Hungarian food than goulash, and it remains one of the most sophisticated styles of cooking in Eastern and Central Europe. Magyars may exaggerate when they say that there are three essential world cuisines – French, Chinese and their own. But Budapest’s reputation as a food capital dates largely from the late 19th and the first half of the 20th century and, despite a fallow period under communism, the city is once again commanding attention. So, too, are Hungary's excellent wines – from Eger's complex reds and Somló’s flinty whites to honey-sweet Tokaj.

Cesky Krumlov , Czech Republic

I have not been to Prague.  I am looking forward to it on the bus tour in Sept. 


Visit Prague at Lonely Planet link

"European Hotspot

The 1989 Velvet Revolution that freed the Czechs from communism bequeathed to Europe a gem of a city to stand beside stalwarts such as Rome, Paris and London.

 Not surprisingly, visitors from around the world have come in droves, and on a hot summer's day it can feel like you’re sharing Charles Bridge with half of humanity. 

But even the crowds can’t take away from the spectacle of a 14th-century stone bridge, a hilltop castle and a lovely, lazy river – the Vltava – that inspired one of the most hauntingly beautiful pieces of 19th-century classical music, Smetana’s Moldau symphony."

Visit Krakow - 10 Things That Will SHOCK You About Krakow, Poland

I am visiting Krakow on a bus tour next month.
This is the beginning of my research.

3 days after this turtle nest hatched outside my window on Hutchinson island, FL

Too bad I didn't see or know of the turtles hatching.

However to my surprise I saw someone digging up the turtle nest this morning from my condo.

The Turtle official said they wait 3 days after the hatching to dig up the next to see what has gone on.

She did rescue a loggerhead baby that was still alive.

 She took it back to the Turtle rescue center center.

She shielded the turtle from the sun. 

She put it in a plastic bucket which I assumed had other survivors.

Sea Turtle Reserve Lady told us she has a permit me to do this.

It is against the law for anyone else to interfere with the nest or the new born turtles. 

A week later there have been turtle tracks below our window.

Update on my Alzheimers

Diagnosis of Alzheimers made December 2017

Now 20 months later I am very happy I could write a point counter point article on:
  
Robert Mueller Hearing at the House link



It required focus and effort but it was very gratifying to accomplish it this week.

First Incident

This morning I tried to pay my credit card bill.  My wife does the other bills.

I have a bill problem transposing numbers.  I have had this problem before Dec. 2017.

I try to be more careful, however I could not sign onto my bank account.

I continued on the computer to change my password.

I have the passwords in a book.

The bank asked me for the data and still did not recognize me.

Then I realized the expiration date I put in was 6-2020.

I got confused that I thought I had passed the expiration date and had not received a new credit card. Concluding that was why I could not sign onto my bank account.

I called HELP at the bank and while signing in again with HELP on the phone,  I realized I got the year wrong.  The card shows expiration date as 6-20.

I finally changed my password.

I also left a better trail of notes with the changes.

Second incident

We recently came back to our Florida residence from Kansas.
This morning I sorted out which refills I needed on my medications.  

I use Hy-Vee in Topeka as my supplemental insurance prefers it to Walmart, which I preferred.

I get Belviq, my diet pill at CVS in Topeka as it sells it very low price.

Today in Florida,  I remembered to call CVS for Belvig.

However, I was thinking of getting the other medications at Walmart.  I even discussed it with my
wife.

Fortunately, before calling Walmart, I remembered we don't use Walmart in Florida either.

Third Incident

My wife drives me to the lab to have my blood drawn.
I check in on the computer kiosk.
The receptionist then tells me there is no order for the lab.
I call the MD's office.  I am told they send the lab to Quest.
I then remember reading that.
For some reason my brain took me to Lab Corp.
No problem, Doc immediately sent a fax order to Lab Corp.
I prefer Lab Corp over Quest.  I guess subconscious was at work?

These sequential incidents of mistakes, increase my stress which make me hyper and angry.

I finally got home and self medicated with a glass of wine.

I get into to these details to show that while I can hold my own writing or speaking about politics, cholesterol or obesity I clearly have cognitive impairment.

I am getting close to finishing my YEAR TWO book on my Alzheimers but as I promised in my YEAR ONE book, my readers can kept track of my disease on twitter and blog.

How is Obamacare doing lately

Despite GOP Lawsuit, Insurers Say Obamacare Having Best Year Yet

Good news for private insurers  link

"The financial stability of individual coverage under the Affordable Care Act and improving health plan margins bodes well for the future of Obamacare."

"Insurers are growing their Obamacare businesses these days."

"Neidorff’s comments come less than a month after the 5th U.S. Circuit Court of Appeals heard a challenge to the ACA brought by 18 Republican-led states. The lawsuit, which has the backing of the Trump White House, puts healthcare coverage of more than 20 million Americans at risk as well as patient protections for tens of millions more U.S. consumers."

"As the case wends it way through the legal system and a potential airing before the U.S. Supreme Court, the financial footing of health plans selling such coverage is strong. Insurers also say their profits are growing because patient care is improving for the customers." 

"Unlike the early years of the ACA when health plans like Aetna, Humana and UnitedHealth Group left the market because they were unable to successfully manage the costs of newly insured patients, health plans now say they are doing a better job retaining customers from year to year and keeping their medical expenses in check."

“We continue to see higher member retention than in prior years,” Neidorff said. “The longer we retain a member, the better it is. We’re bringing the cost down for that person.”

NLA points out the need to use alternative drugs if statin intolerance occurs.

I was taught that the myalgia of statins was a specific myalgia.
I would tell patients the statin did not cause their myalgia.
They would go back on the statin and say the same myalgia occurred.
 This is why I used the triple therapy of low dose statin, Zetia and over the counter Enduracin.

I document my use of triple therapy from 2009 in my book The Tubby Theory from Topeka, replicated here
 Chapter 12 Use of triple therapy link

I always stated w the lowest dose of statin. Dr Dayspring taught some people had good results with low dose.  I advised simvastatin in 2010 as it was inexpensive generic.
Now Lipitor (atorvastatin), Crestor (rosuvastatin) are available in generic form.  These two statins are stronger and safer than Zocor (simvastatin).
 Zetia (ezetimibe) is also available in generic form.
Endur-acin (wax matrix form of nicotinic acid) is an over the counter preparation.


Now more than ever great drugs are available that I have used (see link above).
 Safe and inexpensive.
I would get referrals to treat statin intolerant patients.  I would start with Enduracin (Niacin)
This wax matrix nicotinic acid rarely caused a itchy flush.  Side effects not usually seen at low dose 1,000 mg.  This would be agreed to as it is a vitamin.
Then I would add Zetia. Maybe use 1/2 tablet first.
Finally if not at goal I would start lowest dose statin. Maybe give every other day or once a week.

These 3 drugs should be used first.
Slowly increase statin until side effects occur.

If still not at goal in a very high risk patient then PCSK9 should be considered.

 PCSK9 vs triple therapy link

Listening to Mueller's testimony while looking out at Jensen beach, Florida

After Mueller is a storm coming or will it quickly pass.  

In Florida they quickly pass unless they are hurricanes. 

You can see the Indian river on the left side of Hutchinson Island.

Can Cholesterol be too low for the brain?

Lab from Nov 2014

I obtained a break down of specific cholesterol levels as my LDLp was extremely low. 

Mayo only tells me my desmosterol is at a normal level but not too low?

Subsequently I was diagnosed with Alzheimer's in Dec 2017.

This week I learned of a lecture from Peter Toth stating that low cholesterol does not cause dementia but probably prevents Alzheimer's.

My systolic blood pressure runs between 100-120.

Perhaps my biggest problem is Diabetes Mellitus with Hgb A1c from 7.0 to 8.0

I do have apoE 4 positive in one allele.

My advise keep:

1- non-HDLc less that 100
2- systolic BP around 120
3- check insulin level and fasting glucose.

If fasting glucose greater than 95 go on Low Carb High Fat diet lose 5 lbs and don't gain weight.

Walking and weight lifting also a good idea.



Desmosterol level  of 1.2 mg/l for me is normal according to Mayo Clinic result above.

Difficult to find out what a low Demosterol is?

I am back on Lipitor (atorvastatin) 5 mg with Zetia and Endur-acin. I get my apoB level this week.


A talk this year(2019) given by Dr Peter Toth says there it is more likely that statins lower risk of cognitive impairment.

Slide one

 Slide two

Slide three from Dr Toth's talk.

The Demosterol/Cholesterol ratio?

Should President Bush have had a stent or only statins? What about Supreme Court justice Ginsberg?

Part one

Treatment of new positive CAC in Topeka vs Dallas  

The other disturbing part of John’s CAC report is that all the calcium is at one spot in the left main stem. Should John have had an angiogram and a stent as President Bush did in Dallas?

My 62 yo friend,John visited me from NYC.  

He has Cadillac medical insurance from his Union

 but unlike President Bush he does not get an Executive Check Up each year. 

 Like the President,  John is asymptomatic. 

 Unlike the President, John is 50 pounds overweight with type ll Diabetes 

and only walks a mile a day.  

They both take statins? 

President started on Aspirin and; statin in Dec 04'?

“Although the team of specialists at the National Naval Center in Bethesda, Md., declared President George W. Bush “fit for duty” after his annual physical exam on Saturday, they still recommended that he take a daily aspirin and a statin to help prevent heart disease.”

My note: below 2 years later it is reported he is only on vitamins despite a POSITIVE CAC as noted in item six below. 

Dr Thomas Dayspring writes:

“During his (President Bush)  second year in office during a yearly physical at Bethesda his physician did a routine coronary calcium level which was 4 (trivial).

I wonder if Dr Dayspring would still think a positive CAC score is trivial?

 Even though his LDL-C was fine (approx 100 mg/dL superb by 2001 standards) they started him on a statin and as one would suspect, a low fat diet”

My note: Despite Dr Dayspring’s note above in Aug 2013, the hx. below states he was not on statin in Aug 2006. 

President Bush's medical history  Aug 2006

“There is no past medical history of hypertension, diabetes, tuberculosis, sexually transmitted disease, or stroke.

 The President benefits from a "low" to "very low" (favorable) coronary artery disease risk profile with 

1-favorable family medical history, 

2-absence of modifiable risk factors; 

3-superior fitness, 

4-favorable CAD markers (e.g. CRP, lipids) and

5- functional studies ("stress echocardiogram"), and 

6-"minimal/mild" coronary artery calcification noted on anatomic study (coronary artery computed tomography, 2004).”

“Cardiology: Physical examination of the circulatory system was normal. The resting EKG revealed sinus bradycardia consistent with previous exams and aerobic conditioning. 

Fasting lipid panel: 

(I calculate non-HDLc at 174-60= 114.

 I think this is high and the President should have had apoB or LDLc. 

Remants: 174 -60=114 then minus 101= 13 Very good. )

 total cholesterol: 174 (last year 178; “desirable”<200 span="">

 HDL: 60 (last year 56; and 40);

 LDL: 101 (last year 100; “optimal”<100 desirable="" nbsp="" near="" optimal="" span="">

total cholesterol/HDL ratio 2.9 (last year 3.2); 

Triglycerides: 61 (last year 71; <150 nbsp="" span="">

hsCRP: 0.029 (range 0.0-0.5).

 Homocysteine: 11.5 (range 7.6-20.8). Ankle-brachial index 1.27 (r), 1.25 (l) (normal 0.96 or greater).

 The President underwent Balke protocol exercise treadmill testing (ETT) with echocardiogram. He exercised for a total of 26:02 minutes achieving a maximum heart rate of 179 bpm with a 1-minute recovery of 148 bpm (31 beat differential). No signs or symptoms of cardiovascular pathology were noted. Stress echocardiogram was normal. Screening ultrasound of the abdominal aorta was normal.”

 EKG changes during the stress test yesterday prompted a CT angiogram, which confirmed a blockage that required opening.”

Okay, enough with President Bush, what about my friend John?

John’s older brother died at 56 yo of sudden coronary death at his dinner table.  

The brother had no known heart disease or symptoms before his death.  He did manual labor without difficulty. 

About 15 years ago, John had an abnormal nuclear stress test.  He then underwent an angiogram that was ultimately normal however he went into ventricular fibrillation became unconscious and had to defibrillated back to life while on the table for his angio. 

John’s lab in Aug 2013

Total Cholesterol          137

Triglycerides                 139

HDL-C direct                  49

Non-HDL cholesterol      88

Chol /HDL ratio           1.22 (should be less than 3.56)

LDL-C                            60

VLDL calculated            28 

Hgb A1c                       8.7

John’s medications:

Atorvastatin  10 mg

Wax matrix Niacin 1,000 mg OTC Endur-acin

Diabetes medications but no insulin

Lisinopril low dose

Aspirin low dose

Lovaza 1,000 mg a day

John did not go to the Cooper Clinic in Dallas, he came to Topeka, Kansas and received the Tubby Theory Approach.

Five years ago I had him get a CAC which was zero and a Liposcience panel which he says showed an LDL-P of 750?

On Tues he had a CIMT with a 0.08 mm thickness which is greater than 75% of other males age 62. Cost $100.

On Thurs. he had a repeat CAC of 45, all of it at the left main stem.  Cost $50.  

We are waiting for John’s liposcience report. 

However what do we know now we did not know before?

We know John has the disease of atherosclerosis. (CAC 45, CIMT 0.08 mm) PRICELESS INFORMATION.

How does that change John’s treatment?

John’s triglycerides are around 135.  The lab says that is normal but I am telling him it should be less than 100.

Thus John should increase his Lovaza (fish oil) from one tablet a day to four tablets a day.

If John’s  LDL-P is greater than 1,000, then he has discordance with his LDL-C and he needs to double his atorvastatin to 20 mg.

When John gets home he needs additional testing:

1- Lp a

2- CRPhs

3- Lp-PLA2

The puzzle is that he went from CAC of zero to 45 in five years. Why did that happen if his LDL-C has been less than 70.  His last non HDL-C was 88 which is excellent while his LDL-C was 60. (This might suggest discordance as I would not lower the LDL-C but I might increase his statin to get non-HDL-C to less than 80.)  

The possible answer to the puzzle:

1-DM and central obesity (Rx with weight loss, Atkins)

2-High triglycerides (Rx with Fish oil and Atkins)

3-Inflammation (Rx with more fish oil, exercise and weight loss)

4- Elevated Lp a (get LDL-P less than 750 with statin and zetia)

5- Discordance with LDL-C, with LDL-P greater than 1,000 (wait for this weeks result)

Since his present good treatment has failed to prevent atherosclerosis and since any plaque is prone to rupture especially with his brothers history of sudden death at 57 yo, he needs more aggressive treatment as outlined above and then to determine if that Rx is working he needs to follow his progress with:

1- Liposcience lipid panel at least every 4 months (apo B with Berkley lab or Boston Heart Lab is acceptable) apo B should be less than 60.

2- Get CIMT every two years to see if there is progression or hopefully regression of atheroma.

Low fat diet is definitely not the answer.

Losing weight in short term will help no matter how he does it but maintaining weight almost impossible if he doesn’t continue low calorie diet for rest of life.

To my mind, a diabetic with central obesity should be on Atkins diet.  He doesn’t have to be hungry, he just has to deprive himself of carbohydrates.  Atkins is still restrictive but the best of choices for the long run. 

In addition his HDL-C is "normal" in the 40's.  That again is a test that is not as significant as HDL-P in liposcience NMR lipopanel.  “HDL” in general is still a puzzle in the science of lipidology.

The other disturbing part of John’s CAC report is that all the calcium is at one spot in the left main stem.  15 years ago he had a abnormal nuclear stress test which led to an angiogram.  He had a normal "lumenogram" but he went into ventricular fibrillation on the table and had to be paddled(electric shock)  back to life. 

John has no symptoms now but his brother may not have had any symptoms before his sudden death.  If the atheroma in John’s left main stem coronary artery were to rupture, he might have no warnings before hand. 50% of sudden coronary death has death as the first sign of the disease. 

Scary situation.  Thus someone may want John to get further testing as President Bush did. The Courage and Bari ll trials show Left Main Stem disease does better with bypass than medicine or stents.  But disease without symptoms, should be treated with aggressive medicine, not invasive procedures.

I think four tablets of lovaza and making certain John’s LDL-P is less than 750 by increasing statin (and adding zetia if necessary)and getting particle number count blood test every three to four months is an aggressive medical approach better than getting an angiogram and a stent or bypass.  However if John ever has symptoms then of course do the angiogram.

Thus start the 4 lovaza right away.

Go on atkins.

Walk 10 minutes after each meal.

Check Liposcience again in two months to see how John responds to the 60% fat diet. 

If LDL-P greater than 750 double the atorvastatin.

If the Lp (a) is high then double the atorvastin.

If inflammatory markers are high get serious about Atkins and slowly increase  walking to one hour a day.

Get a CIMT again in two years. 

If President Bush had come to Topeka instead of Dallas his testing and treatment would have been different and cheaper and his treatment much cheaper.  Atorvastatin and Wax Matrix Niacin costs $100 a year. Statin and Niacin much safer that Plavix which is often given with the stent. 

As with John if President Bush ever had symptoms he could always then get an angiogram.

This is part two of President on Statins   

If someone knows he was taking statins in 2012, it would be nice to be know.  I write this blog to the health reporters to show that this is an important fact that they need to ascertain.

My friend responded with this:

"Brian: I have no idea what Bush was on after he left office --  Whatever he was on since he was asymptomatic he certainly did not need a stress test, CT-angiogram, coronary angiogram or a stent"

 My viewpoint:

 If in 2006 President Bush's doctors did take him off statin when they knew he had a positive CAC of 4 (which I believe elevates him from low CV risk to Intermediate CV risk),

 how do they know when to put him back on a statin and to what goal?

The answer is obvious,  they use stress testing.  

Apparently the stress test last year was normal so his Doctors missed the opportunity to get President Bush back on statins.  

A follow-up CAC without contrast might have been enough.  CAC only costs $100 while a Angio CAC is much more expensive and more radiation.  

I have not seen a LDL-C result of less than 100 for President Bush.   Traditional teaching says atheroma build up continues with LDL-C greater than 100.  In fact I don’t know what his LDL-C in Aug 2013 was? To not use the metric LDL-P seems incredible from a major health center in Dallas.  Again I hope reporters have access to this information. 

As lipidologists we are not surprised that off a statin President Bush increased his CAC score from 4 in 2004 to an actual plaque that showed up on Angio CAC in 2013. Would be nice to know how high the CAC score went up to and did it happen off statins?

What is the best way to screen results of treatment? 

Not with a exercise stress test.  Especially with women. 

Cardiologists don't hesitate to do nuclear stress tests periodically after a stent is put in.

  (I don't think this expense of President Bush’s  procedure has been discussed)

Repeat imaging with radiation exposure is a concern.  Repeat CIMT has no radiation and if there is no thickening of the wall with treatment,  there is a reassurance that the plaque is not building up.

No studies for this except in various trials looking for CIMT change with drugs. Use of CIMT with Drug trials.

However, instead of a nuclear stress test,  I sure wish asymptomatic Tim Russert had had less radiation with a repeat CAC (10 yr before his death Mr. Russert had CAC of 200) rather than a false negative nuclear stress test,  a cheaper and safer repeat CAC might have shown a significant jump in calcium score that might then have driven Mr Russert to get a particle count.

 Of course he probably would have gone for an angio which is what happened to President Bush.  We believe more is always better in medicine. Just kidding. 

CAC and CIMT are not perfect but they are cheap and safe.  Of course because no one makes money on them, they are the red-headed step child of medicine. 

 Instead Cardiologists jump to Nuclear stress tests, Echocardiograms and Angio CAC or Angiograms. 

 All of them very expensive and much more radiation.

  No one discusses  Glagov Remodeling of Coronary Artery.  Lumenograms or angiograms are often called normal when the lumen is only the tip of the iceberg in plaque formation. Picture of the coronary iceberg  The large subclinical atheroma can rupture without prior symptoms in 50,000 to 100,000 people a year.

So back to John.

If I had not done a CAC and CIMT,  no one would have done a Lp (a). 

No one would get his Triglycerides under 100 by increasing Lovaza.

He may now be motivated to lose weight because his good present therapy that results in worse CAC of 45, failed.

We await his LDL-P next week but he remembers he had a good one.

I feel sad when President Bush's CAC 4 is minimized as insignificant.  How can anyone say that if you don't know how much hidden atheroma he has?  Get a CIMT to get some idea of what is going on at the wall level, then follow it every two to three years to determine efficacy of treatment. 

John, had one lump of calcium at the Left Main Stem.  Even with a low score of 45, the location should make us much more vigilant in his treatment and followup and CIMT is the cheapest and safest way to do that.

Jimmie Moore has a false sense of security because he has a CAC Zero. 

The only way to break through his denial is for him to get a CIMT. 

I have followed my CIMT over the years with good results despite being on 60% fat. Here are my results

I wish Jimmie had done the same with serial CIMT's. 

Jimmie says he wants a CIMT.  I told him don't go to Dallas, come to Topeka.