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.

Thursday, August 1, 2013

Some Doctors Set Their Own Pay

The Centers for Medicare and Medicaid (CMS) sets the rates all physicians get paid and insurance companies base their rates on the same formula.  So who creates the formula?  Well, it's the doctors, silly!  Or at least some of the doctors.  Here's how it works:

A 31 member committee formed by the American Medical Association is made of of representatives from the various specialty societies.   This Relative Value Update (RVU) Committee meets in private and decides how much value each unit of medical work represents.  That unit of work is then assigned a dollar amount and that creates the pay scale.   The catch is that primary care (Internal Medicine, Family Medicine, Pediatrics) is very poorly represented on the committee.  The surgical specialties; anesthesia, radiology and even tiny surgical specialties (like urology or ENT) are equally represented and as a group they get to decide how to value a doctors time and expertise.   This is why primary care has been "undervalued" and underpaid all of these years.  Somehow something done with a scope or a tube or a scalpel is considered many times more valuable than thinking and diagnosing and treating.

This RVU Committee has been criticized for years but no other system has been designed to replace it.  The value that some specialties like ophthalmology and orthopedics are paid has created situations where doctors are paid the equivalent of 12 hours of procedures in a single day.  The panel estimated 75 minutes for each colonoscopy and, according to The Washington Post, one doctor was able to bill for 26 hours of paid work in a single day.  A colonoscopy rarely takes more than 20-30 minutes and most of the work is done by the nurse setting up the procedure.

I have been writing about the fact that fewer and fewer of our brightest physicians are choosing primary care specialties.  This decline has persisted for years and now we have truly reached a crisis point, especially when ObamaCare goes into effect and more people will be seeking care.  It is no wonder that young graduating doctors with $150,000 in school debt would pick a specialty like anesthesia where they could work 8 hours, never be on call, have no practice expense (except a billing and accounting service) and make 4-5 times what an Internist makes.  Thanks to the RVU for the lopsided value they place on medical care. 

Medicare spending is capped.  There is no way to raise the rates for needed physicians (like primary care) unless the value of other services is ratcheted down.  The current RVU Committee is seriously flawed and the time and relative work estimates some of the specialties have come up with is just wrong. Furthermore, this payment method shows no consideration for quality outcomes or value to society. 

The Unites States is the only country where these wide ranges of specialist physician pay is seen.  The Relative Value, as it is done now,  needs to change.




Saturday, July 20, 2013

Answer to Challenge

Harlequin Color Change
The answer to yesterdays Medical Challenge is...drumroll....

#4:  Harlequin color change

Harlequin color change is a dramatic but benign phenomenon in which the color on 1/2  (downward) of an infant turns deep red, while the upper half is pale.  Usually this color change is abrupt and lasts between 30 seconds and 20 minutes, then it resolves.  Up to 19% of infants undergo this color change which occurs between the 2nd and 5th day of life.  It is attributed to a temporary imbalance in autonomic regulation and it is more common among low-birth-weight infants.

The fact that the baby did not have IV lines or oxygen or evidence of being in an ICU pointed to a less serious cause and was the "hint".

The other conditions would indicate a life-threatening condition.
Collodion baby
Collodion baby is a genetic condition that causes the skin surface to crack and completely peel.  It also includes the mucous membranes, eyes and mouth.  It has the same genetic abnormalities as Bullous ichthyosiform erythroderma. Harlequin Ichthyosis is often called collodion baby so there is some confusion but it is quite different from Harlequin color change.

Cutis Marmorata
Cutis marmorata is an extremely rare congenital vascular disorder that affects the blood vessels of the skin and looks like a reticular pattern on the skin.











Wednesday, July 17, 2013

Medical Challenge


 I couldn't resist this challenge from the New England Journal of Medicine.  Make your best guess in the comment section and answer will be posted tomorrow.  One hint:  The newborn baby doesn't have any IV's or tubes inserted. (click on the image for a close up). 

Any neonatal specialists out there?

1. Bullous ichthyosiform erythroderma
2. Collodion baby
3. Cutis Marmorata
4. Harlequin color change
5. Staphylococcal pyoderma

Thursday, July 11, 2013

Delay Cord Cutting in Newborns

A new study has shown that delaying cutting the cord in a newborn baby is associated with better health for the baby because more blood (hemoglobin) passes from the mother to the baby as the cord is still attached.  Prior studies have also shown this advantage but there was a concern of hemorrhage in the mother if the cord cutting was delayed.  Doctors often rush to cut the umbilical cord as soon as the baby is delivered.  This study, published in The Cochrane Database of Systematic Reviews, shows there is no increased danger of hemorrhage  to the mom and the benefit is for the neonate.

The researchers found that babies who had later cord cutting (after one minute) had higher hemoglobin levels 24-48 hours post-partum and they were less likely to have iron deficiency at 6 months, compared to the early cutting babies.

This is especially important in developing countries where anemia is common.  The World Health Organization (WHO) has long recommended waiting 2-3 minutes to cut the umbilical cord to improve the status of the infant.  In the United States, where low iron is not as much of a problem, the American College of Obstetrics and Gynecology (ACOG) has not recommended the early cut practice.  Concerns about jaundice and the longstanding practice of early cutting caused ACOG to say there is insufficient evidence.

Changes in medical practice to not come easily.  It took over 200 years for sailors and seafaring merchants to accept the fact that deadly scurvy could be prevented in sailors by just taking citrus fruit on board long voyages.  Dr. Ignaz Semmelweis proved that hand disinfectant could prevent child bed fever (with a maternal mortality up to 35%) but his ideas were rejected by the medical community and he ended up dying in an insane asylum.  Despite his publishing of a book that showed the death rate falling to under 1% if physicians would just wash, it was decades before his theories were adopted.

We shall see if delayed cord clamping becomes adopted practice in the United States.  In nature, the mother animal (including humans without medical assist) have to severe the cord naturally and that certainly takes a bit of time.  Maybe there is some selection advantage to that delay in the health of the baby.

Saturday, June 22, 2013

Poem - Do Not Resuscitate



Do Not Resuscitate

I can say
your father is dying.
I can say
wishing will not make it so,
belief doesn't change a thing.

I can say
love does not conquer all,
miracles are pretty stories told in church,
the movies you saw as a child are lies,
blind hope is not a recipe for success,
underdogs usually lose,
death is not the worst thing, it is just
the last thing.
But for you that is not true.

I can say
we have to pretend
that we can bring him wheezing
back to you like an old accordion,
chest pleating in and out,
singing his customary songs,
oxygen bumping its hurdy-gurdy way again
through his ancient heart.

But how can I tell you how
someone will shout down the hallway, kneel
frantic on the bed,
lean his fists against that old breastbone, sharp, frail,
one onethousand, two onethousand, and count it out.

I can say
we should not do this.
He will never be the same.
I can say
if it were my father.

I can say
do not confuse resuscitation
with resurrection, although
neither works particularly well.

You look like you are drowning,
pallid and slow in the waiting room's
underwater light.

So. Tell me.
Tell me again.
Tell me about your father.

Brenda Butka, MD


(From Jama, October 24/31, 2012- Vol 308, No. 16)

Tuesday, June 11, 2013

Morning After Pill Now Available Without Prescription

The U.S. Justice Department has dropped its appeal to block a ruling by a New York Federal Judge to allow easy access, over-the -counter purchase of the "Morning After" pill for birth control. The emergency contraceptive, named for women who either got caught without a contraceptive, or the condom broke, is called  Plan B One-Step.  (I guess that is when plan A fails.)  Plan B is a one dose pill of 1.5mg levonorgestrel that reduces the possibility of pregnancy.  It is to be taken within 24 hours of unprotected sex and the drug’s principal effect is to prevent ovulation, but it may also make the lining of the uterus less hospitable to a fertilized egg.

The controversy about Plan B began when HHS Secretary, Kathleen Sebelius, invoked her authority over the FDA, who had approved the drug for purchase from a pharmacy without a prescription.  Ms. Sebelius, in an unprecedented move, stated that prescription dispensing requirements should not be removed for women of all ages.  She believed younger teens should not have access to the pill without a prescription.  Many lawmakers were surprised by this reaction and criticized the Obama administration of placing politics ahead of science.

Margaret Hamburg, FDA commissioner said "There is adequate and reasonable, well-supported, and science-based evidence that Plan B One-Step is safe and effective and should be approved for nonprescription use for all females of child-bearing potential".

The go-ahead for Plan B will be welcomed by medical groups such as the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists and the Society for Adolescent Health.  They had denounced HHS' decision and said, "As physicians who care for our nation's children, it is our responsibility to protect the health of our teenage patients, and an unintended pregnancy can have significant implications for adolescents' physical and emotional health."

Women who have unprotected intercourse have about one chance in 20 of becoming pregnant. Those who take Plan B within three days cut that risk to about one in 40.  According to the New York Times, as of now, half of all pregnancies are unplanned, more than 40 percent of children are born to unwed mothers, and 1.2 million abortions are performed every year involving one in every 50 women of reproductive age.

Margaret Sanger would be happy.

Sunday, June 9, 2013

Answer to Image Challenge



The answer to the image challenge this week is #1 - Atherosclerosis.  Most of you got the right answer because you obviously know that the diagonal crease seen in the earlobe is known as "Frank's sign".  The sign was originally described as a marker for coronary artery disease, with a moderate sensitivity ( approximately 48%) and specificity ( approximately 88%).  Frank's sign has been associated with other cardiovascular risk factors like atherosclerosis.

Good job, readers!  How many of you have looked in the mirror at your own earlobe?

Thursday, June 6, 2013

Komen Suffers For Its Blunder

How do you wreck a beloved brand?  Just look at Susan G. Komen Foundation For the Cure (Breast Cancer) and remember what a well-known brand they had.  From pink ribbons to breast cancer walks and gala events, corporate and individual sponsors were happy to give to such a worthy cause.  The "Race for the Cure" was catchy and easy to promote.

 Fast forward to January 2012 when Komen foolishly bowed to social conservatives and announced they would "defund" Planned Parenthood because of the highly political abortion issue during the last Presidential race.  The Breast Cancer Foundation decided not to pay for screening mammograms for poor women through Planned Parenthood.

The backlash was rapid, strong and widespread on Facebook, Twitter and other social media.  The Komen board of directors reversed their decision within a few days.  Two top executives at Komen Foundation resigned and apologies were rendered.  But that wasn't enough to keep the brand that women loved from becoming an ugly testament to politics and money.

Now Komen has canceled charity walks in seven cities in 2013 and 2014 that failed to meet fundraising goals.  These were previously top revenue sources for the breast cancer charity and drew the most dedicated supporters, many who also support Planned Parenthood.

Many are asking why CEO Nancy Brinker is still at the top of this organization.  Months after the controversy,  Brinker's handling of the situation became a case study in how not to manage a crisis. A press release said that Brinker "plans to move to a new management role focusing on revenue creation, strategy and global growth...when the search for a new senior executive has been completed."  (What doublespeak!  I thought that was the role of the CEO,  but never mind)

That was 10 months ago.  Oh and by the way...she got a 64% pay raise this year.

So maybe it's the economy and financial uncertainty that is affecting Susan G. Komen Foundation.  Of course, the fact that Avon's Breast Cancer walks are proceeding would suggest that the Planned Parenthood debacle is still haunting the organization.  This should be a warning to politicians and organizations everywhere that women will rise up and defend what they believe in.  Social networking brings a new awareness and bonding to the Community of Women.  (my caps!)




Wednesday, June 5, 2013

Medical Challenge

This weeks Challenge from the New England Journal of Medicine is a good one.  Check out the photo (click on it to see closer) and make your best guess as to the diagnosis.  The answer will be posted tomorrow so put your answer in the comment section and check back to see if you are a good diagnostician!

What condition would cause this ear abnormality?

1.  Atherosclerosis
2.  Fabry's disease
3.  Gout
4.  Hashimoto thyroiditis
5.  Ulcerative colitis

Monday, May 27, 2013

Ovarian Cancer Screening

Here is a real case study from American Family Physician with the correct "answers" that may surprise women (and men).  It is a common case in my practice too as more and more women are health conscious and want to do everything possible to detect early cancer.

CASE STUDY

A 35 year old woman presents for a routine well-woman exam.  She is worried about ovarian cancer because one of her friends was recently diagnosed.  She has no family history of breast, ovarian or colon cancer.  What do you do?

Answer:  Based on U.S. Preventive Services Task Force recommendation on screening for ovarian cancer, you advise against screening tests because they do not have good sensitivity for cancer and there are too many false-positive results.  The screening tests like Ca125 and transvaginal ultrasound have not been shown to reduce the number of ovarian cancer deaths.

Keep in mind that these recommendations do not apply to the following women.  Studies show these woman would benefit from those screening tests:
  • A woman with a confirmed BRCA1 genetic mutation
  • A woman with multiple family members who have had colon cancer (Lynch Syndrome)
  • A woman whose mother, sister or grandmother had ovarian cancer and breast cancer also in the close family
  • An Ashkenazi Jewish woman with close family members with breast or ovarian cancer.
I know being advised NOT to undergo a screening test is hard to understand.  Most patients believe if there is a test that could remotely pick up an early cancer, they want to have it.  Unfortunately we just don't have good tests for ovarian cancer.  False positive tests usually lead to removal of an ovary and the harm outweighs the good.   Perhaps in the future we will have genetic biomarkers that will help detect cancer.  Right now we don't.


Monday, May 20, 2013

Blame Bunions on your Genes

Thanks to KM for sending a pic of her bunions (yes, genetic)
There is good news for women who love high heels and pointy toe shoes.  Contrary to what we've been told, they don't cause bunions.  A new study published in Arthritis Care & Research shows that bunions, hammer toes and other toe deformities can be blamed on your parents.  Yes, like so many disorders, it's all in the genes.

The medical name for bunion is hallux valgus and up to 60% of people get foot disorders and foot deformities in later life.  By using heritability software that performs genetic analysis of familial data, the researchers found out that these conditions are genetically passed down.

Before you throw away those Birkenstock sandals, however, remember there is always an interplay between genetics and environmental factors that affect our bodies.  One look at the feet of dancers shows that constant trauma or strange positioning of the foot structures can cause permanent change.

My advice to women who love heels is to walk barefoot in the sand as much as possible and give your feet a good rest.

Thursday, May 2, 2013

Few Americans Understand Basics of New Health Care Law


I wrote last week about the massive confusion about ObamaCare ( the Affordable Care Act) but it seems that it is much worse than I thought.  The Kaiser Family Foundation came out with a poll that shows 42% of Americans don't even know that ObamaCare is the law.  Seven percent of people think the Supreme Court struck it down and 12% think Congress repealed it. 

I understand that there is confusion about the way it will work and who will be affected.  But my advice to Americans is TURN OFF THE DAMN TV.  Really, we are blessed to live in an age where information about any subject is available with the click of a mouse and  people seem to know more about the Kardashians than they do about a health care law that is as important as Social Security or Medicare legislation.

I'm not surprised, however that most Americans said they don't have enough information to understand how ObamaCare will affect them.  The Administration should have hired the same marketing firm that did the superbowl ads or even the clever ads for Dollar Shave Club.  Sure, I get that health care is more complex than a Pepsi ad, but at least doctors and hospitals should have some understanding of it by now.  This is a huge marketing FAIL so far.

According to the Washington Post, the Administration is waiting until the optimal time to roll-out the details.  A public awareness campaign is slated for this summer, as open enrollment will begin in October.  That seems way too late to me.  Helping 30 million Americans understand that they will be buying insurance, making sure there are networks to care for these people, understanding the subsidies that most will get and understanding the various plan options is a huge undertaking and it will be here in 5 months.  I would say ObamaCare is in a pot of boiling water right now.

It is the private insurers (Cigna, Well-Point, Blue Cross, United Healthcare, etc)  that will have the exchange products to sell.  Has anyone ever truly understood their coverage provisions when dealing with these insurance companies?  Now imagine 3 tiers of new insurance products to chose from, with varying co-pays and pricing.  Now imagine covering Americans who don't use computers or have never really dealt with the insurance system.  Now imagine different options being offered in each State.

I would say there is a lot of work to be done by Health and Human Services. 

 

Monday, April 29, 2013

Poison Oak

Photo from Consultant360.com
As the weather heats up and people are hiking and walking animals outdoors, we physicians start seeing the results of a contact dermatitis known as poison oak or poison ivy.  Some of the tell-tell signs for diagnosing this condition is the severe itching, patchy redness that is in certain skin areas only and also notice the linear streak on the top back area of her neck.  That is a classic rhus dermatitis (poison oak) appearance as are clusters of  fluid filled blisters.

Poison Oak is a leafy shrub that grows wild on the West coast.  Poison Ivy grows on the East coast as does Poison Sumac.   It commonly grows like an ivy vine and as summer rolls on the pointed leaves turn orange color.
The rash is caused by a toxic substance in the plant called urushiol.  Brushing against it or touching an object that has brushed against it (dog fur, shoe laces, backpacks, clothing, hats) can cause an extreme allergic reaction.  Like any allergic response, the symptoms get worse with each successive contact and some people are naturally more sensitive.

The insanely itchy rash appears 8-48 hours after contact with the plant but a first time contact can take up to 15 days for a reaction.

Many people with poison oak rash think they are spreading it by scratching because it keeps progressing over days to weeks with new areas of rash.  It is not spread by scratching or touching the skin.  The body is mounting an extreme antibody reaction to the poison and the areas of rash are increasing from the immune response...not from touching it.

The best treatment is avoidance.  Once you have suffered from poison oak/ivy rash, you learn how to be proactive.  But if you do contact it and suffer severe cases on the face, genitals or large parts of the body, it can be treated with corticosteroid medication to block the immune response.  Small areas may respond to steroid creams, antihistamines and cool baths.  Large areas may require an injection or pills.

And never burn poison ivy or poison oak to get rid of it.  The smoke can carry the resin and cause severe inhalation reaction. 
Thanks to patient KM for allowing her poison oak rash to be shared


This site has some good tips on treating poison oak dermatitis.