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Oct 22, 2018 · Do I need parathyroid surgery?

Dear Doctor: When does a person require parathyroid surgery? I’ve heard it discussed but don’t know much about it.   

Dr. Robert Ashley

Dr. Robert Ashley

As their name implies, the parathyroid glands are located next to the thyroid gland.  You have four of them, two on each side, behind the thyroid gland in the neck.  The parathyroid glands help regulate calcium and potassium levels in the bloodstream. They do this through the production of parathyroid hormone, which is produced in varying quantities depending upon the levels of calcium, phosphorus and vitamin D.  As the calcium levels increase, the levels of parathyroid hormone decrease and vice versa.

Sometimes, however, the parathyroid glands overproduce parathyroid hormone, causing levels of calcium to increase.  Primary hyperparathyroidism is the overproduction of parathyroid hormone due to a defect with the parathyroid gland.  This occurs in three in 1,000 people, and is more prevalent between the ages of 50 and 65; women are 3 times more likely than men to have the condition.

In 80-85 percent of cases, primary hyperparathyroidism is due to a benign tumor on one of the parathyroid glands. About 6 percent of the time, primary hyperparathyroidism is related to enlargement of two or more parathyroid glands. Only rarely, in 1-2 percent of cases, a parathyroid cancer is the cause of this parathyroid hormone elevation.

Most hyperparathyroidism symptoms aren’t obvious.  The condition is generally found incidentally after a blood test shows a high calcium level.  In such cases, patients have often complained of fatigue, weakness, decreased appetite and difficulties with mental tasks.   The classical symptoms of primary hyperparathyroidism are a depressed mood, nausea, poor appetite, increased thirst, increased urination, kidney stones and, very rarely, bone pain and psychosis. Of note, people with this condition have a two- to threefold increased risk of bone fractures.  Further, when primary hyperparathyroidism is severe, the high calcium levels can lead to confusion and even coma.

In such severe cases, surgery is obviously warranted. It is also indicated if calcium blood levels are greater than 1mg/dl higher than the upper limit of normal; if a person has osteoporosis, kidney stones or kidney dysfunction; or if the person is younger than 50.

But, if calcium levels are only mildly elevated, it isn’t clear that surgery is necessary. That said, people who have had surgery due to mild calcium elevations have noted increases in bone density, decreased incidence kidney stones and slight improvement of mood.

For a less invasive surgery, it is important to determine which of the parathyroid glands is overproducing parathyroid hormone.  This is normally done with a SPECT scan and an ultrasound. In the hands of an experienced surgeon, this assessment will lead to a smaller incision, less operating time and less damage to surrounding tissues.

However, when high parathyroid levels are caused by multiple glands over-producing parathyroid hormone (which occurs 15 percent of the time) or if a thyroid abnormality is also found, then a more extensive surgical exploration is needed.   A significant drop in blood calcium levels can happen after surgery, so the levels need to be monitored afterward.

Not everyone is a candidate for surgery.  If this is the case, medications like Cinacalcet can lower calcium levels and bisphosphonates, like Fosamax, can improve bone density.

As with every condition, each person’s needs are different.


Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 22, 2018 · When does a person need parathyroid surgery?

Dear Doctor: When does a person require parathyroid surgery? I’ve heard it discussed but don’t know much about it.   

Dr. Robert Ashley

Dr. Robert Ashley

As their name implies, the parathyroid glands are located next to the thyroid gland.  You have four of them, two on each side, behind the thyroid gland in the neck.  The parathyroid glands help regulate calcium and potassium levels in the bloodstream. They do this through the production of parathyroid hormone, which is produced in varying quantities depending upon the levels of calcium, phosphorus and vitamin D.  As the calcium levels increase, the levels of parathyroid hormone decrease and vice versa.

Sometimes, however, the parathyroid glands overproduce parathyroid hormone, causing levels of calcium to increase.  Primary hyperparathyroidism is the overproduction of parathyroid hormone due to a defect with the parathyroid gland.  This occurs in three in 1,000 people, and is more prevalent between the ages of 50 and 65; women are 3 times more likely than men to have the condition.

In 80-85 percent of cases, primary hyperparathyroidism is due to a benign tumor on one of the parathyroid glands. About 6 percent of the time, primary hyperparathyroidism is related to enlargement of two or more parathyroid glands. Only rarely, in 1-2 percent of cases, a parathyroid cancer is the cause of this parathyroid hormone elevation.

Most hyperparathyroidism symptoms aren’t obvious.  The condition is generally found incidentally after a blood test shows a high calcium level.  In such cases, patients have often complained of fatigue, weakness, decreased appetite and difficulties with mental tasks.   The classical symptoms of primary hyperparathyroidism are a depressed mood, nausea, poor appetite, increased thirst, increased urination, kidney stones and, very rarely, bone pain and psychosis. Of note, people with this condition have a two- to threefold increased risk of bone fractures.  Further, when primary hyperparathyroidism is severe, the high calcium levels can lead to confusion and even coma.

In such severe cases, surgery is obviously warranted. It is also indicated if calcium blood levels are greater than 1mg/dl higher than the upper limit of normal; if a person has osteoporosis, kidney stones or kidney dysfunction; or if the person is younger than 50.

But, if calcium levels are only mildly elevated, it isn’t clear that surgery is necessary. That said, people who have had surgery due to mild calcium elevations have noted increases in bone density, decreased incidence kidney stones and slight improvement of mood.

For a less invasive surgery, it is important to determine which of the parathyroid glands is overproducing parathyroid hormone.  This is normally done with a SPECT scan and an ultrasound. In the hands of an experienced surgeon, this assessment will lead to a smaller incision, less operating time and less damage to surrounding tissues.

However, when high parathyroid levels are caused by multiple glands over-producing parathyroid hormone (which occurs 15 percent of the time) or if a thyroid abnormality is also found, then a more extensive surgical exploration is needed.   A significant drop in blood calcium levels can happen after surgery, so the levels need to be monitored afterward.

Not everyone is a candidate for surgery.  If this is the case, medications like Cinacalcet can lower calcium levels and bisphosphonates, like Fosamax, can improve bone density.

As with every condition, each person’s needs are different.


Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 19, 2018 · How can I get the most out of my doctor appointment?

Dear Doctors: How do I get the most out of my relationship with my primary care physician? The appointments are so short these days and I want to be smart about the way I use the time.

Dr. Elizabeth Ko and Dr. Eve Glazier

Dr. Elizabeth Ko and Dr. Eve Glazier

That’s a great question. As fellow patients who see our own physicians, we share your concerns. And as primary care physicians, we are keenly aware of the need to structure an office visit so as to make every minute count.

Here, drawn from what we do in our own practices, as well as thoughts from fellow physicians, are some ideas to help maximize the time you have with your physician.

Timing: Be strategic when making your appointment. Monday and Friday tend to be busiest. The first appointments of the morning are least likely to have a wait time and your physician won’t be feeling as rushed. And please, arrive early!

Plan ahead: Write down and prioritize your health concerns. Be prepared to describe them succinctly. Symptoms can be physical, mental, and emotional. Include details like when the symptom began, how long it lasts, anything that makes it better or worse, and what you are worried about.

The big picture: Bring a complete list of the medications you are taking, including supplements. Be sure to include specific dosages. If it’s easier, bring the bottles themselves. If you have recently stopped taking a medication, be sure to include it in the list as well. If you have undergone testing with other providers, tell your primary care physician what prompted the tests and provide a copy of the results.

Be a partner: Let your physician know your specific goals for the visit. This allows him or her to manage time wisely and efficiently. Take notes. A lot of information is imparted during a medical appointment and it’s easy to miss important details. Some patients bring a spouse, relative or friend to be another set of eyes and ears.

Be assertive: If your physician says something you don’t understand, ask him or her to repeat it. If you feel you are not being understood or heard, say so. When you require more time than a visit allows, ask whether a nurse or physician’s assistant in the office is available to further answer your questions.

Stay focused: Stick to the topic that brought you to the office. Spending the time delving thoroughly into your main health concerns will have the highest yield.

Stay connected: Ask your physician for the best way to reach him or her in the next few days, a time when new questions are likely to arise. Here at UCLA, we have a patient portal that allows our patients to reach us directly via email. Ask your physician whether that’s an option. If not, learn your physician’s preferred approach which includes how to reach him or her in an emergency.

Keep the conversation going: If you feel your questions or concerns haven’t been met, don’t be afraid to schedule a follow-up visit.


Eve Glazier, MD., MBA, and Elizabeth Ko, MD., are internists at UCLA Health. Dr. Glazier is an associate professor of medicine; Dr. Ko is an assistant professor of medicine.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 18, 2018 · Can turmeric reduce inflammation?

Dear Doctor: I have heard that turmeric supplements work quite well as an anti-inflammatory agent, with less risk than non-steroidal anti-inflammatory drugs. What are your thoughts on turmeric as an anti-inflammatory supplement?

Dr. Robert Ashley

Dr. Robert Ashley

The turmeric powder found in spice racks – and the component of it found in supplements – comes from the underground stem of a plant, native to India and southeast Asia, that is cooked and then ground to create an orange-yellow powder. Long used in Ayurvedic medicine to control inflammation and pain and for upper respiratory infections, turmeric contains compounds with anti-inflammatory and antioxidant affects. The best-known and most-studied is curcumin.

One big problem with assessing the impact of curcumin is that, in its pure form, the compound is poorly absorbed by the body and is quickly eliminated.  A 2016 study reviewed six studies that used turmeric or curcumin specifically for arthritis pain, comparing them to either a placebo, glucosamine or the NSAIDs ibuprofen or diclofenac.  The dosage of curcumin in the studies varied from 100 milligrams to up to 2000 milligrams per day.

The studies found that curcumin decreased pain significantly compared to placebo and that it was comparable to ibuprofen and diclofenac in decreasing pain and stiffness.  Side effects of curcumin included sore throat, gastrointestinal bloating, swelling around the eyes and itching.  These side effects were more frequent at doses higher than 1,200 milligrams.  The authors noted that, while the benefits seen with curcumin were encouraging, the number of people involved was small and the studies had methodological flaws.  Further, the longest study in this group lasted only four months, so long-term side effects or benefits couldn’t be assessed.

That hasn’t quelled enthusiasm for the compound, however, and the anti-inflammatory effects of it are touted even as a possible Alzheimer’s preventive. Amyloid deposits are a telltale sign of Alzheimer’s disease, and curcumin has been shown to have anti-amyloid activity.  Multiple studies in mice and rats genetically modified to have Alzheimer’s have shown that the addition of curcumin to their diets reduced the deposits of amyloid within the brain and decreased the markers of brain inflammation. However, these animal studies used either intravenous or intraperitoneal curcumin, not oral curcumin, so I don’t think that the oral pills you find in health food stores would be as potentially helpful.

As for cancer, research shows that curcumin can inhibit multiple cancers in a laboratory environment and in mice.   This benefit was also seen in conjunction with traditional chemotherapeutic agents, suggesting curcumin might enhance the activity of chemoterhapy and decrease some of its side effects.  The studies are still in their infancy in humans, so it is difficult to make any definitive conclusions.

We truly need more studies of turmeric and, more specifically, curcumin before either can be recommended as a therapeutic agent, but if you’re determined to use one or the other for arthritic pain, I would recommend preparations of curcumin – and in doses of less than 1,200 milligrams to minimize side effects.  In the future, the benefits of curcumin may improve if it’s combined with an inert substance that allows the compound to be absorbed more easily and excreted less quickly.


Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 17, 2018 · What's the best type of exercise?

Dear Doctors: What’s the best type of exercise? I’ve been reading that high-intensity interval training can actually slow down the aging process. Really? Why? I’m not too keen on this approach but I do walk at least a mile every day.

Dr. Elizabeth Ko and Dr. Eve Glazier

Dr. Elizabeth Ko and Dr. Eve Glazier

First, congratulations on exercising regularly. Last year 81 million Americans didn’t take part in any type of regular physical activity at all. That means that 27.5 percent of the population was sedentary. That’s terrible news because being active is an easy, affordable and effective way to maintain good health.

Our bodies change as we age. Cardiovascular capacity decreases, muscle mass is lost, and body fat increases. Decades of studies show that regular exercise can prevent and even reverse these trends. Staying active boosts the immune system, improves muscle tone and balance, enhances cognitive function, improves the quality of sleep, and has a positive effect on mood.

Now, a new study published in the journal Cell Metabolism adds a bit of a twist. While any amount of exercise beats sitting on the couch, a specific kind, known as high-intensity interval training, or HIIT, appears to change the body at a cellular level. Specifically, this type of exercise affects the mitochondria, which are structures within cells that make energy available to the body.

As we get older, the ability of mitochondria to generate energy decreases. HIIT reverses this trend by making mitochondria more efficient. Even more interesting, the older individuals in the study who took part in HIIT had a measurably larger increase in mitochondrial function than did the younger ones. The younger group had a 49 percent increase in mitochondrial capacity. The older group of participants showed a whopping 69 percent increase.

So what is high-intensity interval training? It’s a brief workout performed several times per week. HIIT alternates bursts of intense exercise, during which muscles use more oxygen than the body has available, known as anaerobic exercise, with periods of slower activity in which the oxygen debt is repaid. Often it can be done at home with little or no specialized equipment. We recommend doing some reading and, of course, checking in with your primary care physician, before you begin. In basic terms, HIIT goes roughly like this:

  • Start with a three-minute warm-up, like jumping jacks or jogging in place. Don’t rev up your heart rate just yet.
  • For the next 30 to 40 seconds, perform a high-intensity move such as scissor kicks, squat thrusts, lifting weights, or running at a fast pace.
  • Slow down with 20 seconds of low- to medium intensity activity.
  • Rest for 30 seconds, walking and breathing deeply, to recover.
  • Start the cycle again. Continue for 10 to 20 minutes.

Does HIIT slow the aging process? That depends on what you mean by aging. Yes, this study shows that in terms of mitochondrial efficiency, the clock can be turned back. But whether this translates into longevity remains to be seen. Still, in terms of potential health benefits, finding a way to make peace with your aversion to high-intensity interval training could be a worthwhile goal.


Eve Glazier, MD., MBA, and Elizabeth Ko, MD., are internists at UCLA Health. Dr. Glazier is an associate professor of medicine; Dr. Ko is an assistant professor of medicine.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 16, 2018 · Should I take probiotics? Do they work?

Dear Doctor: Can you explain probiotics? Who should take them and are they harmful in any way? They seem helpful to me in calming my stomach.

Dr. Robert Ashley

Dr. Robert Ashley

For many generations, society feared bacteria, seeing only the devastation that bacterial disease created. Today, with the advent of antibiotics, we have been able to cure infections that once led to illness and death.  However, our primary tool – drugs known as antibiotics – also indiscriminately kill bacteria that don’t cause disease.  Only recently have we come to realize how important these non-dangerous microorganisms are to our health.  With an estimated 40 trillion bacteria in and on the human body, outnumbering the 30 trillion to 37 trillion cells that make up the body, it’s clear that a symbiotic relationship with these organisms is important to our health.

To answer your question about probiotics, first let us look at gastrointestinal bacteria. Many probiotic preparations promise to help replenish beneficial bacteria in the colon, with the theory being that they increase the health of the intestinal lining, suppress inflammation caused by damaging bacteria, and reduce inflammation caused by an overactive immune system.  Most probiotics contain species of the familiar bacterial strains known as Lactobacillis and Bifidobacterium, but some preparations also contain beneficial strains of Streptococcus and Clostridium, or even yeast (Saccharomyces boulardii).

In a 2008 study of 224 children with a diarrheal illness related to rotavirus, participants took either a probiotic preparation (known as VSL#3 and containing various strains of Lactobacillis, Bifidobacterium and Streptococcus) or a placebo.  On the second and third days of the illness, the group that took the probiotic had a decrease in stool frequency, improved stool consistency and less need for either oral or intravenous rehydration. A 2002 analysis of nine studies that used Lactobacillus for childhood diarrheal illness found an average reduction of illness of 0.7 days in children who took Lactobacillus.

A 2010 review of 63 studies assessed the impact of different probiotics on acute diarrheal illness; 56 of these studies looked only at children and infants.  On average, probiotics decreased the duration of diarrhea by 24 hours and decreased stool frequency by the second day.  Although the authors could definitely say there was benefit in children, they could not conclude if these benefits occurred in adults.

As for more chronic illnesses, a 2009 analysis of 16 studies of people with irritable bowel syndrome found that two studies using Bifidobacterium infantis showed a decrease in abdominal pain, bloating and bowel movements.  The other studies were considered methodologically flawed, so the authors couldn’t assess probiotics’ benefits.

Probiotics have had mixed results in Crohn’s disease, but have shown benefit among people with mild to moderate ulcerative colitis, again through the VSL#3 preparation.

Similarly, some studies have found benefit from probiotics given with antibiotics, which kill the “good” bacteria as well as the “bad” and therefore increase the risk of Clostridium difficile infection.  Not all studies show such benefit, but I would consider probiotics if you’ve developed diarrhea in the past when taking antibiotics.

One potential issue with probiotics is that, unlike medications, they’re not regulated, so there is no true way to know exactly what you’re getting.  Some patients do develop bloating with probiotics, but for the most part the preparations are well-tolerated.  If they’re helping you, it seems prudent to continue using your current brand.


Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 15, 2018 · I can't lose weight. Is my gut bacteria to blame?

Dear Doctors: I can’t seem to lose weight and am wondering if my gut bacteria could be to blame. How can I change it?

Dr. Elizabeth Ko and Dr. Eve Glazier

Dr. Elizabeth Ko and Dr. Eve Glazier

In recent years, it has become increasingly clear that the bacteria that live in our gastrointestinal tract, also known as the gut microbiome, play a significant and far-reaching role in our health. Researchers now believe that these bacteria, which number in the trillions, have an effect on immunity, inflammation, allergies, asthma, diabetes, weight issues, and even depression and anxiety. In fact, the metabolic activity of these microorganisms, also known as probiotics, is so complex that the gut microbiome has been referred to as the “forgotten organ.”

So how does the gut microbiome develop?

Just before birth, a baby’s intestinal tract is sterile. The first major infusion of bacteria comes from your mother, both in the birth canal and through breastfeeding. Next come microorganisms from the physical world around you. Throughout your life, your gut microbiome will continue to evolve. Research shows that environmental factors such as contact with pets, farm animals, soil, dust and the outdoors contribute to diversity. Exposure to antibiotics, overuse of antibacterial products, and excessive use of alcohol have been shown to damage the gut microbiome.

Although studies have linked the presence of certain strains of gut bacteria to a tendency to be lean, and the absence of other types of bacteria to obesity, the science is still in its infancy. At this time, there is no reliable information on how exactly to harness the power of the gut microbiome to address weight issues. However considering how important a diverse array of bacteria is to good health, making some lifestyle and behavioral changes to bolster the gut microbiome is a good idea.

Eat more fiber: With what we know about the gut microbiome, the fact is you’re not just eating for one, you’re eating for trillions. According to new research, fiber not only provides nourishment for gut bacteria, it helps with diversity. So skip the processed foods and snacks. Instead, choose fruit, vegetables and whole grains. New attention is now focused on prebiotics, which are indigestible fiber that is believed to nourish gut bacteria. Natural sources of prebiotics include asparagus, Jerusalem artichokes, leeks, bananas and jicama.

Choose healthy oils: Replace refined omega-6 rich vegetable oils with a good-quality extra-virgin olive oil. Amp up your omega-3 intake with salmon, halibut, sardines, kale, Brussels sprouts, flax seeds and walnuts.

Skip the sweets: According to the USDA, we Americans consume 94 grams of sugar per day, which is about half a cup. But your gut bacteria crave complex carbohydrates so try reaching for an orange or a handful of walnuts when that afternoon snack attack hits.

Pick probiotic foods: Fermented foods like yogurt, kefir, miso, kimchi, sauerkraut, kombucha, brine-cured olives, tempeh and miso provide a variety of friendly bacteria. No need to go overboard – using them in moderation is all it takes.


Eve Glazier, MD., MBA, and Elizabeth Ko, MD., are internists at UCLA Health. Dr. Glazier is an associate professor of medicine; Dr. Ko is an assistant professor of medicine.

Ask the Doctors is a syndicated column first published by UExpress syndicate.

Oct 12, 2018 · Ask the Doctors - Should I take a bone-building drug for osteoporosis?

Dear Doctor: I’m 71 and, after a recent bone scan, my doctors are insisting I take a bone-building medication. I couldn’t tolerate Fosomax, so they want me to take Prolia. I’m worried about it, but my mother had severe osteoporosis, so I’m worried about that too. How can I choose what to do?

Dr. Robert Ashley

Dr. Robert Ashley

Your worry is well-founded.  Osteoporosis is defined as a decrease of bone density greater than 2.5 standard deviations below the bone density of a healthy young adult – and it’s more than three times more common in women than men.  Women ages 65 to 80 have a 21 percent incidence of osteoporosis; those over 80 have a 35.6 percent incidence.

In addition, women fall more often than men, making bone loss especially dangerous. Three-quarters of all hip fractures occur in women. Not only are such fractures extremely disabling, requiring surgery and hospitalization, the overall one-year mortality after a hip fracture is 21.2 percent. Spine fractures are even more common than hip fractures in people with osteoporosis. Although they often go undiagnosed, they can cause debilitating pain.

So, obviously, if there is a way to improve your bone density and decrease your chance of fractures, you should do it.

Taking 500-1000 milligrams of calcium a day and maintaining an adequate blood level of vitamin D are important, but to increase bone density, the first-line drug therapy is a bisphosphonate. These drugs, including Fosamax, increase bone mass and decrease the incidence of fractures. I would assume that you couldn’t tolerate Fosamax due to irritation of the esophagus and stomach.  If that’s the case, you could consider injectable bisphosphonates such as Boniva or Reclast.

That said, all bisphophonates can have rare, but potentially serious, side effects such as osteonecrosis of the jaw, an increased risk of fractures of the femur, and in the case of Reclast, atrial fibrillation.  Also, note that people with kidney failure should not take bisphosphonates.

Prolia, given by injection twice a year, is different. It’s a monoclonal antibody that binds specifically to a receptor within bone, inhibiting the normal bone breakdown. Clinical trials showed that, after three years of use, Prolia improved bone density in the spine by 9.2 percent and, after eight years, by 18.4 percent.  It improved bone density in the hip by a lesser amount, 4 percent after three years and 8.3 percent after eight years.  The drug was also linked to a 68 percent decrease in the rate of spinal fracture and a 40 percent decrease in the rate of hip fractures. In a trial comparing Prolia to Fosamax, those taking Prolia showed a slightly greater improvement in bone density after one year.

That’s not to say Prolia is for everyone. Like Fosamax, it can occasionally lead to osteonecrosis of the jaw and atypical fractures. And, for people with kidney disease, it can lead to drops in calcium levels that can cause muscle spasms and abnormal heart rhythms.  Finally, because Prolia is injected into the skin and may affect immune function, it may slightly increase the risk of skin infections at the site of the injection.

In summary, if you cannot tolerate Fosamax, you should consider injectable Reclast or Prolia. These medications do have rare, but severe side effects, but their benefit appears greater than their risk.


Robert Ashley, MD, is an internist and assistant professor of medicine at the University of California, Los Angeles.

Ask the Doctors is a syndicated column first published by UExpress syndicate.