Saturday, September 10, 2016

How to know if something is infected



How can you know if an injury is infected?  Patients are often concerned when wounds don't heal right away and this causes them to make needless visits to the doctor or emergency room.  Here is a pic of a wound that is about 6 days old.  My little dog scratched my arm while I was giving her a bath.  (Isn't she cute?)

 Is this scratch infected?

If you said no, it is healing well, you would be correct.  Even though it is still swollen around the scratch and it is obviously red and a little warm, these are signed of normal skin healing. I can picture my white blood cells and monocytes racing to the area to deal with bacteria from the scratch.  The redness and swelling are an inflammatory response that my immune system is producing to contain the bacteria and turn over new cells.

Signs of infection would be redness that continues to extend outside the wound that is worsening over time.  The swelling wouldn't stay the same, it would expand day by day.  The cut it self might start oozing under the scab that is forming.  If any of that occurred, it would be time to get it checked out.

As we get older (ahem!) we heal more slowly.  Cuts and lacerations might take weeks to heal, rather than the days of healing that occurred when we were youths. This is normal also.

The best thing to do when you get a scratch or cut is to wash it with regular soap and water.  Antimicrobial soaps do not offer any advantage and sterile water is not needed.  Cover the wound with a bandaid or clean gauze.  If it is a deep cut that continues to bleed, that is a sign that sutures (stitches) might be needed.  Otherwise just let your body do its magic and heal.`


Wednesday, July 6, 2016

Why Can't I Have a Dentist EHR?



Imagine my surprise and delight when I saw my dentist this week for a check-up and found the electronic health record to be both informative and patient friendly. As I sat in the dental chair, the large monitor screen was swung over in front of me and my dentist was at my side going over it with me. The monitor was not a barrier...it was part of my exam. The print was large, the information on the screen was easy to understand. Together we updated my health history, current meds and corrected errors. She held a small pad and changed things as we spoke. As the exam progressed she was able to swing the monitor over and show me X-rays, a fracture line in my tooth, a hazy spot that needed more investigation. We looked back in time and compared. The computer was a welcome addition in the exam room and the amount of clicking and recording of information was simple and intuitive.


Compare this with the EHR that I use, which by the way, is rated one of the best and is extremely expensive to purchase, install, and maintain.  The user interface is so busy and non-intuitive that to show it to a patient would be distracting and eye-numbing. The number of clicks, scrolling and entries needed to see even one piece of information makes it nearly impossible to use as education for a patient. In fact it is so time consuming and such a burden in the exam room that an entire new industry has sprung up to deal with the EHR called "scribes". It an attempt to free up the beleaguered physician and restore patient-physician eye contact and connection, many doctors are paying for a 3rd person to be there in the room just to record the visit notes and do the electronic paperwork.


My dentist was done charting by the time I left the exam room. I, on the other hand, face hours of after visit typing into my EHR, often long into the night. Even a simple ordering of an e-prescription requires about 6 clicks, entering diagnoses, proper ICD-10 codes,  dealing with alerts that tell me that diagnosis does not qualify to be covered by Medicare, secure sign-ins and special authorizations needed for schedule 2 and 3 drugs, and on and on. That's just one function and one medication. Multiply that my thousands.


No doctor wants to go back to paper charts but we shouldn't accept the current stock of medical electronic health records.


The dental EHR was clealy developed for true dentist workflow and user satisfaction. The medical EHRs were developed for billing, coding and government requirements. I want what the dentists have. And I bet my patients do too. 

Tuesday, May 24, 2016

What is Shingles?

Thanks to my patient for allowing me to use her photo to talk about a common condition known as Shingles.  The medical name is herpes zoster and it is caused by the re-activation of the chickenpox virus (varicella zoster).  This crazy virus lays dormant in the nerves and something causes it to flare up years or decades later.

The first signs of the rash
This patient noticed a small rash behind her right ear and thought it was insect bites after a camping trip.  She had some tingling (a common sign) and swollen and tender lymph nodes.  Two days later when I saw her, the rash had spread down her neck and shoulder and she definitely had lymph node swelling at the neck and above the clavicle. (nuchal and supraclavicular nodes).  She had no fever but felt a little down.

Most shingles occurs in older people but it is not uncommon in younger folks too, like this patient.
The rash takes about a week to develop and can last about 2 weeks with varying degrees of pain and annoying tingling.  Some patients have pain that lasts in the nerves long after the rash has resolved.

We treat Shingles with antiviral medication (Valcyclovir ) and pain control.  People over the age of 60 are recommended to get Zostavax vaccine to help prevent an outbreak.  It reduces the chances of Shingles by 51% and even higher reduction of post-herpetic neuralgia pain.

No special tests are needed to make the diagnosis. This is another reason everyone should have a primary care physician who can make the diagnosis and get the patient started on treatment.

Monday, May 16, 2016

Transparency Price Tools Did Not Lower Health Costs

For years experts have been saying if consumers knew the price of certain health care services they would be able to decide what services bring "value" and they could be better "shoppers" of health care.  Since so many patients have large deductibles and copays, it has been conventional wisdom that providing transparent prices would lower overall costs.  As people are spending their own money, giving them prices to compare should make them savvy consumers, right?
Wrong!  The Journal of American Medical Association, JAMA, did a study of employees that were given access to price transparency tools and it did not lower health care spending.

The authors compared the rate of change in health care spending among employees of two employers who offered a tool where they could compare prices of what they would pay out-of- pocket for various physician, lab and hospital services.  Top searches were for colonoscopies, obstetric services, office visits and gastric bypass surgery.  The majority of searches was for services over $500 and more than  half had price estimates over $1250.  They compared the spending of people who had access to these price estimators and those who did not.  They even found that people who had the price estimators, had increased out-of-pocket health care spending compared to those who did not. The study matched the two groups for age, sex, health condition and type of insurance plan.

What can we make of this strange result? First, only a small percent of employees who were offered the tool even used it.  Obviously it has to be used to be effective.  Maybe it was too cumbersome or difficult to use. Another reason may be patient perception of quality. Other studies have shown that patients erroneously think higher price means higher quality. If patients think a lower cost health service is inferior, they might shy away from it.  And since most of the searches were for expensive services, patients might think they were already using their entire deductible so they may as well go for the expensive ("perceived higher quality") medical service.  

It is also quite possible the health care is NOT like going to the grocery store or other retail purchases. Patients may not like price shopping and comparing when it comes to something as important as their health.  A recommendation from one's trusted physician about who to see and where to go may override a price comparison website.  Health care can be scary and baffling to many people and the risk of making the wrong choice is much more serious than buying the wrong Ketchup at the market.

This important study showed that we may need to look at other ways than price transparency tools to help patients bring down the cost of health care in the United States.

JAMA, May 3, 2016,Vol 315

Friday, May 6, 2016

Frozen Vegetable Recall



This week the U.S. Centers for Disease Control announced a huge recall on over 350 frozen vegetable and fruit items because of an outbreak of Listeria monocytogenes bacteria.  Frozen green beans, broccoli, peas, edamame, kale, potato medley and even stir fry packages and fruits sold under 42 brands of U.S and Canadian store labels have been implicated. 
At this time the CDC reports 8 people have been infected. Six in California and one in Maryland and Washington.


Listeria is a fairly rare but dangerous bacteria.  A person with a good immune system can do fine, but it can cause severe sepsis and death if it enters the blood stream.  Immune compromised, older people, infants, and pregnant women are most vulnerable. Listeria can cause miscarriages and stillbirths among pregnant women.


Listeriosis causes muscle aches, fever, diarrhea and GI symptoms. Again, a healthy person can deal with it but it can cause rapid worsening with confusion and sepsis in older adults.  There have been a number of outbreaks in the recent past in milk, cheese, ice-cream and even caramel apples. The largest outbreak was from cantaloupes in 2011.  The current frozen vegetable outbreak has been tracked to CRF frozen foods packing plant in Pasco, Washington.  Since May 1, 2016 approximately 358 consumer products sold under 42 separate brands were recalled.


What can you do?  For now, I would advise you not to purchase frozen fruits or vegetables unless you know the source.  Both organic and non-organic were involved. The affected products have the "best by" dates or "sell by" dates between April 26, 2016 and April 26,2018 so check what is in your freezer and toss them if these are the dates. 

Monday, May 2, 2016

Are Drugs Past Expiration Date OK?

Pharmaceutical drugs, both prescription and over-the-counter come with an expiration date.  This manufacturer expiration date applies to unopened containers and many patients think they should discard expired meds or that it will be dangerous to take them. But do they really need to toss the "old" one and buy something new?  Is there a problem with safety?  What about the efficacy...will it still be potent?

The Medical Letter on Drugs and Therapeutic, a well respected and non-biased publication, looked at shelf life extension and the stability of expired medications.  They showed that all drugs they tested were stable for a year past the expiration date, and most drugs stored in unopened original containers were fine for 66 months. (that's 5 years!)  One drug, theophylline retained 90% of potency 30 years past its expiration date. 

Solutions and suspensions are less stable than solid medications. Epi-Pen auto-injectors may lose potency after the expiration date so that is one that should be replaced if expired.

So the answer to the above questions about using expired medications are here:
1.   Is there a problem with safety?  No. There are no reports of toxicity.
2.  Will it still be potent?  If the medication is in a cool, dry place in the original container, it is probably 90-100% potent and good for at least a year after expiration and maybe even up to 5 years later. Exceptions would be Epi-Pen, liquid antibiotics and insulin.


 

Monday, April 4, 2016

Marijuana Use Lowers Metabolic Syndrome


Marijuana is one of the most widely used drugs in the United States and many states have legalized the medical use of cannabis. Marijuana is legal for recreational use in Colorado, Washington, Alaska and Oregon.  Despite an increasing use of marijuana in different forms, good scientific studies are not often done. A new study on the effects of marijuana on the metabolic syndrome was published in The American Journal of Medicine in February, 2016. This is the first study that examined relationships of marijuana use with the metabolic syndrome across stages of adulthood. 
 
The Metabolic Syndrome is a dangerous combination of hypertension, obesity, high triglycerides, high glucose and low HDL (good) cholesterol. It is a significant risk factor for cardiac disease and diabetes. Until now we have not understood the effects of tetrahydrocannabinol (THC), the active ingredient in cannabis on cardiovascular health. 

The study analyzed marijuana use in persons 20-59 years old, including past and present use and how much marijuana they used. They also looked at race, socioeconomic level, cigarette and other drug use and age. They found that 60% of the subjects used marijuana at some point in their lifetime, 20% used within the last 30 days. The majority (53.2%) of middle-aged adults were past users.

The results showed a lower mean waist circumference (a measure of dangerous obesity) among marijuana users compared to those that never used. Despite the fact that marijuana contains cannabinoids and appetite-stimulating compounds that attach to receptors in the brain and other parts of the body, weight gain was not increased in users. The study also showed higher (good) HDL cholesterol levels in users compared with never users and lower glucose levels in past and current users. The one element that differed was systolic blood pressure that was higher in marijuana smokers, compared to non-smokers.

 In summary, current and past users of marijuana were associated with a lower prevalence of metabolic syndrome and most of its components, except for systolic blood pressure. Older adults that previously used cannabis had significantly less metabolic syndrome and younger adults who currently used were 54% less likely than never users to have metabolic syndrome.  

This study does not answer the big question "Why". We need to look at biologic pathways to figure out those relationships. But the more we know about the effects of this commonly used plant on our health, the better decisions can be made about legalization or medical use. 


Sunday, March 20, 2016

Best Practices and When Your Doctor Says No


The American College of Physicians and the Centers for Disease Control give guidelines (known as high value care advice) to physicians based on the best current scientific evidence. Physicians try to treat patients based on those guidelines even when patients want a different treatment. Here are three that create the most problems when physicians try to do the right thing.


  • (No antibiotics for acute bronchitis) Acute bronchial bronchitis can last up to six weeks with a    purulent or dry cough. It is one of the most common out-patient diagnoses we see. More than   15 excellent scientific studies show no benefit in treating with antibiotics and a trend toward       adverse complications when antibiotics were used.        
All Primary Care physicians and Emergency Department physicians experience the constant request for Z-Pac throughout the winter. "It helped my friend, family, kid." "It's the only thing that works for me." It is hard to see a suffering patient who wants to be helped and resist the request. That is why 70% of patients with acute bronchial bronchitis get an antibiotic.

  •  (No antibiotics for pharyngitis unless testing positive for Strept) Only 15% of acute sore throats are caused by bacterial infections. The remainder are viruses that do not respond to antibiotics.
  •   (No antibiotics for acute rhinosinusitis AKA: Sinusitis) More than 4.3 million adults are diagnosed with sinusitis annually and 80% receive antibiotics despite the fact that it is usually a self limited illness caused by a virus, allergy, or irritant that causes inflammation in the tissue in the nose and sinus cavity. A bacterial cause usually lasts longer than 10 days and is associated with fever.
Doctors are often put between a rock and a hard place if they follow evidence-based guidelines. We want to please them and help them and when we don't, patient satisfaction scores go down.  But some studies are showing that doctors who offer symptomatic relief and take the extra time to explain why antibiotics are not needed can still get good survey scores.

According to the Annals of Internal Medicine, reducing inappropriate antibiotic use will improve quality of care, decrease health care costs and preserve the effectiveness of antibiotics.
           

Saturday, March 5, 2016

Zika Pandemic - Early 2016


The Zika virus was first discovered in a rhesus monkey in 1947.  The Aedes species of mosquito transmits the Zika virus as well as dengue and yellow fever.  This mosquito is found in tropical and subtropical regions around the world. Since Brazil reported Zika virus in May, 2015, infections have occurred in at least 20 countries in Central and South America.  And now, in 2016, it has pandemic potential with outbreaks in the Americas, Africa, Pacific Islands and Southeast Asia.

It's important to know that  80% of Zika virus infection cause no symptoms at all.  The rest have just mild fever, rash and muscle/joint pain.  There is no effective treatment.   But we are seeing other serious effects like congenital neurologic malformations and microcephaly in Brazil and French Polynesia.  Brazil has had 4000 cases of suspected microcephaly in 2015, a 20 fold increase since 2010.  Evidence of the virus has been found in the placenta and amniotic fluid of mothers and in the brains of fetuses and newborns.  New research shows that the Zika virus affects developing cells in the brain's cortex.

The Zika virus can live in semen longer than blood and we believe it can be sexually transmitted from an infected man to a partner.  We don't know if women can transmit it and we don't know if it can be transmitted orally.  Pregnant women or women trying to get pregnant are advised not to have sex with  partners from endemic areas without protection.

At this time there are no reports of Zika being spread from animals.  At this time there are no reports of Zika transmission in the United States and the only Zika infection is from travelers from endemic areas.








Saturday, February 13, 2016

Geographic Tongue



The answer to yesterdays diagnostic challenge was #1 Geographic Tongue.  Also known as benign migratory glossitis, this is condition has irregular and smooth patches on the tongue.  It is fairly common and can last a long period of time.  It is more common in older people and the cause is unknown.  No treatment is necessary but any lesions or changes in the mouth should be evaluated by your doctor or dentist.


Wednesday, February 10, 2016

Tongue Image Challenge

It has been awhile since we have had an image challenge for you to solve.  This is a fairly common condition that we see.  What do you think the diagnosis is?
1.  Geographic tongue
2.  Oral candidiasis
3.  Lichen planus
4.  Oral hairy leukoplakia
5.  Pemphigus vulgaris


Make your diagnosis in the comments section and check back tomorrow for the answer.

Thursday, January 21, 2016

The Health Benefits of Dry January


My under 30 year old hairdresser mentioned to me that she was having a "Dry January".  I had never heard that term and she explained that she wanted to be bikini ready for a trip to Maui so she was having no alcohol for the month.  According to a UK magazine called New Scientist, she is on the right track.


According to an article in National Public Radio Online, the staff at the magazine used themselves as guinea pigs and swore off booze to see what the health benefits would be.  Of the 14 staff members, 10 of them gave up alcohol for 5 weeks and 4 continued to drink as they usually do.  Their drinking patterns varied from a "low" of 8 bottles of beer to a shocking 64 beers a week.  (Those Brits do like their pubs!)


They analyzed the results of lifestyle questionnaires, ultrasounds and blood samples and found some remarkable differences in just that short period of time.  The abstainers saw their blood glucose levels fall by an average of 16%.  Blood glucose is a key factor in the development of diabetes.  They also found that those who stopped drinking for 5 weeks lowered their liver fat (seen on ultrasound and blood tests) by 15-20%.  Fatty liver is caused by obesity and excessive alcohol intake and is a major health problem and cause of chronic liver disease. 


And what about people who want to lose weight, like my beach bound hairdresser?  It turns out her "Dry January" was the thing to do.    There are about 120 calories in a 5oz glass of white wine.  Only 1.5oz of tequila or vodka contains 96 calories.  A 12oz bottle of beer is 150 calories.  By cutting out alcohol, you eliminate thousands of empty calories.  Some abstainers reported more energy and that means more activity, which also sheds pounds.


The researchers don't know if one month off alcohol translates into long term better health.  We know from other studies that the key is making changes that last and are part of our lifestyle.  Rather than a dry month, it would be better for our health if we cut back on alcohol consumption all year.  

Monday, January 18, 2016

Why Did Glenn Frey Die?


The untimely death of Glenn Frey, one of the talented leads in the famous Eagles band, has left his fans saddened and the music industry has lost another great.  Early reports from his publicist say his death was from Ulcerative Colitis, Rheumatoid Arthritis and Pneumonia. You may wonder how someone dies of pneumonia in 2016.

At the turn of the Century, before we had antibiotics, pneumonia was considered "the old man's friend".  A slight pulmonary infection often led to death and I remember my grandmother saying; "Cover up or you'll catch your death of pneumonia".  In her day it was serious and fatal.  But now we have effective antibiotics to treat pneumonia and it mainly effects people who are very young, immunocompromised or who have multiple other organ failures.  So what may have happened to Mr. Frey?

Both Rheumatoid Arthritis and Ulcerative Colitis are treated with medications that can affect the body's natural immune system.  Because they are both "auto-immune" diseases, effective medications turn off the body's cells that cause the disease but these same medications also turn off the white cells and macrophages that fight infection.  It is always a delicate balance when we use medications that affect the same cells that cause certain disease flare-ups  as well as prevent infection from taking hold.

It is just speculation without knowing  Mr. Frey's medical history, but he may have been too immune compromised to fight off the pneumonia...even with the best antibiotics.  Rheumatoid Arthritis and Ulcerative Colitis can be life altering themselves, but death from infection (pneumonia) is often what happens if a person is very ill.

It is important for older people or persons with chronic diseases to get a pneumonia vaccine.  Babies are also immunized with this vaccine.  This vaccine is effective in nearly 100% of Streptococcal Pneumonia strains of bacteria.   But there are dozens of other bacteria and viruses that can infect the lungs also and cause pneumonia and in a person who is immunocompromised, as I suspect Glenn Frey was, the body can become overwhelmed with infection and sepsis.  Even the most heroic advances in medicine can fail in some cases.

Glenn Frey was a wonderful musician and has left behind a great body of work that continues to bring joy to the listeners.  RIP, Mr. Frey


Thursday, January 14, 2016

Go Ahead And Eat Grapefruits With Your Statin



Statins are the most commonly used medications in the U.S. and are used by millions of people to reduce cardio-vascular disease, heart attacks and stroke.  For patients who take the three most commonly prescribed, Simvastatin, Lovastatin and Atorvastatin, the current medical advice is to avoid grapefruit juice while talking these medications. Grapefruits and grapefruit juice increase the concentration of these drugs in the body.  But a new study published in The American Journal of Medicine says we have it all wrong!  Patients who like grapefruits should go ahead and enjoy them with their statins.  Here's what the researchers say:

Fresh grapefruit juice contains bergamottin which has an effect on an intestinal enzyme (CYP3A4 for you chemists) that prevents the breakdown of certain statins.  The consequence is that the blood level of these three statins are increased when taken with grapefruit juice.  We've known about this interaction since is was discovered  by accident in 1989 when researchers were studying another drug that is affected by this enzyme.  Since that time, patients have been advised to avoid grapefruit juice.  But since we know that standard doses of these medications reduce LDL (bad) cholesterol by 37%, doubling the dose reduces it by 43%.  So we should think of grapefruit juice as an enhancer of Statins.  Each reduction of LDL in the blood further reduces risk of heart disease.

The perception that grapefruit juice is contraindicated for people on statins is misleading and the conclusion from this study is that it can enhance the positive effects of these three statins.  Grapefruits are low in calories and high in Vitamin A and C and with a low glycemic index they have a positive effect on blood sugar.  This is good news for people who like grapefruit juice and who take statins.
There is no reason to avoid them.

(brand names are Zocor, Mevacor and Lipitor)


Tuesday, December 29, 2015

If Health Care Worked Like Amazon

It's been a busy Holiday season and I've been using Amazon a lot!  The experience is so good and effortless it made me wonder how great it would be if Health Care could be run like Amazon.  Imagine this:
  • Log into your secure doctor's office website and you are recognized..."Hi Toni".
  • The web screen has easy navigation and point and click for "recent labs", "immunizations due", "make an appointment", "email the office", "update insurance info/address/credit card". etc.
  • The web screen provides a link for pricing of office visits, procedures and immunizations with your copay amount depending upon your personal insurance and deductible.
  • The web screen has links for information on how to stay healthy and timely messages from the office that relate to your personal health issues.  (healthy recipes, workout tips, managing high cholesterol or diabetes, exercises for arthritis etc)
  • After a visit or encounter an email arrives with the information your doctor provided all itemized and easy to understand with links if more instructions are needed.
  • Prescriptions can be refilled online with a click request from you and should you request (and pay for) delivery, it will arrive within 24-48 hours to your door.  If it cannot be refilled, you will receive a message and instructions within a few hours.
  • Your medications are listed on your web page with instructions on how to take them and how long to take them.
  • After a visit,  an easy 5 question email survey is sent out asking you to rate your experience.
Unfortunately, there is no way to guarantee quality, medical diagnostic skill and compassion. You can't make a purchase return on health care like you can on Amazon.  True exceptional health care cannot be commoditized like retail, nor should it be.

But certainly we have the technology to provide a better patient centered service than we do. Wouldn't it be great to use the Amazon web platform with its intuitive customer interface and make it work for Health Care.  

     

Tuesday, January 20, 2015

Probiotics - They Actually Work


Bacteria in your GUT- Aren't they pretty?
Probiotics are live bacteria and eating or drinking them can have a profound beneficial effect on your health.  Before you say "ewww", let's look at the science and why the right bacteria is essential for our well-being.

The human gastrointestinal (GI) tract is filled with millions of microbes known as microbiota.  Your microbiota is specific only to you and was started at birth when you acquired the bacteria from your mother.  Over the years it continued to evolve depending upon your gender, geography, health and diet.  If you took antibiotics, it probably knocked out your good intestinal microbial environment for at least a month.  Some strong antibiotics affect the gut for up to 4 years.

Probiotics are bacteria found in foods and a number of digestive illnesses are helped by taking them.  They prevent the growth of bad bacteria, they lower intestinal pH (thereby preventing  bad bacterial growth) and they increase the production of mucin which acts as a blockade and prevents bacteria from adhering to the intestinal wall.

Here are some ways Probiotics can help:
  • Can reduce crying time in breastfed babies with colic.
  • Can prevent travelers diarrhea
  • Can help with infectious diarrhea symptoms
  • Can reduce the risk of antibiotic associated diarrhea
  • Can reduce diarrhea in patients receiving pelvic radiation
  • Can reduce atopic eczema and asthma in children
  • Can improve atopic dermatitis in adults
But all probiotics are not the same and different strains and strengths  exist.  They are alive so it is important to know the manufacturer and what bacteria it contains.  Here are some brands I recommend and Whole Foods Market also carries fresh yoghurt and dairy products that are filled with good probiotics.

DanActive or Florastor:  Good to take along with antibiotics (if you MUST take an antibiotic) to prevent diarrhea in 60% of cases.  Start it with the antibiotic and continue for at least a week afterward.  Take it two hours apart from the antibiotic dose.

Activa: 1-2 servings a day for two weeks can help regulate the digestive system

Culturelle : 2 capsules a day treat infectious diarrhea and can be taken during a trip

Align: Good for IBS symptoms of pain, bloating and flatulence.  1 capsule a day

Remember, your GI tract should be in perfect homeostasis with your natural microbiome if you eat healthy.  If it gets thrown off, restoring the bacteria with Probiotics can help.
Read more about your microbiome here!

Friday, January 2, 2015

Healthy New Year

You only need three resolutions for 2015 to become healthier.  Only three!  And research shows that these three are the most important for healthy aging, longer life and feeling better overall.
Are you ready?  (Insert drum roll here)

1.  Quit smoking.  No more excuses. Throw those packs and ashtrays away and become a non-smoker.  Need help?  Go here. 
I don't need to tell you why or coax you more.  You already know it.  If you don't smoke, yippee...you only need two resolutions.

2.  Plan your meals and eat more plants.  I didn't want to say the diet word because it is loaded with meaning for everyone.  We've all tried diets that fail.  We are told confusing things about what to eat and what is a healthy diet.  But planning meals and eating more plants at every meal will automatically mean we are eating healthier.  The worst way to eat is on the fly, eating quick fast food or grabbing what's most convenient.  Because without planning, what is most convenient is processed food like chips, pizza slices, fries and sweets.  If each of us committed to preparing more foods at home, grocery shopping on the edges and not the middle aisles and eating an apple when hungry we would automatically be eating a healthier diet.  Try it and stick to it.

3. Walk 10,000 steps a day.  If you already exercise you can keep doing what you are doing.  But if you have become less active as the years have gone by, this is the time to change.  Walking is something that most everyone can do.  It requires no equipment and only a good pair of shoes.  The step trackers can help.  Park further away from your destination.  Take the stairs instead of the elevator.  Walk your neighborhood and see things you could never see from the car. 

If these resolutions seem elementary to you  because you are already a vegetarian mountain climber or elite athlete, your year can just be doing more of what you already do.  Your resolution might be "be nicer".   For the rest of us, keeping it simple is the way to start.

Thursday, October 16, 2014

Let's Talk Ebola

Ebola is all the rage so it is time for EverythingHealth to "talk ebola". Unless you have been in a coma, you are aware that Ebola is sweeping through West Africa and there have been 3 identified cases in the United States.  This is a big news story so anxiety and fear are being felt by anyone who picks up a paper, goes on the internet or watches TV.  What does EverythingHealth say?  First....

Calm down, everyone!

Here are some ebola facts:
  • There are actually 5 different ebola viruses that cause hemorrhagic (bleeding) fever.
  • Ebola is not very contagious because it is not air-borne
  • Initial symptoms are fever, body ache, diarrhea, stomach pain and vomiting
  • The incubation period is up to 21 days

The average American is not going to be at risk for ebola. Direct contact with body fluid is needed so standing in a room or an airplane with an ebola victim will not cause infection. Gunshots kill more than 30,000 Americans a year.  Now there is a risk for you to worry about!

Healthcare professionals, trash collectors and  airline clean up crews are the most at risk of exposure to Ebola virus.  Those workers should keep abreast of current events and take precautions.  Until the infection can be controlled in Africa, there is always the chance that a traveler will have silent disease.  The best way the World can protect itself is to help Africa contain the infection.  This does not mean closing airports.  That would simply prevent needed help and cause the virus to spread across borders to other countries in Africa.

What can you do?  First, get a flu shot.  As winter approaches, influenza will be here and it causes some of the same early symptoms as ebola.  I worry about our Emergency Departments being crushed by people with flu symptoms who think they may have ebola.  Please make it easy on all of us and

Get a Flu Shot!

Second, send some $$ to your favorite relief organization.  I recommend Partners in Health and International Medical Corp.   I have personally worked with both of these organizations and they do wonderful relief work around the world. 


Monday, August 4, 2014

Summertime Photosensitivity

EverythingHealth got a little behind in posting the answer to the image challenge this week.  Click back on the link to see the photo.  The answer was #3 - Phototoxic dermatitis.  The erythema (redness) that you see in the photo is only on the sun-exposed skin, with sparing of a linear area on her nose and much of her head, areas that were covered by glasses and hair. That is a big hint in the diagnosis.

It is not uncommon for facial products or even systemic medications to cause a photosensitivity when the skin is exposed to ultraviolet radiation.  The patient's lesions responded to sun protection and cortisone cream.

Photosensitivity is a type of sun toxicity of the skin.  Certain antibiotics (tetracycline, sulfa) can cause it in certain people.  Even NSAIDS like Advil or Naprosyn have been implicated as well as anti-fungal drugs and perfume fragrances.  It can occur minutes to hours after sun exposure and looks like an exaggerated sunburn.

Treatment is to avoid the causing agent, protect from the sun and symptomatic relief.

Thursday, July 31, 2014

A Summer Image Challenge

It's been awhile since I have challenged EverythingHealth readers so here it is from the New England Journal of Medicine.  You be the diagnostician.

Click on the photo for a closer look.  Put your answer in the comments section and return tomorrow for the answer.

Tuesday, July 8, 2014

Is it a Kidney Stone?


Kidney stones (nephrolithiasis) affects 1 in 11 people in the U.S.  Some say its the worst pain they have ever experienced.   There are a number of causes for these stones, including diet, hereditary, chronic urinary infections, gastric bypass surgery or inflammatory bowel disease, and other medical conditions.  Sometimes we just don't know the cause, although they are more prevalent in men than in women.

Patients with acute flank pan often show up in the emergency department with severe pain.  Because other things can cause abdominal or back pain, patients will often undergo lots of tests (cat scans, ultrasounds etc) to determine the cause.  The British Medical Journal has published a study that shows a clinical prediction rule that proved valid in determining that the patient did, in fact, have a kidney stone.  Here is what they found:

Eight factors were associated with the presence of a ureteral stone. Each of them was assigned points:
  • male sex (2 points)
  • duration of pain-greater than 24 hours (0 points) 
  • duration of pain-6-24 hours ( 1 point)
  • duration of pain less than 6 hours (3 points)
  • non black race (3 points) (stones are rare in black race)
  • nausea alone (1 point)
  • vomiting alone (2 points)
  • microscopoic hematuria (3 points)  (blood in urine)
Add up the points and if 0-5 - low probability (10%) for stone, 6-9 points is moderate probability (50%) and 10-13 points is high probability of a stone (90%)

Alternative causes (non-stone) were found in 1.6% of the high=probability group.  these causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm and pancreatitis.

This algorithm was tested and validated in an emergency setting and it could help physicians with diagnosis and help prevent unnecessary testing.
 

Saturday, May 31, 2014

Saturday, March 15, 2014

When to Get a Colonoscopy

When you turn 50 years old, you enter the "procedure years".  Fifty is the magic age for getting a screening colonoscopy.  Why age 50?  Most gastrointestinal cancers are more prevalent as a person ages.  So guidelines are set to benefit the largest numbers of patients by recommending "screening" tests to detect cancer while it can still be removed completely and cured.  The key word here is screening.  That means there are no symptoms and the doctor is just doing surveillance. If a person has symptoms, family genetic cancers or other conditions that increase the chance of cancer the magic age of 50 doesn't apply and colonoscopy can be done at any time to diagnose a problem.

what your colon looks like with a good prep
There are also clinical guidelines for continuing follow-up screening and here is where it gets muddled.  Gastroenterologists often don't adhere to these guidelines and patients can be confused as to when they should get a repeat exam.  These guidelines assume the baseline colonoscopy was complete and the physician was able to get the scope up to the cecum, the bowel prep was adequate for good visualization and any polyps were removed.  If you have a colonoscopy and a polyp was removed, remember to ask for the path report and keep it.  This report shows what type of polyp it was because that makes a difference to when the next colonoscopy is due.

Here are the guidelines as recommended by the US Multi-Society Task Force on Colorectal Cancer:

  • No polyps  -  repeat in 10 years
  • Small (< 10mm) hyperplastic polyp in rectum or sigmoid  -  repeat in 10 years
  • 1-2 Small (< 10mm) tubular adenomas  - repeat in 5-10 years
  • 3-10 tubular adenomas  - repeat in 3 years
  • > 10 adenomas  - repeat in less than 3 years
  • Any adenoma > 10mm  -  repeat in 3 years
  • Any adenoma with villous elements (villous or tubulovillous) or with high-grade dysplasia -  repeat in 3 years.
  • Any sessile or serrated adenoma  -  repeat in 3 years
  • Serrated polyposis syndrome  -  repeat in 1 year
When can you safely stop screening?  If the patient's life expectancy is less than 10 years, there is no reason to continue with screening colonoscopy.  

In medicine, it is just as important to prevent overuse as it is to make sure everyone gets the right screening at the right time.  If you are lucky enough to have a good primary care physician, she will make sure you are tested at the right time.  But more and more people are trying to manage their own health without expert help and knowing your pathology report and following these guidelines will help you with timing.

Tuesday, February 25, 2014

Forget Supplements-It's All About Diet



Millions of intelligent Americans are spending money on supplements that have no proven benefit in health or longevity and are ignoring what numerous studies have shown; preventing disease and dementia is all about the food you eat.  This is real science with reproduced results in numerous studies.  Here it is, folks.  Change your diet and change your life:

  • Avoid high glycemic carbohydrate diets:  Carbs with high glycemic index  have been shown to increase inflammation and oxidative stress leading to dementia.
  • Eliminate completely high sugar diets : Even intermittent small blood sugar elevations lead to dementia...even in non-diabetics
  • Eat one ounce of nuts/day:  Provides a great source of Vitamin E
  • Avoid trans fats and fast food:  Numerous studies from different Countries show a dose/response relationship of increased depression and anxiety, not to mention heart disease and early death.
  • Real fruit is better than fruit juice:  Real fruit is loaded with natural sugar but it has equal amounts of fiber that help metabolize.  Real fruit is always a good choice, not the juice.
  • Eat more eggs:  Don't worry about the cholesterol in eggs.  Eggs provide perfect protein in a nutrient-rich, low-calorie, low-fat package.

Diets high in fruits, vegetables, fish, plant oils, nuts and whole grains, with lower intakes of sugar, processed meat, and animal fats, are likely to be the best bet in supporting the health of our brain as well as the rest of our body.  If you eat this way you should not need vitamins or dietary supplements to maintain health.

Pay attention to everything you put into your body and lower your risk of disease and poor health.

Tuesday, January 21, 2014

How to Tell if it's the Common Cold or Flu


The "I feel awful" season is upon us.  I challenge any reader to say they don't know someone who is out sick with some type of upper respiratory infection.  Congestion, cough, body aches and fatigue can hit even if you wash your hands and take precautions.  So how can you tell if it is a viral cold or influenza?  And does it really matter since they are both viruses?

The symptoms of a cold or the flu can be quite similar and hard to tell the difference but here are some differentiating tips that doctors know and you can use too.  First, did it start slowly with a scratchy sore throat, sneezing and then build over a couple of days?  If you answered yes, it is probably a viral "cold".  The influenza virus usually hits with a slam.  You awaken feeling awful with body aches, fever and like you were "hit with a Mack truck".   People with the flu can tell you almost what hour they got sick and influenza is always respiratory.  That means a racking cough and maybe even vomiting.  The flu generally brings a fever and maybe even chills.

H1N1 virus
It is important to try and tell the difference because we can often lessen the flu symptoms if we catch it early and use the anti-viral; Tamiflu.  This year 90% of the flu cases are H1N1.  This years strain affects children and young adults and any flu is bad for people that have underlying lung problems or are pregnant or immune-compromised.

Both a cold virus and influenza last about 10 days.  Illness that goes longer should be evaluated by your physician.  For either infection listen to your body.  Rest, drink lots of water and herbal tea with honey.  Ibuprofen or Aleve are good for body aching and fever.

 Do not ask your doctor for antibiotics.  They will not help and will likely destroy your own good bacteria that keeps your intestines healthy

But  you can still get vaccinated for influenza: The vaccine lowers your chance of getting the flu by 60-65 percent. And if you do get it, your symptoms will likely be mild.

Wash your hands, make sure you are getting enough sleep, avoid crowds and eat an apple a day to stay healthy through cold and flu season.

Tuesday, December 17, 2013

The Microbiome

I am fascinated by the new research and information on the gut microbiome.  These microorganisms (germs, bacteria, microbes) live harmoniously in every part of our body and especially in our gastrointestinal system.  It wasn't even really discovered until the late 1990s and we now know that these microbial communities affect our health in ways we never dreamed.  The human microbiome may play a role in obesity, immune response, diabetes, irritable bowel syndrome, and maybe even anxiety, depression and autism.

Anything that is this new has many possibilities the science is just starting, but there is clearly something very important here.   The Human Microbiome Project  is a NIH initiative with the goal of identifying and characterizing the microorganisms which are found in association with both healthy and diseased humans.  They intend to test how changes in the human microbiome are associated with human health or disease.

A new study published in Nature this week showed that adaptation to the gut microbiome can change in a day.  This is important because dietary changes can have a huge immediate effect on disease.  The researchers showed how immediate changes occur, depending upon subjects eating a plant based or animal based diet.  They fed the volunteers either plant (grains, legumes, fruits and vegies) or animal (meats, cheese, eggs) diets for 5 consecutive days.  They tracked food in the digestive tract, how the subjects felt and bowel movements.

The researchers analyzed 16S ribosomal RNAs to identify microbiome components in fecal samples, which were collected for several days before the dietary changes and each day during the study.
The animal-based diet clearly had a greater effect on the microbiome than the plant-based diet. Even after 1 day, the microbiome of those eating the animal-based diet differed significantly from baseline analyses.

The researchers found fecal bile acid changes in the animal based diet that are associated with liver cancer and Irritable bowel disease. These bile acids change the bile tolerant bacterium that is associated with IBD.

There is no cause-effect found here and the study size was too small to know what is actually occurring.  But the fact that changes could be found in the gut microbiome in such a short amount of time is compelling.  It is simply another potential explanation why diet is so important to health.  And changing our diet can have an immediate effect on our health.


Saturday, December 14, 2013

Answer to Medical Challenge



OK, the answer to yesterday's Image Challenge was #3, Squamous cell carcinoma.

Ninety percent of all mouth cancers are squamous cell cancer.  Factors that increase your risk of mouth cancer are:
  • tobacco use of any type (including smoking, chewing, cigars and pipes)
  • heavy alcohol use
  • Human Papillomavirus (HPV)  (think of Michael Douglas)
Usually surgery is needed to treat squamous cell carcinoma in the oropharynx, along with radiation therapy to eradicate all of the cells.

Wednesday, December 11, 2013

Image Challenge

Back by popular demand is this weeks medical challenge where you get to make the diagnosis. (click on the image for a close up view)

The patient opens his mouth, says "ahhh" and this is what you see.  Is it:

1. Aphthous stomatitis
2.  Pyogenic granuloma
3.  Squamous-cell carcinoma
4.  Syphillis
5.  Traumatic fibroma

Make your diagnosis in the comments section and check back tomorrow for the answer.

Sunday, December 8, 2013

Things Doctors Do (That Normal People don't)


I have been too swamped to blog recently on EverythingHealth, spending lots of time with my physician colleagues (as well as patients).  I realized that doctors are really not normal when it comes to a few things.  Here is a list of things doctors do that normal people don't.  You may have more to add!
  1. Eat standing up, while walking or while charting on patients
  2. Take expired medication (we know that expiration date is phony)
  3. Work hard-core, even when sick
  4. Don't get regular check-ups
  5. Cannot watch doctor TV shows (House is especially intolerable)
  6. Freely discuss body functions at dinner.  Nothing is off limits
  7. Silently diagnose medical conditions on strangers.  No lump or rash goes unnoticed.
  8. Combine vacations with work
  9. When we shake hands, think "Oh, that's a nice vein"
  10. When our child is hemorrhaging, we can fix anything with steri-strips
  11. Seldom use antibiotics on ourselves or family
  12. Listen to lectures and medical information while commuting
  13. Take suitcases full of journals to catch up on when on vacation
  14. Carry stethoscope, and full medical supplies in our trunk because "you never know"
  15. Seldom take vitamins or supplements
I'm sure I'll hear from my nurse and doctor readers, or spouses of medical people if I got something wrong. 

Tuesday, November 5, 2013

Sunday, October 6, 2013

Oral Melanoma


The answer to yesterday's image challenge was #4- Melanoma.  Many of you diagnosed correctly.

Oral malignant melanomas are uncommon and like other melanomas of the skin they arise from melanocyte cells.  Unlike cutaneous (skin) melanoma which are linked to sun exposure, the risk factors for oral melanoma is unknown.  We think they arise de novo (from no cause).

Oral melanomas are more common in Japanese race and occur in men more than women (2:1)  It is rare in people under 20 and more common in men over 40 years.

Good oral exams by the dentist are always important to identify mouth lesions.  Most are benign and many other less serious conditions can cause pigmentation.

Wednesday, October 2, 2013

You Be the Doctor


This 42 year old man came to the doctor with these changes in his gums.  What is the diagnosis?

1.  Chewing tobacco
2.  Implantation of amalgam
3.  Lead Poisoning
4.  Melanoma
5.  Peutz-Jegher's syndrome

Make your diagnosis in the comment's section and check back Friday for the answer.  Can you be the doctor that gets it right?

Tuesday, October 1, 2013

Ignore these 15 Obamacare Myths


I've pulled my head up from frantic medical work just in time to give faithful readers 15 Myths that are being spread about Obamacare.  I have been first to admit that the government has done a lousy job of explaining the plan and it is no wonder the Tea Party has had a field day with mis-information.  But now that sign-ups for the Exchanges are open to the uninsured and under-insured population, these are the lies you should avoid:
  1. Congress is "Exempt" from the Affordable Care Act  
  2. Premium prices will increase due to Health Care Law
  3. The Affordable Care Act includes death panels
  4. Shutting down Government over Obamacare funding will stop the Health Care Law
  5. The ACA is "socialized medicine" and a "government takeover"
  6. People will be able to commit subsidy fraud on the Exchanges
  7. Obamacare "Narrow Networks" will constrain health choices
  8. The Affordable Care Act is bad for women
  9. The Affordable Care Act covers abortions
  10. The Affordable Care Act is a job killer
  11. With full access to medical records, the IRS will discriminate against conservatives
  12. Navigators will abuse private information
  13. Obamacare mandates doctors to ask patients about sexual history
  14. The Medicaid expansion will force doctors to turn away patients
  15. Obamacare is to blame for a projected 30 million people who will remain uninsured.
There is plenty to be mad at the government about.  The fact that the Tea Party has literally shut down government is atrocious and bad for mankind and bad for business.  Obamacare isn't the problem.  it isn't a perfect law but it is the same act the GOP came up with during the Bush years and it is a (minor) step in the right direction.

If you want to learn more...go here.

Aren't you glad I'm back with facts and the truth? 


Thursday, August 15, 2013

New Hep C Screening for Baby Boomers

If baby boomers weren't special enough,  now the U.S. Preventive Services Task Force has singled them out as a special group to be screened for Hepatitis C virus (HCV).  Individuals born between 1945 and 1965 are recommended to undergo this one-time blood test screening because they are at high risk for the virus.

What is it about this age group that gets special notice?  According to the Centers for Disease Control, baby boomers account for three out of four people with HCV.   Many of them contracted hepatitis C from blood transfusions or needle procedures before we had a screening test for the virus.  Others may have caught it from high risk behaviors like injecting drugs, HIV or piercing or tattoos in unclean environments.  It is less common to contract it through sexual relations but it can happen.

We have had a test that could screen for Hepatitis C antigen for many years but only recently are we able to treat chronic Hepatitis C with anti-viral medications.  There is an increased incidence of hepatocellular carcinoma (liver cancer) in people who acquired HCV two to four decades earlier and many people have no idea that they are carrying the virus.  It is hoped that by screening patients in this age group, patients can be identified at earlier stages of disease and receive treatment before developing complications from liver damage.

HCV infection is the leading cause of complications from chronic liver disease.   More than 30% of U.S. adults that receive liver transplants have HCV.

Baby boomers just need to undergo screening once.