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.

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  Seven percent of people think the Supreme Court struck it down and 12% think Congress repealed it.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. 

 

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.

Health Care Reform Confusion

If you think you are confused about ObamaCare and what it will mean to you and your family, you are not alone.  Confusion is rampant and open enrollment for the health exchanges is supposed to start October 1.   Yes that is a mere 6  months from now!  Despite this looming date, the various States still don't know what they will be offering and doctors and hospitals also have no idea how it will work.  There seems to be no plan on how to get the word out to the uninsured public.
Most uninsured people don't even know they will have new insurance options under the Affordable Care Act.   If you have insurance now through your employer, not much will change.

Here are some basics that we do know:

• The exchanges will start covering patients on Jan 1, 2014.  Each state will have its own exchange for people who don't have employee coverage.  There will also be a plan for small businesses to offer to employees.  The vast majority of people who have health insurance from their jobs will not see a change.

• There will be three types of exchanges to start: those run by states, those run by the federal government and private partnerships. 

• Patients will be able to pick from a range of private plans and the government will help eligible people with the premiums.  We have no idea what those premiums will be but if the last few years of rising health insurance cost is any indication, it will not be affordable.  Low income people will be steered to safety-net programs like expanded Medicaid.

• Only legal residents of the United States will get help with premiums.

• There are confusing formulas for different plans.  All of the proposed plans have deductibles and co-pays on top of the premiums and people will need to choose their plan based on premium price and deductible.  

• It is unknown which doctors or hospitals will be within the various exchanges or networks because they aren't even formed yet.  Providers are just as confused right now as the general public.

• Insurers will be forbidden to deny health insurance for pre-existing conditions or other health status.

• It is predicted there will be a vast shortage of doctors and clinics to care for the new patients with insurance and the new demands for health care.

• 48 million Americans (15% of the population) have no health insurance now.

Stay tuned over the next few months.  Hopefully some clarity will start to be revealed.

Answer to Image Challenge

psoriasis

The answer to yesterday's diagnostic challenge is...drum roll...
# 3.  Psoriasis.

The scattered reddish, scaly, indurated papules on the lower back and buttocks are psoriasis.  The acupuncture needling of the skin produced trauma that caused Koebner's phenomenon and subsequent psoriatic flare.  This is a rare event and it was treated with a steroid cream.

Thanks for your guesses.  This was a hard one.

What is the Diagnosis?

Today's image challenge from the New England Journal of Medicine is a tough one.  Full disclosure - I missed it.  (bragging rights: I usually get about 99% right) 

This patient had acupuncture to the area and developed these lesions.  What is the diagnosis?
1.  Herpetic whitlow
2.  Nummular eczema
3.  Psoriasis
4.  Ringworm
5.  Scabies

Click on the image for a closer view and make your diagnostic guess in the comment section. The winner gets a free subscription to EverythingHealth.   Check back tomorrow for the answer! 

Fake Drugs

In Africa drugs are sold without proper handling or control

Unfortunately many of the drugs that enter the United States (and other Countries) are fake.  Research shows that more than half of the drugs sold by online pharmacies may be fake. Globalization of the pharmaceutical manufacturing industry and distribution system is contributing to the problems of false and substandard drugs. 

A clinic in Burma with unregulated drugs

And low and middle-income countries are the hardest hit by these falsified drugs.  Many patients in these countries are forced to buy their medications from poorly regulated markets and some of the drugs they buy are useless...or even worse, toxic.  Substandard drugs in developing countries have contributed to the emergence of drug resistant malaria and tuberculosis.

More and more people in the United States are buying medications on-line, hoping for a price break from the exorbitant cost of pharmaceuticals.  The best way to ensure that you are dealing with a reputable pharmacy is to verify it with the NABP (National Association of Board of Pharmacies) Verified Internet Pharmacy Practice Sites.  You can find that website here.

Meat and Heart Disease

We have known for decades about heart disease and the effects of red meat and saturated fats being a cause of elevated cholesterol.  But we've also known that is not the whole story and now surprising new research is pointing to gut bacteria and the actual chemical that is produced by meat as the culprit for heart disease. 

Carnitine is found in red meat and is also used by body builders as a supplement for energy.  Researchers have found that in the intestinal tract, bacteria convert carnitine into a metabolite called TMAO and TMAO promotes thickening of the arteries.  Steak consumption caused subjects in the study to immediately produce large amounts of TMAO.  Vegetarians did not produce the chemical.

Many people who become vegetarian say that they can no longer digest red meat.  It turns out that they actually lose the ability to metabolize carnitine over time because they do not develop the gut bacteria that meat eaters have.

How did the researchers know it was the gut bacteria?  They gave the study participants large doses of antibiotics to wipe out the normal flora in the intestinal tract and then none of the meat eaters or vegetarians produced TMAO after eating steak or taking carnitine pills.

The researchers from Cleveland Clinic, examined record of 2595 patients who had undergone cardiac evaluations and found that patients with high levels of TMAO and carnitine were the most likely to develop heart disease, heart attacks, strokes and death within the next three years.

"Cholesterol is still needed to clog the arteries, but TMAO changes how cholesterol is metabolized-like the dimmer on a light switch," said lead author Stanley Hazen.  "This may explain why two people can have the same LDL level, but one develops cardiovascular disease and the other doesn't."

It would appear that carnitine alone is not the problem but a regular diet of meat creates the gut bacteria that break carnitine down into TMAO.  Vegetarians and meat eaters have very different gut bacteria.  TMAO may be a waste product but it is significantly affecting cholesterol metabolism and deposition into arteries.

What should you take from this study?

• The Mediterranean diet is still the most heart healthy diet.  (Small amounts of meat and red wine; grains and vegetables in large amounts. Avoid processed foods)
• Try to eat only organic local farmed meat and chicken.  It takes an effort but is worth the time and money to avoid antibiotics, growth hormones and horrible animal conditions.
•  Never take carnitine supplements or energy drinks.
• Small amounts of meat means no more than 4-6 oz.  Think about that the next time you think about steak. 

Unhappy Nurses

I am sad to read that a new survey reported in Forbes shows that nurses are the 4th most unhappy profession in the US.  The survey evaluated 10 factors of the workplace including  work environment, relationships with co-workers, compensation, and control over one's daily responsibilities.  They required at least 50 employee reviews to qualify in a category.


 Careerbliss  found out that associate attorneys are the most unhappy followed by customer service associates, clerks  and coming in 4th on the unhappy scale was the registered nurse.  Equally sad was that teaching came in 5th on the unhappiness scale.

What workers were most happy?  Number one was Real estate agent followed by Senior Quality Associate Engineer.  Sales Reps and Construction Superintendents were also happy in their jobs.

Overwork, lack of opportunity for advancement and poor workplace culture were the biggest factors in the dissatisfied categories.  Nurses were most unhappy with the workplace culture and the people they worked with. We can only guess that that means doctors, other nurses and administrators.  Teachers, on the other hand were happy with their work and the people they work with.  They were dissatisfied with rewards for their work,  lack of support and lack of growth opportunities.

Nurses are the unsung heroes of health care.  Not enough attention is paid to increasing their satisfaction and professionalism.  This small survey should ring some alarm bells, somewhere.

Tuberculosis Made Easy

Tuberculosis (TB) is a contageous infection that is caused by a bacterium called Mycobacterium tuberculosis. One third of the world population has been infected with TB and it caused over 1.5 million deaths in 2010.  We don't hear as much about TB in the developed world but new infections in third world countries occur at a rate of about 1 per second.    Risk factors for TB are:

• A weakened immune system such as diabetes or HIV
• Working in health care or refugee camps
• Traveling to countries where TB is endemic
• Living in overcrowded situations or extreme poverty

 The disease usually affects the lungs and is spread when people cough or sneeze and spray moisture droplets.  In the old days, TB was called "consumption" and at the turn of the century it was treated by isolating patients in sanitariums for months to years and hoping they recovered. In the 19th Century, TB killed more people in New England than any other disease.

Active TB is when a person has symptoms (fever, cough, night sweats, fatigue, wasting) and has a positive ppd skin test.  These people can spread the bacteria.

Latent TB is when a person with no symptoms has a positive ppd skin test and the bacteria is in a dormant or inactive state.  These people are not contagious.  A chest XRay can distinguish between active and latent TB.

We treat patients who have active TB with antibiotics and treatment usually lasts for 6 months to get rid of the infection.  Persons with latent TB are also treated as a preventive for the infection flaring up again.  Multidrug-resistant TB is a form of active TB caused by bacteria that do not respond to the medications most commonly used to treat TB.

Health care workers, child care workers, home-care professionals and immigrants should all have regular ppd tests to make sure they have not been exposed to TB.  Once a ppd test is positive, it will always remain positive, even if the infection has been treated and resolved.

Ten Sleep Facts That May Surprise You

I think we all know that sleep is not only beneficial for good health, but lack of sleep can lead to a number of serious disorders and diseases.   Here are ten sleep facts that may surprise you:

1.    When we are awake our brain cells produce adenosine as a byproduct. The build-up of adenosine in the brain is thought to be one factor that leads to our perception of being tired. (Incidentally, this feeling is counteracted by the use of caffeine which blocks the actions of adenosine in the brain and keeps us alert.)

2.    Older adults need about the same amount of sleep as younger adults (7-9 hours) but seniors go to bed earlier and wake up earlier than when they were younger.

3.     We dream only during REM (Rapid Eye Movement) sleep but get the deepest sleep during non-REM cycles.

4.     It is not only important to get sleep to learn, but it is also important to get good sleep after we learn something new to process and retain that knowledge.

5.     Insomnia is the most common sleep disorder after age 60.  People with insomnia have trouble falling asleep and staying asleep.

6.    Major restorative functions in the body like muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep.

7.    Hitting the snooze button makes getting out of bed more challenging than simply getting up with the first alarm, because a few more minutes of shuteye causes the brain to enter a deeper sleep cycle.

8.    Losing just a few hours of sleep a week - similar to the effects of jet lag or cramming for final exams - can lead to almost immediate weight gain.  The good news is getting extra sleep can cause those pounds to shed.

9.    Recent studies show that daylight savings time increases risk of getting into an accident by 11% and your risk of myocardial infarction by up to 10% in the three weeks after the change.  To get used to the change, experts recommend soaking in the sun in the evening with the later sunset,  getting some exercise and going to be earlier.

10.   Residents in the Southern U.S. states experience the most sleep disturbances and daytime sleepiness, according to a new "sleep map" that outlines how geography can influence sleep patterns.  Residents of the West Coast report better sleep.   Check out the sleep map here.

Here is something I just learned this week.  If you have an iPhone with Siri (4S or later) you can ask Siri to wake you in the morning at a specific time.  It is a great alarm.

Blogger Malaise

For the past few weeks I have experienced Blogger Malaise.  This is a little different than writers block.  I have had a number of subjects swirl through my head that I thought would be of interest, but had no motivation to translate them into a thoughtful blog.  As each day went by I made excuses not to do the research and writing.  I even started feeling a little sorry for myself and wondered if I should even continue blogging.

It didn't take much to re-inspire me, however.  I got an email from an old patient I haven't seen or heard from in years who mentioned a blog that helped her tremendously. (Thanks, Lynn).  Today at a management meeting I got unsolicited, kind,  blogging feedback from people I seldom see. (Thanks, Shaun, Richard and Susan).  And my stats show that even without writing for the past couple of weeks, I still had 2700 page views yesterday so I realized people are reading the blog and, hopefully, getting something from it.

That is all I need as a health blogger.  People ask me what I get out of this and I truthfully say I want to share information and help readers think about new things.  If I can inspire someone to get a check-up, a needed test or even self diagnose and save themselves money and time, I believe I have done a service.  If they learn something about our crazy health system that helps them with decision making, I am happy.  If they see the world differently or realize that everyone is facing some type of challenge, I have succeeded.

Blogging keeps my mind sharp and as Shaun (a communication expert) said today "Mindful blogging is darn hard".  It is.  But it's fun too.

Thanks for reading.   (Insert happy face here!)

Ascaris Lumbricoides

The answer to yesterday's Image Challenge was #1 - Ascariasis

Ascaris lumbricoides worms were causing intestinal obstruction in this child from Kenya.  After the intestine blockage was removed, the child recovered.

Ascariasis is a disease caused by roundworms.  The parasite, Ascaris lumbricoides  is one of the most common infections in the world and it affects up to one fourth of the worlds population and up to 95% of Africans are infected with roundworms at any time.   The life-cycle of this parasite is amazing.

Infection starts when food contaminated with Ascaris eggs from feces are swallowed.  the larvae hatch in the intestine, burrow through the gut wall and migrate to the lungs through the blood system.  They then pass through the alveoli, up the trachea and esophagus where they are coughed up and swallowed.  They then pass through to the stomach for a 2nd time into the intestine where they mature into adult worms,  Adult worms have a life-span of 1-2 years.

The adult worm can be from 6-13 inches and the female worm may be as thick as a pencil.  Up to 100 worms could potentially infect the human body.

A person could be infected with Ascaris lumbricoides and have no symptoms.  In heavy infections symptoms may be vague abdominal pain, coughing, wheezing or pneumonia when they are in the lungs, or complete blockage of the small intestine.

Diagnosis can be difficult until the worms are adults, but stool samples showing eggs or live worms will make the diagnosis.  Treatment with mebendazole, albendazole, or pyrantel pamoate are effective to eradicate infection but where there is poor sanitation, re-infection is common. 

When we see these gross pics, it is hard to believe that this infection is so common in the world.  Remember that over 40% of the world's population does not have  good sanitation.  That is 2.5 billion people and women in developing countries walk an average of 6.5 kilometers ( almost 4 miles ) each day just to get water.

Image Challenge

In keeping with our GI theme this week, I present to you this image challenge from the New England Journal of Medicine.  This is a loop of bowel removed from a child from Kenya.  In case you aren't familiar with the appearance of bowel, I can tell you this is not normal.  What is the diagnosis?
Make your best guess in the comment section and I will post the answer tomorrow.

1.  Ascariasis
2.  Kala-azar
3.  Meckel's diverticulum
4.  Strongyloidiasis
5.  Trichobezoar

Click on the Image for a better view and go for it!

Fecal Microbiota Transplants

Yes, you read it right.  I said "Fecal Transplants".  It may sound disgusting but there is increasing evidence that placing a healthy patient's feces inside the GI tract of a patient with Clostridium difficile gut infection may be the wave of the future.  And it shows just how important our normal gut microbe flora is for good health.  Here is how it works:

Our GI tracts are colonized by hundreds of microorganisms at birth as we pass through the mother's birth canal.  These bacteria live in  balanced homeostasis, helping digest food, helping absorb Vitamin K and Vitamin B complex and helping our immune response.  When this balance is upset with antibiotics, Clostridium difficile bacteria overgrowth can occur.  Clostridium difficle infection is serious and it is the most common cause of hospital acquired diarrhea and often leads to severe illness and death. As patients are treated with yet more antibiotics to eradicate the infection a month later recurrent C. diff  can commonly return.

Fecal microbiota transplantation involves taking stool from a healthy donor (a relative is best) and instilling that stool into the GI tract of the infected patient.   The donor is screened for HIV,  hepatitis, syphilis, parasites and C difficile.  The stool is made into a slurry with saline in a household blender and then instilled into the patient.  This can be done with a nasogastric tube directly into the stomach or placing it in the colon with a colonoscope or enema. A recent multicenter long-term follow-up study showed that diarrhea resolved within 90 days after fecal transplantation in 91% of patients.  Some patients also reported to have improvement of preexisting allergies and peripheral neuropathy and other autoimmune diseases.   And a study published in the New England Journal of Medicine in January, 2013 showed infusion of donor feces was significantly more effective for the treatment of recurrent C difficile infection than the usual treatment with Vancomycin.

The Human Microbiome Project is focusing on understanding the role of human genetic and metabolic bacteria that may help other diseases such as inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, rheumatoid arthritis and sjogrens syndrome.  These early trials point to the benefits of millions of microbes in our bodies and one can't help but wonder about our factory farmed animal food supply that is so injected with antibiotics and how that may contribute to disease.

Fecal transplants make a lot of sense as we appreciate more and more how important it is to have healthy gut microbes.  To keep your gut healthy please:

1.    Avoid antibiotics unless necessary for a known serious bacterial infection
2.    Buy only organic, local farmed meat and poultry that has not been fattened with antibiotics
3.    Eat more fiber, fruits, vegetables and legumes
4.    Drink water between meals

Price of Health Care a Mystery for Patients

You have a $5000 annual deductible and need a test or treatment.   It should be easy to find out upfront what it will cost, right?  Good luck with that one!

I've written before about the problems with health care price transparency and hidden costs but there hasn't seemed to be much improvement over the years.  A new study published in the Journal of the American Medical Association (JAMA) found that only 16% of hospitals surveyed were able to provide an estimate for the total cost of a hip replacement procedure.

The researchers surveyed 122 hospitals covering all 50 States and asked each hospital to estimate the cost of a hip replacement for a 62 year old, uninsured individual who would pay "out-of-pocket".   They found that:

• Only nine of the 20 orthopedic hospitals and 10% of the other hospitals could provide a full cost estimate for hospital and physician fees after a minimum of five phone calls;
• 12 of the orthopedic hospitals could provide a complete cost estimate after the researchers contacted the hospital and affiliated physicians separately; and
• 54 of the remaining hospitals could provide a complete cost estimate after the hospitals and affiliated physicians were contacted separately.
• Many of the people they asked at hospitals seemed perplexed with the question and many times researchers were told they needed to make an office visit just to get an estimate.

Now are you ready for this?  The cost estimates varied from $11,000 to more than $125,000.

It is unlikely that they were comparing apples to apples.  Some estimates failed to cover physician fees or all costs but still, the question was quite simple and direct.  They also found no correlation between high cost and top-ranked hospitals and there is no data that shows certain high cost hip implants were better than cheaper options.

There is no way consumers can be "market driven, cost conscious" if they can't get accurate pricing information. And there is really no justification for the price variance.  It can't be explained by quality outcomes or any other measure.

If you live in the USA, you cannot be an informed consumer of health care. 

Technology and Health Care

One of my tennis friends asked me about new innovative smart phone technology and why it hasn't been embraced in health care.  She had just watched a video about Dr. Eric Topol, Chief Academic Officer at Scripps Health in San Diego, and his demonstrations of how a smart phone could monitor blood sugar, take EKGs and cardiac ultrasounds and really deliver health care to the patient at home. 

My friend's question; "If this technology is here, why isn't it being used?"

According to Dr. Topol, new apps for the smart phones could eliminate 80% of echocardiograms that are done in facilities at costs between $300-$1500 each.  Having patients come into the office when they experience symptoms or for diabetics to get their blood sugar regulated could be eliminated.  New technology could be data driven and personalized and save millions of wasted dollars in health care.  So why is medicine so far behind the innovation curve?

The answer:  No-one pays for it. 

Why aren't all physicians using email to communicate with patients and save them an office visit?  The  politically correct answer is "remote medicine is not as good as seeing the patient in person and making sure the diagnosis is correct".  The real answer is:   No-one pays for it.

United States health care has complicated payment systems for work done.  The payor for health care services is either Medicare/Medicaid (CMS)  or hundreds of different (for-profit) insurance companies.  CMS sets the payment rules that everyone follows.  Medicare and all insurers will only pay for face to face visits.  Reimbursement is for doing more and the more you do the more you get.

The doctor that tries to save a patient time and travel by covering a number of problems in one office visit will not be rewarded and, in fact, will be reimbursed less.  If you do a skin biopsy on the same day you do a visit for arthritis flare, CMS and insurance companies will not pay for both things.   Do them on separate face to face visit days and...voila...a better reimbursement for your time and skill.

Email, remote monitoring, remote echocardiograms, discussing tests via a smart phone are freebies.  No patient visit means no reimbursement.  The cost of putting in high technology is borne by the physician too.

Most physicians and hospitals and surgery centers and labs and pharmacies are happy with this status quo.  There is great fear of change and so we continue to spend more on health care than any Nation in the world.  We do wasteful mass screenings and 1/3 of all prescriptions are a waste.  People who need care are not getting it and others are getting too much that they don't need.

ObamaCare is trying to make some gradual changes by supporting pilot programs to change the way healthcare is delivered.  But it is slow going and innovative answers are out there.  If we could just figure out how to pay for services, while using new cost-saving technology we would all be following Dr. Topol's future dream.

New Info on Tennis Elbow

New information has come out on what works and what doesn't work for lateral epicondylitis...aka: tennis elbow.  A new study published in JAMA will change how we have treated this condition for decades.

Being a tennis player myself, I have suffered from this condition.  The outside elbow, where the lower arm tendon inserts on the epicondyle bone gets inflamed and swinging a racket or even lifting a carton of milk out of the refrigerator can cause excruciating pain.  This is a very common condition and can be caused by any repetitive motion of that muscle.  One of my patients got it from clipping roses.  Traditionally the treatment is anti-inflammatory medication (ibuprofen, aleeve), ice and rest.  For serious cases, physiotherapy and injection with a corticosteroid has always proved effective in my practice.

The researchers found, however, that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for re-injury at 1 year relative to placebo. Eight weeks of physical therapy appeared to have no long-term benefit with the exception of decreased analgesic use.

The researchers compared corticosteroid injection with placebo injection and found no difference at one year.  The corticosteroid injection did reduce pain at four weeks compared to placebo injection.  At 26 weeks that corticosteroid injected patients did worse than the placebo injection.  Physiotherapy patients had better pain relief at 4 weeks but no difference at one year.

How can we explain these results?  The decreased pain relief at 4 weeks may have allowed the patient to resume activity or engage in excessive activity before the healing was complete.  Pain is the body's way of telling us to do something different. 

The take home message here is that we need to be willing to change our treatment modalities as new evidence is presented.  Lateral epicondylitis is a condition that will benefit short term from physical therapy and corticosteroid injections should not be done.  As difficult as it is for a tennis player, resting the tendon and allowing the body to heal is the best medicine.

Baby Boomers Health Lags

The baby boomers are strictly identified as being born between 1946-1964.  The boom lasted 19 years and delivered 76 million total births.  "Leading Edge" boomers were between 1946 and 1955.  They were the generation that were the wealthiest, most active, and most physically fit generation that had ever lived.  They were special and expected to have better lives than their parents.

Well, those leading edge boomers are now middle age and getting AARP bulletins.  And a new study published in The Journal of the American Medical Association  reveals their overall health status was lower than prior generations, with only 13.2% reporting 'excellent' health compared with 32% of individuals in the previous generation (P < .001). To really paint the picture, researchers reported more than twice as many baby boomers used walking assist devices (6.9% vs 3.3%), more were limited in their work by disability (13.8% vs 10.1%), and 13.5% vs 8.8% were coping with some type of functional limitation.

But wait...that's not all.

In addition, more baby boomers are obese compared with the previous generation (38.7% vs 29.4%), and they reported exercising significantly less often (35.0% vs 49.9% exercised >12 times per month). In fact, more than half the baby boomer respondents said they engaged in no regular physical activity (52.2% vs 17.4%). 

How can this be? The baby boomers have the benefit of great scientific research, all the health information in the world available on the internet and they are fat and sedentary?

These same baby boomers make up 26.1% of the U.S. population. That is a lot of unhealthy people.

So if we piece this study together it means that these baby boomers may live a few years longer than prior generations but they are more likely to suffer chronic illness and be unable to care for themselves.

As a baby boomer myself,  I find this study to be alarming and depressing at the same time.  It's not too late for boomers to save themselves and save their children from the burden of caring for them.  They can start with learning the toxic effects of sugar and pre-packaged foods.  Instead of going to Wallmart and buying more stuff we don't need, how about starting a rooftop garden or a walking group with friends.  Buy a pedometer and a blood pressure monitor and take charge of your health.

I know this sounds preachy but this is just plain "messed-up" (as my 17year old would say). Baby Boomers, save yourselves!  I don't want to watch everyone in an electric cart as I get older and I know there won't be enough doctors to take care of all of the chronic disease.

DNA Proves Inocence

Source: TopCriminalJusticeDegrees.org

Health Benefits of Coming Out

Sometimes we need a study to tell us what is obvious.  A new Canadian study published in Psychosomatic Medicine shows gays, lesbians and bisexuals who "come out" about their sexuality are less anxious, burnt out and depressed than those who stay in the closet.  AND they are even less anxious than straight people of similar age!

The researchers studied 87 men and women around 25 years old of various sexual orientations.  They measured stress hormone levels, 21 bio markers related to immune function and symptoms of depression and found that the subjects who were open about their sexuality were the most mentally healthy compared to those who were still in the closet.   Gays and lesbians who were honest with family and friends about their orientation no longer had to live a double-life and pretend to be something they weren't.

This study helped explain another study published last year in the American Journal of Public Health.  That one found that after Massachusetts enacted its same-sex marriage law in 2003, there was a significant drop in medical and mental health care visits by gay men.  Of course costs also went down.

It isn't a surprise that living an authentic, honest life and being open with one's values is a building block for emotional and mental health.  It is stressful to lie, hide or feel ashamed about one's self and stress hormones are released that contribute to anxiety, depression and even heart disease.  I see patients all the time that are ill because if "dis-ease" more than disease.  When we push feelings inside and don't deal with problems directly, it manifests in impaired immune systems, poor sleep, anxiety and disease.

So now we have at least two studies that show living honest, authentic lives are associated with better health.  I think we knew that all along.

I Love My Blog

Thanks to my faithful blog reader, KM, for reminding me that I have been blogging for six years.  I can't believe it has been that long but I love being a health blogger and interacting with readers and other bloggers across the globe. 





Recent visitors to EverythingHealth have come from Indonesia, Mexico, Australia, Taiwan, Hong Kong, India, South Africa, France, UK, Germany, Dubai, Turkey, Pakistan, Costa Rica, Kenya, Italy, Brazil, Malaysia, Singapore, Philippines, Canada, Uganda, Kuwait, Poland, Norway  and of course, the United States.

Shame on the U.S. Congress

 The U.S. Congress has an approval rating at less than 5%.  In fact, porn, polygamy and the BP oil spill rate higher than Congress.  Pakistani President Asif Ali Zardari's rating within his country in 2011 was twice as high as the U.S. Congress current approval rating.   And this was before the New York Times shined a light on their shady dealings with pharmaceutical giant Amgen that cost the American people more than 1/2 billion dollars.

Millions of dollars spent by Amgen, who has 74 lobbyists in Washington, kissing up to members of congress has come back to them in a nice gift...with a bow.  Our trusted public servants were happy to help Amgen by delaying price restraints on a class of drugs used by kidney dialysis patients.  They inserted this paragraph into the fiscal cliff bill and, behind closed doors, approved it.  The delay will cost the Medicare program (and your tax dollars) $500 million over the next two years.

Note that Senator Max Baucus (D, Montana) and Orrin Hatch (R, Utah) supported this shady transaction.  Both senators have political and financial ties to Amgen, as does Mitch McConnell, the senate minority leader, who also influenced the deal.  These three senators received substantial contributions from Amgen's PAC, $68,000 to Baucus, $59,000 to Hatch and $73,000 to McConnell.

If this isn't enough to mimic flu symptoms, Amgen had pleaded guilty a few weeks before and agreed to pay CRIMINAL and civil penalties of $762 million, the largest fine ever for a biotech company.  You would think that would make them persona non gratis on capitol hill but no...they have friends in high places!

Really Happy CEO

Amgen's CEO, Kevin Sharer's pay package is $21 million.  That doesn't include his personal use of Amgen's jet ($247,743) a car and driver and $15,000 for financial planning services.  After all, with that kind of money, you need to find lots of tax loopholes to keep it.  How a company can plead guilty to CRIMINAL activity and then get the taxpayers to pay 75% of the fine is amazing.  I guess Corporations really are "people"...special people with friends in the Senate.

The next time you wonder about the price of healthcare in this Country, think of our policymakers and how crooked and dishonest they are.  The Fiscal Cliff was a Fiscal Gift for Amgen.

Herpes Simplex

The answer to yesterday's Diagnostic Image Challenge was #2 Herpes Simplex virus infection.



  The usual mouth Herpes Simplex looks more like this:

Oral Herpes is also called Herpes Labailis or cold sores.  Herpes is a virus that can occur anywhere on the body but usually appears on mucous membranes.  Most people are exposed to the Herpes Virus 1 (hv1) by the time they are 10 years old.  The virus can lay dormant in the body and emerge at times of stress, radiation (sun) exposure, or other illness.   The symptoms can cause malaise, tingling followed by pain, swollen lymph glands and generally last about 10 days. Antiviral medications like acyclovir and valtrex are very effective for prevention and for shortening the time of an outbreak.

New Strain of Norovirus Hits

A new strain of Norovirus has hit the United States with a vengeance.  The Centers for Disease Control (CDC) reports it is from Australia and was first detected in March 2012.  The new strain is proving to be very fast spread and virulent.  It is called GII.4 Sydney.  During the last 4 months of 2012, GII.4 Sydney accounted for 53% of 266 norovirus outbreaks in the United States reported through an electronic laboratory surveillance system called CaliciNet. About  half of the new virus outbreaks resulted from direct person-to-person transmission; another 20% were foodborne.

Norovirus comes on suddenly and causes nausea, strong vomiting, diarrhea and abdominal pain.  It is highly contagious and spreads easily in closed environments like cruise ships, day care, nursing homes and military barracks.  Norovirus is most prevalent during the winter months and is the most common cause of gastroenteritis or food-borne illness. 

What can you do to protect yourself against Norovirus or other types of food poisoning?   Most importantly, washing hands with soap and water, disinfecting surfaces, rinsing fruits and vegetables, cooking shellfish thoroughly and not preparing food or caring for others while ill.

For everything you ever wanted to know about Norovirus...go here

What's the Diagnosis?

It's time for you to play doctor (or if you are a doctor, prove your skill) by making the correct answer on the  New England Journal of Medicine Image Challenge.  What does this patient have?

1.     Hand-foot-mouth disease
2.     Herpes simplex virus
3.     Herpes Zoster virus
4.     Folliculitis
5.     Scalded skin syndrome

Click on the image for a better view and post your answer in the comment section.  The diagnosis will be posted tomorrow.