Romney Should be Proud of Massachusetts Health Care

I don't understand why Mitt Romney is running away from the Massachusetts health reform that was enacted in 2006 under his reign as Governor. They are in their 6th year and by any standards it can be considered a success.

The plan included Medicaid expansion, subsidized private health insurance, a health insurance exchange, insurance market reforms and requirements for individuals and employers. Is the fact that the Federal Accountable Care Act (Obama-care) has many provisions of Mass. health reform the reason Mr. Romney and the GOP want to bury it's success?

Oh, you didn't know it was a success?  How strange...

Let's look at the plan and what it has done for the citizens of that State. Insurance rates did not sky-rocket and employer-sponsored insurance is still strong. Access to health care remained strong and there were reductions in emergency department visits. Hospital stays declined and there were improvements in self-reported health status. Since the act, 94.2% of adults now have health coverage. That compares to 77.7% in the rest of the Country. Remember the scare that employers will drop insurance coverage when The Accountable Care Act is fully implemented?

In Massachusetts more than 2/3 of adults age 19-64 reported coverage through an employer, significantly higher than before health reform. Since Massachusetts Health Reform, more employees rated their employer sponsored insurance plans as very good or excellent. Patients also were more likely to have preventive care visits (up 5.9%), a specialist visit (up 3.7%), dental care (up 5%) and even have a usual place to go when they were sick or needed advice (up 4.7%). Also these patients were more likely to report that they got doctor care, tests and treatment when it was needed. Readers, this is amazing yet Mitt Romney and the GOP are running from it like Herpes.

OK, it's not all rosy. The Massachusetts 2006 health reform initiative did not tackle the high cost of health care in the state. Insurance premiums continue to rise and health care costs in Mass., just like the rest of the Country, continue to grow faster than inflation. Despite that, it did become more affordable because there was less out of pocket health care spending by patients (excluding premiums). There was no change in patients' problems paying medical bills before or after health reform.  Health Care in the United States just plain costs too much.

What does it say about Mr. Romney and the rest of the GOP that they wouldn't take this successful ball and run with it?

If I were on the Mitt Romney's team, I would tell him to change the dialog. He should be bragging about what was done in Massachusetts. He should take credit for it and reveal these statistics. With the political noise and posturing, American's deserve to know the facts.

If Mitt wants to run from something, try the dog on the car roof or his trickle down economics.  Now that would be something worth hiding. 

Heavy Menstrual Bleeding

Heavy menstrual bleeding is common and 10% of all women experience it in their reproductive years.  Women who are NOT in menopause and who have heavy bleeding that occurs during their regular cycle usually have a benign reason for the bleeding.   Fibroids and endometrial polyps are common causes of heavy bleeding periods.

Menorrhagia is the medical term for abnormally heavy periods.  This bleeding is often associated with severe cramps.  What is considered heavy?  Soaking through one or more sanitary pads or tampons every hour for several hours or needing to wake up during the night to change protection is heavy.  Bleeding for longer than a week or passing blood clots is abnormal also.  Menorrhagia should be evaluated by a physician to rule out polyps, bleeding disorders and other medical conditions like pelvic inflammatory disease, endometriosis or thyroid problems.

Once reversible causes have been excluded, most women respond to treatment with oral contraceptives to regulate hormones and minimize bleeding.  For women who do not want to go on the pill, nonsteroidal anti-inflammatory drugs (NSAIDS) are very effective in reducing blood flow and cramps.  The best choice is Naproxen at 500mg twice a day.  Ponstel is another drug that is effective for bleeding and hormone associated migraine headaches.

Women who took Naproxen were 10 times more likely to report an improvement in symptoms compared with placebo and there was a 30% reduction in blood flow.  Naproxen is cheap and does not require a prescription. (Aleve)

Migraine Headaches and Oral Contraceptives

Women who are taking oral contraceptives (Birth Control Pill) and develop new migraine headaches or increased severity of headaches after starting the Pill should be told to discontinue the Pill.  Women with migraine who use oral contraceptives are at a 2-4 fold increased risk of ischemic stroke compared to women who have migraines and are not on the pill. 

The risk of a young woman having a stroke is very small if she is not a smoker.   Smoking increases this risk and women who smoke should not take the Pill because it increases the risk of both heart attacks and strokes.  Even the low dose oral contraceptive is not completely safe in smokers. 

A  woman under age 35, who does not smoke and has longstanding migraine headaches without "aura" may be prescribed OCPs because the risk of stroke is small in this group.  New migraine, however, is an indication to stop the pill and use another form of birth control.

A Novel Approach: Ask the Primary Care Doctor

The government, academics and policywonks are always in the process of "redesigning" health care.  Patients with increased health care needs are considered "complex" and these patients consume the major health resources (translate: "money").  In fact 65% of total health care expenditures are directed toward the 25% of patients with multiple chronic conditions.  Eighty percent of Medicare spending is on patients with 4 or more chronic diseases.  For the first time a study has been done and published in The Annals of Internal Medicine  that actually asks primary care physicians (PCPs) what defines patient complexity.  Who better than the treating doctor to answer this question?

The researchers asked 40 primary care physicians to rate the complexity of 120 of their own patients and to document the characteristics associated with complexity.  Over 1/4 of patients were described by the doctors as "complex".  The doctors were not told what defined "complexity", but instead were asked to describe it in their view.  Once a patient was described as "complex" the doctor was given 5 domains to chose from, developed from previously published concepts.  The 5 domains were:

• Medical decision making (cognitive effort needed to make appropriate diagnoses and therapeutic decisions)
• Coordination of care (overseeing care involving others and for making sure that the medical system is working for the patient)
• Patients personal characteristics (challenging patients)
• Patients with mental health issues (includes substance abuse)
• Patients socioeconomic circumstances (home and work issues, inability to afford medication)

Some characteristics of PCP-defined complex patients stood out.  They were more likely to be over age 60 and women.  They were more likely to have government insurance (Medicare/Medicaid) than commercial insurance.  They were more likely to be undereducated and had many office visits.  They took more than twice as many prescribed medications.

I find it fascinating that most of the PCP identified complex patients were not considered high risk by the Medicare model and other known models.  The algorithms that guide payment and other policy decisions didn't hold up.  The patients identified as complex by PCPs affect their workday and time, yet the known models would not have called them complex.  More than co-morbidity and other case-mix definitions, factors like inadequate insurance, alcohol related problems, prescriptions for anxiety and other mental health issues were all associated with increased complexity per the physicians.  These patients generated more visits, more high cost procedures and more need for mental health services.

The fact that doctors are finally being asked about their work is promising.  It is predicted that 32 million uninsured Americans will come into the primary care system with the passage of the Patient Protection and Affordable Care Act.  This at a time when fewer medical school graduates are entering primary care and many PCPs are leaving clinical practice due to work related stress and decreased job satisfaction.

These results actually provide insight that should be considered in designing a health care system that works for patients and care-givers.  It should influence payment mechanisms, office support and allow the extra time it takes to care for complex patients.  These changes would go a long way to increasing the work satisfaction for PCPs.

The fact that this was the first study that actually defined complexity from the PCP perspective is amazing.  Let's hope it is the start of something that will ultimately improve the health care system for patients and PCPs.

The Many Faces of Psoriasis

This 26 year old female noticed that her nails had been changing over a 6 month period.  Note the small pits and separation of the nail plate from the nail bed.  This lifting is called onycholysis.  There is only one disease where both of these findings are seen together and that is psoriasis.

Most people think of psoriasis as a skin disorder with patchy silvery plaques that form on the elbows, arms, knees and back.   But it is a genetic condition that can also affect the nails and 1/3 of patients develop psoriatic arthritis.  It is actually a very common disorder with wide variation in skin, joint and nail involvement.   The condition can come and go and there are a number of treatments to control symptoms, but no cure.

severe psoriasis

Before and after treatment

Psoriasis is not contagious and you cannot "catch" it.  The National Psoriasis Foundation conducted a survey of patients with psoriasis in 2008 and 71% said psoriasis was a difficult problem for them with self consciousness and embarrassment about the condition.  More than a third said they limited social activities and limited intimate interactions.

Education is the key.  If everyone understood the skin and nail changes of this condition they would know there is nothing weird about it and nothing to fear.

Bone Mineral Density Tests

The recommendations for when and how often women should be tested for osteoporosis with bone density testing (DXA Scan) has been vague.   Many women are tested in their early 50s when they go through menopause with follow up tests as frequently as every year.  Others break a hip without ever being tested.

 A new study published in The New England Journal of Medicine states that bone loss develops slowly and women who have a  normal test when they are 65 do not need to be retested for 15 years!  Even women who show some bone loss can wait many years before they are tested again, according the the study authors.

The study followed 5,000 women over age 67 for over 10 years.  These women did not have osteoporosis at the beginning and they found fewer than 1% of women with normal beginning bone density developed osteoporosis over the next 15 years.  Only 5% of women who started with mild bone loss developed osteoporosis.

This study points to the fact that we have been over testing normal women who would not develop significant bone loss.  But there are a few aspects of the study that are important to note.  They only studied women with normal or slightly low Bone Mineral Density (BMD).  Women who have had prior broken bones, or who have significant bone loss at the time of screening should be followed more closely...perhaps every 3-5 years.

Not everyone agrees with the 15 year recommendation either.  "An interval of 15 years is too long", says Felicia Cosman, MD, senior clinical director for the National Osteoporosis Foundation.  She cites flaws in the study design.

Here is what I recommend for patients.  Get a screening BMD test at age 60-65.  If you are a smoker, take corticosteroid drugs,  are thin and fair, or have a mother or sister with osteoporosis or a broken hip, have the first screening test within 5 years of your last menopause period.  If that first DXA test is in the normal range,  there is no reason to repeat the test for at least 10 more years.  If the first test shows mild to moderate bone loss, repeat in 3 years to assess stability.  The most important test is the first one to establish a baseline and further testing should be tailored toward each individual woman.

There is an easy online tool that can help women and men calculate their risk of having a fracture in the nest 10 years.  It can help guide us to when we need to get a Bone Mineral Density (BMD) test by taking account of certain known risk factors.

Skin Conditions With Aging

Patients often have growths or skin changes that they wonder about.  After examining them, in many cases I say "happy birthday"...it's a manifestation of getting older.  Aging leads to a number of skin and hair changes and when you add the effects of sun, smoking and the environment,  the changes can be profound.
Over time the epidermis thins and by age 60 the dermis is 20% thinner than before.  It is even thinner in areas that have been exposed to the sun.  But even skin that has not been exposed to ultraviolet radiation has 50% fewer mast cells and reduced blood flow, not to mention diminished elastic fiber and collagen.

Pictures are worth a thousand words so here are some to show the changes.

Fine and deep wrinkles are evident on this face.  Thin skin around the eyes causes bags and drooping of the eyelid.

Actinic Keratosis are benign, dry, reddish, crusty lesions that appear on sun exposed ares like the face, ears, hands, chest and arms.  Sometimes a biopsy is needed to differentiate from a squamous cell carcinoma but sun protection from an early age is the best way to avoid them.

 Senile Purpura is really just bruising in older skin.  These dramatic purple blotches form because the blood vessels are fragile and the skin is so thin.  It does not indicate vitamin deficiency or any bleeding disorder.

Healthy skin can be maintained by avoiding cigarettes and sun.  Those are the two most damaging influences for skin and blood vessels.

Haiti Remembered

This is the 2nd anniversary of the terrible Haiti Earthquake that measured 7.0 on the scale. The disaster killed 316,000 people and displaced 1.5 million more.  Even now more than 500,000 people are still in makeshift shelters and only half of the aid pledged for reconstruction has been spent. 

My organization sent medical teams and supplies to the disaster zone and our doctors and nurses continue to support a hospital with teaching and supplies.  I led a team of dedicated caregivers to Port-Au-Prince where we served under the most austere conditions.  Supplies were non existent.  There was no running water in the hospital and the magnitude of the health problems required infrastructure that was not there...and still is not there.  

The following is a reprint of a blog I did on 3/20/2010.


I can't get the stories of Haiti out of my mind.

A patient showed up at the Port Au Prince hospital ward with a massive left sided paralysis, an obvious stroke. This 48 year old woman had collapsed the day before and was now accompanied by her three grown daughters, who were most attentive and worried. I examined her in the bed with other patients and families gathered around. (There is no sense of privacy and even an exam seems to be everyone's business in Haiti). One daughter spoke broken English but I had a good translator that helped me get the information I needed.

It was a sad story. They had been on the 5th floor when the Earthquake hit. They fell straight down and dad was killed. One of the children had a crush injury to his leg and the entire remaining family was now "on the street". Just surviving must have been such a strain. Then...mom has a massive stroke.

As I was examining the patient further, one daughter handed me a quickly scrawled note. It read. "I have a problem She have a AIDS" In this private way, the daughter wanted me to know her mom had AIDS.

In a country with such poverty, lack of health care and lack of education, it is not a surprise that HIV and AIDS remains a significant problem and Haiti is the Caribbean island most affected by AIDS. There also remains a stigma and HIV infection is a big secret. Once I asked my Haitian interpreter to ask an emaciated patient if he was HIV positive and the interpreter couldn't even ask the question. It is just not done. It was a real act of bravery for that daughter to pass me the secret note.

Needless to say, AIDS will be the least of this family's problem. I can't begin to imagine how a woman with a stroke, who will likely not receive any rehabilitation, can live on the street. By the time I left, she needed 2 people to assist her out of bed into a chair...where she could not sit straight. 

This is the continued tragedy of the Earthquake and the aftermath of human misery it left.

Patients Owning Their Medical Records

Traditionally, the patient chart stayed in the doctors office and rarely did a patient get a glimpse of anything in the record.  Photocopying the chart is expensive and no physician would let a chart leave her office because the record must be held safely for a minimum of 7 years.   Now more and more offices are doing away with clunky paper charts and electronic medical records are becoming the norm.  With electronic portals, is there any reason a patient shouldn't have access to their own medical record? 

A study published in the Annals of Internal Medicine reported that up to 97% of patients queried thought the ability to have "open visit chart notes" was a good thing.  Doctors weren't quite so eager.

The study found that doctors worried that open visit notes would result in greater confusion and worry among patients and they anticipated more patient questions between visits.  But the patients overwhelmingly wanted to see the notes and were not worried about being confused.   They thought seeing their own record would provide information that would help them be healthier.  They could see the treatment plans and the test results directly.

One of the study authors, Dr.  Joann Elmore at University of Washington School of Medicine, said that access to records is important for indigent patients or people who move frequently for continuity of care.

It is a new world of sharing of information and there is no reason medicine shouldn't be part of the change.  Patients have access to research studies on-line as well as multiple medical websites  to look things up. (Some  are just junk and filled with ads).   If open records helps create a dialog about good health and allows patients to understand and take ownership of their own life it can only be a good thing.

I do worry a bit about the overly obsessive patient who might misinterpret every slight lab value that is outside of normal.  They will need to understand that not everything carries the same weight in medicine and slight variations of normal can in fact be...normal.

What do you think?  Do you want to see your medical record?

Nail Trauma Paronychia

My patient welcomed in the New Year by doing a midnight 21 mile run through the streets of San Francisco.  It was a clear, crisp night and what a healthy and invigorating way to celebrate New Year's Eve!  The next day, however, her 2nd toe looked like this.  It was throbbing and tender to the touch.  She did not remember any specific trauma.

By the looks of the photo, it is a paronychia, an infection around a fingernail or toenail.  This infection is probably the result of repeated trauma as her foot struck the ground and the top of the nail struck her shoe.  A little bacteria (staphylococcus) was able to take hold in the skin as it broke through the protective cuticle.

Because she is healthy, without diabetes or other immune problems, I advised frequent hot water soaks to increase blood flow and (hopefully) promote natural immune healing.  If the swelling worsens or pus appears, it can be cured by excising it to drain.  Topical antibiotics are of no use and rarely are oral antibiotics needed unless the infection is worsening.

Seven Tips for Healthy 2012 Planning

As we welcome a new year it is an opportunity to re-evaluate, consider the coming year and make intentions for improving our health and sense of well being.  EverythingHealth sifts through the latest medical literature and evidence to offer these proven recommendations for staying on top of your game.

• If you are 50 or older and haven't had a colonoscopy, schedule one in 2012.  It's time! 

• Go online and check your Body Mass Index (BMI).  If you are too high, plan and execute on that diet.  (contact me for a diet coach referral if needed)

• Get rid of sugar and soft drinks.  Stevia is a natural sweetener that is safe and yummy.  The average American eats 160 lbs of sugar a year. Break the sugar habit in 2012

• Stop smoking. For motivation go here.

• Relax your mind.  Start yoga, meditative dance, meditation.  These practices have been shown to lower blood pressure and general stress.

• Send one thank you note a week.  That is 52 notes in 2012.  You can send it to your child, co-worker, grocer, doctor, spouse or even an acquaintance.  The act of thanking and reaching out to others is healing for both sides.

• Become an activist.  Find one cause that you feel passionate about and get fully involved. Here are some to consider,  but there are hundreds of other great organizations and it has to be your own interest.

                                                                Kiva.com      (micro loans to people around the world)

          Women for Women International.    (adopt a sister in a war torn nation.  Many of these women  have suffered atrocities, have no money and support many children.  If you help the women, you raise the standard for the whole community)

         U.S Humane Society  (They do wonderful work to protect animals, expose inhumane and unhealthy farming and promote legislation to make humans and animals safer)

         Foster Children -  (You don't need to adopt,  but you can get involved in a number of organizations that help these kids transition out of foster care into adulthood.  When they reach 18 the system is "done" with them.  Can you imagine your own 18 year old making it alone?  Check in your own community for programs and mentorships.)

 

Happy New Year to all of my readers!!!!

 

Top EverythingHealth Books of 2011

We at EverythingHealth love end of the year lists and we love reading.  Here is our pick for the best read Health (and everything)  books in 2011.  (not in order...all are terrific)

• The Immortal Life of Henrietta Lacks, by Rebecca Skloot
  
• Cutting For Stone,  by Abraham Verghese
• Outliers,  by Malcolm Gladwell
• The Help,  by Katheryn Stockett
• The Checklist Manifesto,  by Atul Gawande
• Middlesex,  by Jeffrey Eugenides
• The Known World,  by Edward P. Jones
• Complications,  by Atul Gawande
• The Curious Incident of the Dog in the Night-Time,  by Mark Haddon
• A Short History of Nearly Everything,   by Bill Bryson

If you have other favorites, let us all know.

Answer to Medical Challenge

The answer to the CT scan image medical challenge is #3, Intercostal Muscle Rupture.

The image shows subcutaneous emphysema and an intercostal muscle defect between the ribs.  the patient recovered after repair of the intercostal hernia.  Subcutaneous emphysema is air under the surface of the skin. 

It is not unusual for these muscles between the ribcage to be strained or even get small tears with sports, extreme coughing or trauma.  It is very unusual for the tear to be this extreme and affect the pleura around the lung and the lung itself.

Thanks for your diagnoses.

Medical Challenge

For my non medical readers, this is an abnormal CT scan.  The CT scan takes a transverse image sliced through, so you are looking at the patient sliced in half transversely.  This is the chest area. I will orient you:

The whitish circle and v-shaped part is the vertebral column.  So you know that is the back.   Bone shows up whiter than organs.  The small whitish lines in a circle are the ribcage (more bone) sliced through.  Air shows up dark so the big dark areas are the lungs.  Notice there is darkness streaking on one side and not the other.  As my 16 year old would say: "That is messed up".  What ruptured to allow air to penetrate the muscle area? (click on the image for a better view)


1.  The diaphragm
2.  The esophagus
3.  An intercostal muscle
4.  The interventricular septum
5.  The pericardium

Medical professionals and others:  Make your diagnosis.  The answer will be posted tomorrow.

High Ratings for Personal Physicians

It's time for some good news!   A study that looked at online patient ratings  about their physicians from 2004 through 2010 showed that the average physician rating was 9.3 out of 10.  That is amazingly high and shows that patients (at least the ones who posted on Dr.Score) are very content with the care they receive from their doctor.  Even though some patients will post a nasty comment about the doctor, the overall patient satisfaction is high.  Seventy percent of doctors earned a perfect 10.

The survey asked patients to rate physicians on attitude, the thoroughness of the visit,  how well the doctor communicated and how long they sat in the waiting room.  It is not a surprise that the longer patients waited, the lower was the rating.  Forty two % of doctors were primary care physicians and the remainder were specialists outside of primary care.

Patient satisfaction is finally getting attention in medicine.  More than 60% of health care organizations are using patient satisfaction scores to determine physician incentive payments and large medical groups measure satisfaction and give the doctor feedback on a regular basis.  Medicare will also link patient satisfaction with hospital payments and hospitals who do not rate high will lose revenue. 

We read a lot about the problems in health care in the United States but those issues are usually concerned with cost and access.  In fact a November Gallup poll found that 82% of adults say the quality of health care they receive is "good" or "excellent".  A 2010 study by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems found that 94% of nearly 42,000 patients rated their physicians a seven or higher on a 10-point scale.  (that group needs a new name)

Another study I read shows that 90% of physicians feel stressed nearly every day.  It is good news that that stress is not being felt by the patients and that we are delivering the patient-centered care that we pledged when we took our oath.

Holiday Dinner from the Boss

Marney is bossy.  Click to read her instructions for the Thanksgiving Potluck and be glad you aren't invited.

EverythingHealth tip:  Stay out of the stores today.  Rest, play games with the kids, Take a long walk in nature with the entire family and the dog and then drink the rest of the Christmas wine.

Happy Holidays EverythingHealth

I get a lot of pleasure out of being a health blogger and it is only possible because of you, the reader.  Thank you for visiting EverythingHealth and allowing me to keep my mind sharp by researching articles and healthy living for you to read and enjoy.

Merry Christmas, Happy Hanukkah, Happy Holidays, and may we all have a wonderful 2012, no matter where we live on Earth. 

Kwashiorkor in Northern California Means Fraud

Kwashiorkor in Niger

Is it plausible that one small hospital in rural Northern California treated 1,030 cases of Kwashiorkor within a two year period?

Before you answer that, let me explain what Kwashiorkor is.  It is a severe form of protein malnutrition...starving to death actually.  It is the type of starvation you see in African children.  It is so severe that the patient needs special nutritional support including special re-feeding with vitamins and it occurs mainly in children ages 1-4.   Adults can starve to death, but they do not develop classic Kwashiorkor.

Medicare pays hospitals a flat rate based on diagnosis codes for patients.  Patients with more severe coded illnesses get paid at a much higher rate.  Shasta Regional Medical Center, located in Redding, Shasta County, California is under the microscope for billing Medicare (our tax dollars at work) for 1,030 cases of Kwashiorkor to the tune of $11,463 for each diagnosis.  This medical center is a 246 bed facility in a town of about 90,000 people.  The entire county is less than 200,000 population.  The median home price in 2010 was $245,000 and the average household income is $62,222.  Hardly the demographics for Kwashiorkor.

Patient described as kwashiorkor

Prime Healthcare Services owns 14 California hospitals, including the one in Redding.  After they took over the hospital in 2008, the diagnosis of Kwashiorkor exploded.  One of the patients that they billed Medicare for was interviewed and she said she was never malnourished and was never told she had Kwashiorkor.  She had diabetes and kidney failure and, according to her daughter, was actually overweight. There was no notation in her chart about edema swelling or nutritional consult.  She received no vitamins. 

A former medical coder at another Prime Healthcare Hospital told California Watch that she was pressured to write up patients for kwashiorkor if they had low albumin levels and were diagnosed for ordinary malnutrition.  Low albumin is very common in hospitalized patients and it can accompany a number of medical illnesses.  Coding these as kwashiorkor is fraud, plain and simple.

Most hospitals across the Country are doing their best to take care of patients and function with the byzantine regulations of Medicare and hundreds of insurance companies.  The majority of hospitals lose money on Medicare patients.   Flagrant abuse in billing, such as is suspected at Shasta Regional Medical Center, gets no sympathy from me.  I hope the CEO ends up in stripes and that all of the Prime Healthcare Hospitals are closely investigated.

Strange Compulsion

Pica is a medical term that refers to people who eat substances that are not nutritious like clay, dirt, paper or starch.  Lithophagia is the eating of rocks or pebbles.  The Xray above is from a 48 year old homeless man who came to the emergency department with abdominal pain, constipation and intermittent blood in his stool for 2 weeks.  The abdominal Xray showed small radio-opaque pebbles and gravel that the patient admitted eating over the last 9 months.  He believed that "God might turn it to bread in his belly."  He was given the diagnosis of nonspecific delusional disorder.

The patient underwent a purge with polyethelene glycol electrolyte solution.  (It is the same solution that is used for bowel prep before a colonoscopy).  Some of the pebbles had to be manually removed under general anesthesia.  His symptoms improved and follow-up Xray showed compete removal of the stones.  Unfortunately the patient was lost to follow-up after discharge from the hospital.

Geophagia is the eating of clay or dirt and it is not uncommon in the setting of famine and poverty.  There have only been 2 cases of lithophagia reported in the medical literature.

(Case from University of Wisconsin School of Medicine and Public Health, ConsultantLive)

Osteoarthritis

Severe osteoarthritis of the hands

One of my patients came to see me today with severe right knee pain.  This is not a new problem, and in fact, we have been dealing with flare ups of  her osteoarthritis for years.  It mainly affects her knees and hands and today her right knee was swollen and felt like the "bone was rubbing together" with each step. She could hardly walk because of the pain.

Osteoarthritis is also known as degenerative arthritis and it is one of the most common maladies of aging joints, affecting millions of people.  The cartilage in joints wears down and inflammation causes the bones to build up spurs and small micro tears.  It affects women more than men and  the cause is unknown.  There are likely genetic factors as it tends to run in families.  Arthritis can occur in any joint but the most common are the fingers, wrists, hips, neck and spine and knees.  Stiffness (especially in the morning) and pain are the main symptoms that limit mobility.

You can see the bony changes that have occurred over time in my patient's hands. (click on the photo for a better view)  Note the swelling at the wrists and the way the thumbs angle inward.  She cannot stretch those thumbs out and there is wasting of the intrinsic muscles in her hands.  Surprisingly, she was not experiencing any pain in her hands or wrists today, although in the past it has been a problem.  Today it was the knee.

Because arthritis is chronic and affects millions of people, there are many purported "cures" and treatments.  Many of them are a big waste of money.  Here is what has worked for many patients:

• Stay active and keep weight down.  Work on flexibility and range of motion.  For severe arthritis pain, aquatic exercise helps without causing more pain.
• Yoga
• Heat on the painful area alternating with ice as anti-inflammatory.
• There is no proof for the "anti-inflammatory" diet, but eliminating sugar, glycemic white flour and processed foods increases energy levels and helps with weight control.  If you aren't exercising you probably need very few calories and they should be mainly fruits, vegies, grains and protein.
• Trial of gluten free diet
• Pain relievers like Nsaids, tylenol and aspirin can help
• The evidence is still not clear for glucosamine or other supplements.
• Cortisone injections
• Hot tubs/hot baths
• Joint replacement

A cortisone shot will hopefully help this patient and quite down the flare up in the knee.  Osteoarthritis is truly a pain and it requires a lot of attention.

Affordable Health Care Act Provides Senior Benefits

While the courts and politicians wrangle about the Affordable Care Act (ACA, "Obamacare"), some of the benefits have kicked in for Medicare beneficiaries.  The Act empowered the Center for Medicare and Medicaid Services (CMS) to eliminate co-payments for a number of preventative services and to cover services that were not included before.  Patients on Medicare now receive:

• Bone mass measurements
• Cervical Cancer Screening
• Cholesterol and other cardiovascular screening
• Colorectal cancer screening
• Diabetes screening
• HIV tests
• Annual influenza, pneumococcal and Hep B vaccines
• Mammograms
• Medical Nutrition therapy
• Prostate Cancer screening.

Previously Medicare did not cover screening tests or required co-pays.

It's not just seniors who have benefited from ACA.  It also allows young adults to stay on their parents' health plan until age 26 years.  These young adults do not need to live with their parents or be listed as a dependent on the tax return to be eligible.  This alone allows 1.2 million more Americans to be covered by insurance.

Unfortunately people with conditions such as diabetes who cannot find affordable health insurance will have to wait until 2014, when it will be unlawful for insurance companies to discriminate against preexisting conditions.  For now there is a temporary program to act as a bridge for patients until 2014.  There is a preexisting Condition Insurance Plan (PCIP) that can provide insurance for someone who has been uninsured for at least 6 months, has a preexisting condition or has been denied health coverage because of a condition.  For an estimated premium range for a given state, go to HealthCare.gov.

Americans should be embracing health care reform and demanding their legislators come together to understand the complicated law and change it if needed and strengthen it to make it better.  We understand that it does nothing to address runaway costs, although there are many provisions to educate and reinforce healthier diets and lifestyle.  The plan is complicated and includes provisions that few legislators have taken the time to understand.  In the meantime, health plans across the U.S. are posting record profits and raising rates up to 60% a year.  There is nothing that has occurred in the ACA that can be blamed for this. 

As I have said before.  Why do Health Insurance Companies raise rates?  Because they can... and Wall Street rewards them handsomely for doing so.  They are only doing what we have asked them to do. 

Women Don't Need As Many Pap Tests

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin' because new guidelines issued by the US Preventative Services Task Force and the American Cancer Society say women should undergo screening NO MORE OFTEN than every 3 years starting at age 21.  To further strengthen this recommendation, even the American Society for Clinical Pathology (those folks that read the pap smears) agrees with the recommendation.  They also recommending stopping routine pap smears after age 65 for women who have had 3 negative Pap test results in the past 10 years.  These women are just not at high risk.

So why the change?

The pap smear is a screening test for cervical cancer.  Evidence shows that more frequent screening than every 3 years doesn't find more cancer and we now know that cervical cancer is the result of infection with Human papillomaviruses (HPVs).  Women that have not been exposed to HPV are not at risk of cervical cancer.  Furthermore, out of 150 related viruses, of which 40 are sexually transmitted, only certain ones are high-risk, oncogenic (or carcinogenic) HPVs.    Persistent infections with these high-risk HPV types can cause cell abnormalities that are picked up on pap tests.  But the majority of infections with even high-risk HPV types go away on their own and do not cause cancer.  Two types of HPV (types 16 and 18) cause 70% of all cervical cancers and they are very slow growing.

When a pap test detects cervical cell changes, an HPV DNA test is usually done.  If the HPV test is negative, a women is safe from cervical cancer for many years.    Even if a pap test shows equivocal changes, if the HPV test is negative, it is recommended she be re-tested in 3 years.

Despite these recommendations, annual testing remains a common practice in most gynecology offices.  Even in women who have been tested for HPV and found negative, less than 15% of physicians recommended that patients wait 3 years before repeat testing.  Women are still being told to come back annually.

Why?

Some doctors may not know about the guidelines, even though they are also supported by the American College of Obstetricians and Gynecologists.  Doctors as well as patients are in the habit of "the annual pap test".  Doctors are also concerned that if they don't recommend pap smears, women will not come in for an annual exam and other preventive screening.   But doing unnecessary testing is not a way to have women come in.

For most women this will be a welcome change.  Stretching out those gynecologic screening exams will save time, money, false positive tests and unneeded follow-up.   Keep in mind this only refers to non-symptom screening.  Women who have any gynecologic symptoms (unusual bleeding, discharge, pain, pressure) or any other  concern or questions should see their physician.

Fingernails

Let's see how much you know about fingernails?  The arrow points to what part of the fingernail?
1.  Lunula
2.  Eponychium
3.  Cuticle
4.  Nail groove
5.  Proximal nailfold

If you answered #1, you would be correct.  The lunula is most noticeable on the thumb.

Did you know that nails on your dominant hand grow faster than nails on the nondominant hand?  As you age, nails are usually thicker and they grow more slowly.  A six month old will grow a new fingernail in 3 months.  A 70 year old will take twice as long.

Toenails take 12-18 months to regrow.

Photo and info credit to Medscape

Unhealthy Food at Childrens Hospitals

A study published in the journal Academic Pediatrics reveals that 93% of California children's hospitals offered unhealthy food to outpatients, visitors and staff in the cafeteria and snack bars.  Said another way, only 7% offered healthy food.  What did these foods consist of to be called "unhealthy"?  Try fried food, sweetened beverages, burgers and lots of sugary sweets.

The study found that 81% of the cafeterias placed high-calorie, high-sugar items like ice cream right by the cash register, a well known marketing plan to tantalize and increase selection.  Forty four percent didn't even offer low calorie salad dressing and fewer than 1/3 had no nutrition information.

Health care workers, like the rest of America, suffer from increasing obesity.  One study showed over 54% of nurses are overweight and both stress and shift work can contribute to unhealthy eating and weight gain.  If the cafeteria offers high calorie food, it is no surprise that obesity will prevail.  The study didn't mention it, but I wonder how many of these hospitals use contracted food vendors.  Sugar, fat and empty carbohydrates are, unfortunately, cheaper than fresh, nutritious food.  We have seen the results of this in cafeteria school programs across the United States.


This study should wake up hospital administrators and they should choose only vendors that care about and supply healthy food.  If you work at a hospital...check out your own cafeteria and speak up if changes need to be made.

Don Berwick Says Medicare is Wasteful

I was thrilled when Dr. Don Berwick took over as head of the Center for Medicare and Medicaid Services (CMS).  It was a politically charged appointment and the GOP wasn't standing for his type of medicine.  He would have never been confirmed and now he is saying goodbye to Washington.  Dr. Berwick admits Government is more complex than he realized and said "Government decisions result from the interactions of many internal stakeholders-different agencies and parts of government that, in many cases, have their own world views."  Ya think?

He also said the GOP criticism of him and his policies was "purely political, a world of sound bites" and that they "completely distorted his meaning."

Berwick reflected on his 17 months in office and said these are the ways we waste money in healthcare:
1.  Over treatment of patients
2.  Failure to coordinate care
3.  Complex administrative restrictions on the health care system
4.  Burdensome rules; and
5.  Fraud

I would say 9/10 physicians queried would agree 100% with this assessment.  As Berwick says, "Much is done that does not help patients at all, and many physicians know it."  The problem is that patients don't know what is helpful and what is wasteful.  They depend upon our judgment and ethical decision making to know. 

Items 3 and 4 regarding the complexity and burdensome rules placed on caregivers is also true.  The complexity of treating patients is enough without jumping through government and insurance hoops that add no benefit to anyone.  Despite the restrictions, Fraud is rampant and more rules and regulations will not stop it.  Simplify the system and it will be easier to detect fraud.

We truly do need health care reform, not just health insurance reform.  Obama is headed in the right direction by insisting we have 100% coverage for all people...no opt out of the system.  Can we at least agree on that and work together to improve health care for everyone?

Ciao, Dr. Berwick.  Thanks for trying.

Scientists and Tattoos

Prof Datta's  Love Tattoo

A surprising number of scientists have tattoos hidden under their lab coats and these tattoos are examples of their cool geekiness.   Prof Sandeep Robert Datta has a tattoo of a twisting ladder of DNA.  The DNA message spells out the initials of his wife, Eliza Emond Edelsberg.  True love manifested through amino acids that are the building blocks of protein!!!  
Science journalist, Carl Zimmer, posted a blog at Discover Magazine and asked scientists if a tattoo like this was a trend.  Without trying, he became the curator of tattoos and a scholar of science ink.  He found out that many scientist sport tattoos of carbon atoms, DNA, ancient fish, embryos...just about anything that interests them and is meaningful.  He has published a book called Science Ink.

Body ink has been around for thousands of years.  Two hikers climbing the Austrian Alps discovered the freeze-dried body of a 5,300-year-old hunter whose skin was preserved in the ice.  He had tattoos made from fireplace ash rubbed into incisions on his skin.  Ancient Greeks used tattoos as a method of secret identification and communication between spies.  In ancient Asia, tattoos were used to signify rankings in life and tattooing has been among the Polynesian culture for over a thousand years.

Most people who get tattoos find designs that are meaningful or mark a certain passage in life.  I often hear of mothers and daughters getting tattoos together and I find that really charming.  I guess it is no surprise that scientists would use tattoos to signify their work and what is important to them also.

Thanksgiving Idea

Happy Thanksgiving to EverythingHealth readers.

Thanks to KM for this way to appreciate Thanksgiving.  I did it and it only took about 7 minutes.  Here's the concept:

Get a piece of paper or a word doc on your computer.  Write one thing you are grateful for for each year of your age.  If you are older, you have lots of reasons to give thanks.  Don't over think it or try to put it in order of "importance".  No-one has to see it,  but the act of giving thanks for your life is an exercise that will improve your entire being.

Have a great day and Thanksgiving weekend.

Smoking is still a Huge Problem in the U.S.

I live on the West Coast and where is rare to see a smoker.  Because it is not socially accepted,  smokers are not out in the open.  They lurk behind buildings to take a smoke break at work and I don't even own an ashtray for friends because none of my friends smoke.  But San Francisco isn't the rest of America.   In 2010 there were 45.5 million Americans who smoke, with men smoking more than women.  Tobacco remains the single largest preventable cause of death and disease in the United States.  Each year approximately 433,000 people die of smoking-related illness.

Here are some more stats on American adult smokers.  The highest prevalence is American Indians/Alaska Natives (31.4%) followed by whites (21%).  Smoking incidence decreases with increasing education and improved economics.  By region, the Midwest has the most smokers in Oklahoma, Arkansas, Mississippi, Louisiana, Kentucky, Ohio and West Virginia (22-27%).  That is huge.

California and Utah have the lowest percentage of adult smokers at 9-12%.

During 2005-2010 the overall proportion of U.S. adult smokers declined, but not nearly as much as it should have.  Also, the decline (about 3million people) was not uniform across the population.  The study of smokers was conducted by the Centers for Disease Control and Prevention and likely underestimates the number of current smokers.  The fact that more than 1/5 Americans still smoke is a huge problem for our health care system.  Here is a list of diseases that are associated with smoking:

Lung cancer Cancer of the mouth Cancer of the throat Cancer of the larynx Cancer of the oesophagus Stomach cancer Kidney cancer Cancer of the bladder Cancer of the pancreas Liver cancer Cancer of the penis Cancer of the anus Cervical cancer Prostate cancer

Heart attack Coronary heart disease Cardiovascular disease Congestive heart failure Stroke Atherosclerosis Abdominal aortic aneurysm Peripheral artery disease Ischaemic heart disease Angina Leukaemia Emphysema Chronic bronchitis Pneumonia

Asthma Diabetes Stomach ulcers Cataracts Gum disease High blood pressure Crohn's disease Premature aging of the skin Loss of smell and taste Osteoporosis (women) Gangrene Impotence Reduced fertility

I think most people know the risks of smoking.  Nicotine smoke, like inhaled cocaine, moves into the bloodstream and up to the smoker's brain within 7-10 seconds.  It is not a "bad habit", it is an addiction.  But with more than 4000 toxic chemicals in nicotine, it is far worse on the body than other addictions.

Stopping smoking is one of the most healthful things a person can do for themselves.