Sunday, April 29, 2007

A Bump on the Head

Even a minor blow to the head can lead to serious trouble. A close relative of mine is an active, sharp guy in his 80's. He was hospitalized a few weeks ago with an infection and like many older folks, he wasn't aware of how weak he was and he tried to get out of the hospital bed and go to the bathroom and "whoops", he slipped and fell. Hospitals all have procedures in place to prevent falls and they monitor the number of patient falls and try very hard to get to zero. But, try as they do ...falls happen. OK, he got a bump on the forehead and a bruised shoulder but, fortunately no broken bones.

Fast forward 4 weeks. One weekend Allen was slurring his words and not walking well. You would think they would rush to the hospital to get things checked out, but they decided to wait and see if he was better the next day. This is a HUGE mistake. In a prior post I wrote about stroke and the need to seek immediate attention for any change in speech or one sided weakness. I am always surprised at how many patients do not seek medical help and instead wait to see if things will improve on their own. Ten out of ten times, symptoms like this do not improve.

Allen and his wife finally went to their doctor and he was immediately admitted to the hospital. A computed tomography (CT) scan revealed a large hematoma on his brain. The fall that occurred several weeks earlier had caused bleeding around the brain. Blood vessels can be damaged when the skull receives a blow, especially when the head hits a hard surface like the pavement. A hematoma is caused by a bleeding vessel and a subdural hematoma occurs when blood collects in the small space between the brain and the skull. The blood clot presses against the brain and the resulting pressure can severely damage the brain unless a neurosurgeon removes the blood. Fortunately, blood and blood clots are easy to detect with a CT scan.

After the subdural hematoma was diagnosed, Allen was rushed to surgery and the blood clot was removed. He has a large "s" shaped scar where the skull was removed (and replaced) and he is now home and doing great. His speech is back to normal and he continues to improve each day. Without surgery, Allen would not have made it. It is always nice when a story has a happy ending.

There are several take home messages here:
1. Any sudden change in speech or weakness or trouble walking needs immediate attention at the Emergency Department of the closest hospital.

2. Any fall that causes facial bruising or loss of consciousness needs evaluation.

3. Any time the head smacks against a hard surface, there is a chance of brain trauma because the brain can strike the inside of the skull.

4. Symptoms can show up weeks after trauma so don't ignore changes in personality or behavior, especially in older folks.

Saturday, April 28, 2007

Update from the Medical Journals

This should be welcome news for all those parents who have been saying "Stop playing those video'll never amount to anything...."

Impact of Video Games on Training Surgeons

Surgeons in the 21st century need to have different skills than in the past. Laparoscopic surgery requires a different hand/eye coordination that is similar to the equipment maneuvers and screens that kids use in playing video games. Researchers looked at the link between playing video games and surgical skill and suturing. They did an analysis of the performance of surgical residents and attending physicians with past experience with video games and current level of play. They controlled for the number of laparoscopic cases performed , their level of surgical training and the number of years in medical practice.
Guess what? They found that video game skill and experience are significant predictors of laparoscopic skills. Past video game play in excess of 3 hours/week correlated with 37% fewer errors, and 27% faster completion of surgery. They concluded that video games may be a practical teaching tool to help train surgeons.
Note to kids: You still need organic chemistry, physiology and anatomy to be a surgeon so listen to your mom when she says turn off the Xbox and get back to studying!
Archives of Surgery

I have sent a number of patients to the neurosurgeon for epidural steroid injections in the hopes their severe back pain and sciatica would be relieved. So much of what we do is not backed up with evidence.

Epidural Injections Benefit for Back Pain Questioned

Giving epidural corticosteroid injections to treat back pain has been an increasingly common practice over the past 50 years. There have not been rigorous studies that prove the effectiveness and safety of this expensive procedure. An analysis of studies that covered 300 patients found that there was no benefit at 24 hours postinjection, at 3-6 months or 1 year later.
The epidural steroid injections had no impact on patient's day-to-day functioning, need for surgery, or long-term pain.
The authors recommend future studies of epidural injections compared with other therapies to more accurately determine the degree and duration of pain relief.

I love these maggot reports. Once you get past the "eeew" factor, it makes sense.

Return of the Maggots
Staphylococccus aureus is a common skin bacteria that is becoming more resistant to antibiotics. When a diabetic patient gets a resistant Staph foot ulcer, they are difficult to treat and often require surgery and long treatment with IV antibiotics.
Researchers applied larvae (maggots) of the green bottle fly to ulcers on 13 patients (aged 19-80 years) for four days. The infection was completely cleared after two to eight maggot applications in all but one patient. No adverse events were reported by any of the patients.
Maggot treatment is the first non-invasive and risk-free treatment of this increasing problem.
Diabetes Care

Thursday, April 26, 2007

EverythingHealth Depends Upon a Clean Environment

I took these photos last year in Alaska. We saw the melting icebergs up close.

It is so great to hear someone like Lee Iacocca admit that Vice-President Al Gore had a major impact on him and he is now hip to the reality of global warming and the fact that American needs a real energy/environmental policy. If the former chairman of Chrysler Corporation, the origin of America's love of gas guzzling SUVs, can admit Hybrids are the future, there is hope that America can develop a new energy economy. A quote from his new book "Where Have All the Leaders Gone" says "Stay the Course? You've got to be kidding. This is America, not the damned Titanic. I'll give you a sound bite. 'Throw the bums out'"

A recent study conducted for the Center for American Progress found only 27% of people feel that our current energy policy is headed in the right direction, while 65% say our energy policy is seriously on the wrong track. A majority of Americans believes the U.S. is either falling or has fallen far behind other countries in developing clean, alternative energy.

A group of environmental entrepreneurs have created a web site, to host online forums where voters can study the Republican and Democrat candidates policy positions. Voters need to keep asking the candidates about their views and policies on the environment. Individually we can make changes in our lives that support energy conservation,(start with Frankly Green and EcoFabulous), but that is not enough. Our Government needs to see climate change as the giant threat it is and enact policies that reverse the greenhouse effect immediately. It is our job to make sure the next administration does it.

"We are all born ignorant, but one must work hard to remain stupid" Benjamin Franklin

Saturday, April 21, 2007

The Supreme Court-against medical opinion

The U.S. Supreme Court has put the health of women at risk with their 5 to 4 decision to uphold a congressional decision banning intact dilation and evacuation (D&E) abortion this week. Despite the fact that there is clear medical consensus that intact D&E is safer than alternative procedures for the mother in certain circumstances, the Supreme Court overruled six Federal courts that said the 2003 Federal law is an "impermissible restriction on a woman's constitutional rights".

The Supreme Court of the United States is the highest body to review legislative findings and they need to be especially thoughtful when fundamental constitutional rights are restricted. Every Federal Court that reviewed the 2003 law found it to be "unbalanced, unreasonable and not factual."

It is important to note that this decision does not affect Roe v. Wade. Ninety percent of all abortions still occur within the first 12 weeks and are not affected by this decision. But they have banned a procedure that medical experts testified is safer than other means of ending pregnancy at times when the mother's health is at risk. Intact D&E is used in women with heart disease, bleeding disorders, compromised immune systems, placentia previa and accretia and for fetuses with certain anomalies like severe hydrocephalus. The American College of Obstetrics and Gynecology (ACOG) testified that intact D&E is "necessary and proper in certain cases."

I have had a few patients and one friend who were faced with the tragedy of a medical situation that was not known until the 2nd trimester of pregnancy. The grief and impact of terminating a dangerous pregnancy is now compounded when the procedure the physician chooses as the safest for the mother's health is not allowed. Her future reproductive ability can be affected as well if something goes wrong (bleeding, infection).

The debate about abortion will continue to be waged in this Country. Both sides are passionate with their beliefs and there is a wide impasse. Our forefathers were clear in their separation of church and state and our Supreme Court has crossed the line by imposing personal morality as a basis for constitutional intrusion.

Your comments are welcome.

Tuesday, April 17, 2007

Chondroitin for Arthritis - save your money

I'll give you the take away summary first: A new study from the Annals of Internal Medicine shows that chondroitin sulfate does not work to relieve arthritis pain. Before you fire off a comment that mentions how much it helped Aunt Tilly....the postscript is that there were no frequent or severe adverse affects so go ahead and take it if you think it helps you.

Osteoarthritis affects millions of adults and the most popular OTC (over the counter) supplement for pain relief is glucosamine plus chondroitin. Chondroitin alone is a $1 billion/year market in the U.S. It is a large molecule that is only 12% absorbed into the bloodstream. It is not incorporated into the cartilage and arthritis affects the entire joint anyway, not just the cartilage. Inflammation plays a large role in arthritis pain and numerous past trials have suggested that chondroitin may act as an antiinflammatory. Some past trials showed benefit and one even showed it worked better than joint replacement!!

This meta-analysis trial looked at all past studies and found that the quality of many trials was poor. Some did not blind the investigators and others did not publish results that showed no good effect. After reviewing all the studies, these researchers identified the high quality scientific trials and they tried to find convincing evidence of the effectiveness of chondroitin. They found no benefit greater than placebo. A large multicenter NIH study in 2006 also showed glucosamine and chondroitin sulfate alone or in combo was not better than placebo.

Orthopedic doctors recommend this combo and there are hundreds of liquid, topical and pill forms of glucosamine/chondroitin on the market. Pure science would say it is a waste of money but it does not appear to have adverse effects. Despite the lack of science, we all know that different people respond differently so even if it is a placebo effect, if you think it works for you there is no reason to stop.

Evidenced based medicine is what we are all striving for. This is a good study and the evidence does not bear out the claims of chondroitin for relief of osteoarthritis hip or knee pain.

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Sunday, April 15, 2007

When Boss Lives Large - time to sell stock

I was on vacation this week and catching up on reading some non-medical journal news. I came across one piece in the Wall Street Journal that I wanted to share. It ties into EverytingHealth because losing hard earned money is usually not good for one's mental health.

It seems that when a CEO of a publicly traded company buys a trophy home, investors should use that as a clue to sell their stock. It is called the "mansion effect": the bigger the CEO's home, the worse the company stock performs. Researchers from Arizona State University (my alma mater) estimate that if investors sold the stock when the CEO moves into a palatial home, they would reap returns of 29% after one year, and 46% after two years.

Top Executives who pay for their trophy homes by selling company stock also underperformed compared to market benchmarks. The reason can't be related to the number of shares sold since those numbers are small compared to the total number of shares. The researchers speculate that top executives may have become "entitled" , lazy and entrenched in the company. Perhaps these CEOs demoralize other executives and employees and affect overall corporate performance.

Whatever is going on, it is a fascinating study that covered 488 primary residence homes of executives at S&P 500 firms. Some of these homes featured tennis courts, boat houses, formal gardens, detached guest houses and servants' quarters. One spread had a private polo field and equestrian ring. About 12% were waterfront properties and 8.5% were on golf courses.

I've never seen an annual report that mentions the top exec's personal properties. If anyone knows how to find out this information, let me know.

Thursday, April 12, 2007

Recall Mouthwash

Just a quick note to let readers know that Johnsons and Johnsons has recalled 4 million bottles of Listerine Agent Cool Blue Glacier Mint and Bubble Blast (for kids) mouth rinse. Both show contamination with bacteria.

Tuesday, April 10, 2007

The Uninsured - Don't think it won't be you!

Today I got a copy of a letter a daughter of a friend sent to Blue Cross of California Insurance:

"Today I was notified that my healthy, young, family of four was denied further health coverage on our current plan because we went to the doctor for routine health appointments. We are not sick. We have no history of sickness. We work, we exercise, and we eat right. We pay our premiums on time. We were denied the most minimal of coverage.

As I write this we have no health insurance. I know we are not alone. In fact we are a rapidly growing population. What are families with even minor health issues doing? What are people with major health issues doing? Should I lose my house to pay the hospital bill if I have an accident? Is this the American way?

My children’s pediatrician that we have gone to since our children were infants had to close his practice and join an HMO because he could not afford to sort out the insurance issues while in private practice. My internist does not take any insurance at all anymore. I, unfortunately, cannot afford to see her now. I found only one doctor who was accepting new patients under my now old insurance plan.

Our “health care system” does not work for us. It does not work for our doctors.
Our country does not have a health care system. Whatever it is we have is broken.
Of all the things my taxes pay for, I wish they paid for a universal health care plan. I would gladly pay more taxes to go to bed tonight and not worry that if my child falls off his skateboard tomorrow I won’t have to choose between my next mortgage payment and his hospital bill. "

This is a story I have heard countless times and every doctor has spent hours advocating for patients, trying to save their coverage. Usually we fail. I have had patients be denied coverage because they saw me for conjunctivitis (pink eye) or seasonal allergies. I have seen patients denied coverage because they had a repeat mammogram that was normal. Patients are denied renewal if they had travelers diarrhea or just came to the office "too many times". If a person has a serious or chronic problem; cancer, heart disease, rheumatoid arthritis....affordable insurance is out of the question.

Lets's take our heads out of the sand, folks. The next denial could be you. I will endeavor to write more about our lack of US healthcare policy in the future and your comments and dialog are welcome.

Sunday, April 8, 2007

Calcium and Your Bones - Mini Medical School

One of my patients said she heard calcium supplements are not that important in post menopausal women. She couldn't be more wrong. Read this and you will be as informed as most physicians about calcium and bone health.

2/3 of our bone mass is made up of the mineral calcium phosphate. Because bone is alive, there is constant removal and replacement of calcium, called bone remodeling. The parathyroid gland secretes a hormone called PTH and that determines the amount of calcium that gets pulled from the bone into the bloodstream. When we have enough calcium in our bloodstream, it decreases PTH and more is absorbed to preserve bone. Vitamin D is also important to absorption of calcium into the bone mass. Inadequate amounts of calcium and Vitamin D cause reduced bone mass and weakness leading to fractures. Reduced bone mass is called osteopenia and severe bone loss is called osteoporosis. Have you noticed that older people seem to shrink with age? That is largely because the skeletal structure is collapsing due to weakened bone mass.

There is no scientific doubt about the importance of adequate calcium to build and preserve skeleton. But calcium alone does not prevent bone loss. Exercise, adequate protein and Vitamin D are also needed - especially after midlife.

We need to take in 1000mg/day of calcium up to age 50 and 1200-1500mg/day after that. Calcium is not well absorbed from the diet and we lose calcium in our urine and sweat. Calcium intake in North American post menopausal women is 550-650 mg/day below the recommended amount. At low intakes, bone mineral is being lost. At adequate intakes the bone is at steady-state, maintaining its integrity. However, at higher intakes, no further bone is built. We don't store calcium for later use by the skeleton. Since most adults don't get enough calcium from our food, if you are going to take any dietary supplements, calcium is the most important.

Despite the huge body of scientific evidence about calcium and bone strength, one study showed only 23% of physicians recommended calcium to patients with osteoporosis. The bisphosphonate drugs that are used to treat osteoporosis (Fosamax, Actonel and Boniva) all used supplemental calcium in the studies that showed effectiveness. Without supplemental calcium, we don't know if they work at all. Other studies showed 3/4 of patients taking bisphosphonates are not taking sufficient calcium supplements. The US Surgeon General said " Calcium has been singled out as a major public health concern today because it is critically important to bone health, and the average American consumes levels of calcium far below the amount recommended for optimal bone health."

Calcium in our diet comes from milk, hard cheese, yogurt, cottage cheese, broccoli, Chinese cabbage (bok choy), green leafy vegies, dried fruits, nuts and seeds. For an extensive list of calcium in foods go to food pyramid

The best calcium supplement to take is one that is easy and inexpensive. Calcium carbonate delivers more calcium than calcium citrate and taking with food also helps with absorption. Start slow with 500mg a day and add until you reach the recommended dose. For best absorption it is better to take calcium twice a day but all at once is better than none at all. There are some drugs that may interact with calcium and cause altered blood levels of the medication and they are:
*digoxin (a heart medication)
*levothyroxine (a thyroid pill)
*phenytoin (for seziures)
*thiazide (a common diuretic)
*glucocorticoids (cortisone)

For more detailed information on types of supplements go to calcium supplements

The Surgeon General said "The gap between what we know about calcium and its application in the community remains large and needs to be closed". Now we are narrowing that information gap. A calcium supplement may help make the difference in how healthy your bones are as you age.

Thursday, April 5, 2007

Cost of The War - wouldn't you rather have health care?

It is hard to get my head around the figures that are published about how much the War in Iraq is costing. At the end of 2006, BEFORE the surge, the total cost to America was somewhere between $750 billion (conservative estimate) and $1.2 trillion. I don't know what a trillion is. It's like counting grains of sand or stars in the sky. But I do know what treating disease costs and the comparisons are staggering.

Currently, the Iraq War is costing Americans $200 billion a year. For a fraction of that money we could provide health care for all the people in the U.S. that are uninsured. We could provide treatment for every American whose diabetes or heart disease is going unmanaged. We could immunize the entire World's children against measles, pertussis, tetanus, TB, polio and diphtheria. We could provide 3,733,163 new housing units. That would certainly take care of the Katrina victims as well as the Tsunami victims.

After we provide these health services, we still have lots of the $200 billion left over. We can double cancer research funding and provide universal preschool for 3&4 year olds and then we can beef up our national security at our airports and seaports.
We still have money left to hire more teachers and help rid Afghanistan of the Taliban. They are back, you know.

The administration is seeking $142 billion more in war funding for next fiscal year.

Tuesday, April 3, 2007

High Blood Pressure - The Silent Killer

So much has been written about hypertension (high blood pressure) that we physicians think patients already know all there is to know. We forget that of the 50 million Americans that have hypertension, 1/3 don't even know they have it. Also, it is human nature to pay attention to something only when it has a direct connection to our lives. As we age, high blood pressure becomes more of an issue. In case one of the readers of EverythingHealth has just been diagnosed or has never even had their blood pressure tested, I offer this information....and I hope it is useful.

Blood Pressure is always reported as two numbers and normal blood pressure is 120/80 or below. The top number is the systolic (blood flowing through the arteries when the heart is contracting). The bottom number is the diastolic (pressure of the arteries when the heart is resting between the beat). Hypertension is a reading of 140/90 or above. If a persons blood pressure is over 140/90 on 3 testings, it is hypertension and needs attention to bring it down to a normal range.

Why do we care? Hypertension can cause stroke, heart failure, heart attack, aneurysm and kidney failure. If you smoke, drink heavily or have high cholesterol on top of hypertension the risks increase.

Here are some myths:
* "I can feel my blood pressure when it is high" (anxiety can be felt, high blood pressure is silent)
* "My blood pressure is only high when I see you, doctor" (even episodic hypertension is dangerous and it is probably higher on other occasions)
* "I know lots of people who weigh more than I do and they don't have hypertension"
(overweight people have twice the hypertension as normal weight folks)
* "But I'm thin, I can't have hypertension" (thin people can have hypertension-it isn't always weight related)
* "But I've always had low blood pressure" (we don't know the cause of most hypertension. Blood pressure rises with age and genetics play a roll)

The good news is that most hypertension can be controlled with lifestyle changes and medication. Weight loss, regular exercise and avoiding salt may be all a person with mild hypertension needs. If that is not effective after a few months, there are many prescription medications that will bring blood pressure to the normal and safe range. The good news is that there are dozens of different medications that work so we should be able to find one that is easy to take, doesn't cause any side effects and is effective.

Control of hypertension is one of the reasons fatal heart attacks have decreased over the past few decades. It is an important risk factor and even a "little" high blood pressure should be lowered. It's fine to start with lifestyle changes but get it checked again soon and don't be afraid to start on medication if the pressure is still elevated. Don't forget, there are no symptoms but that doesn't mean it isn't there.

Sunday, April 1, 2007

Life after Katrina - The Disaster Continues

It has been 18 months since Hurricane Katrina hit New Orleans and Mississippi. Within a few days of the flooding, as the city was being evacuated, I went to New Orleans and Baton Rouge to offer medical help. It was a life changing experience to be in the heart of such a disaster and I am keenly interested in how the people are getting their lives back.

Katrina took a terrible toll. Fifteen hundred lives were lost, 780,000 people were displaced and 200,000 homes were totally destroyed. The medical community...doctors, nurses, hospital facilities were also destroyed. When I was there we set up makeshift medical clinics serving 5,000 homeless men, women and children who were shell shocked, without their medications and displaced from loved ones. You might remember them as the "rooftop people" and each family had a horrific story to tell. The city was under water and communication was impossible. We had basic supplies and needed to use common sense and compassion as our first line weapons. Rebound from those first weeks and months of chaos has been difficult.

The American College of Cardiology held their 2007 meetings in New Orleans last week and local physician speakers reported that medical services are far from adequate in the City. The hospitals are still not operating to full capacity and many physicians lost their records, equipment and even their own personal homes. There remains a dire shortage of primary care physicians and certain specialists to care for the remaining population of the Gulf Coast.
There is a serious shortage of hospital beds and emergency departments are full. As of the end of 2006, only 3 of 15 health clinics had been reopened. To further increase the problems, hospitals must deliver more uncompensated health care as people have lost jobs and the city is full of transient workers. This fragile health infrastructure is being held together by the dedication and goodwill of the health care workers, many of them who live in FEMA trailers themselves.

When I was in New Orleans, the American Red Cross was on the ground providing shelter, food and some level of coordination for the evacuees. There are no easy fixes for the Gulf Coast in the aftermath of Katrina but we should not forget that the crisis is still there and help is still needed. If you want to learn more or help, check out St. Thomas Community Health Center, New Orleans or The American Red Cross.

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Journal Update

It's been a confusing week with two different studies on breast MRI. I have already had a number of patients call, trying to figure out what it means.

MRI for Screening

The American Cancer Society released new guidelines for use of MRI breast screening. They recommend screening for women who have been tested and are positive for the genotype BRCA 1 or 2 or for those that are first degree relatives of BRCA carriers. A first degree relative is a parent, child or sibling. They also recommend annual MRI screening for women who have had prior radiation to the chest between ages 10-30(for instance treatment for Hodgkins Disease).
The ACS does NOT recommend MRI for women with dense breasts or women with a personal history of breast cancer. They do not recommend MRI for women with atypical hyperplasia of the breast or lobular carcinoma in situ.
(American Cancer Society)

MRI in Opposite Breast after diagnosis of Breast Cancer

A 2nd report was released that looked at using MRI in the opposite (contralateral)breast after breast cancer is diagnosed. They found a 3% pick up rate for breast cancer in the opposite breast when MRI was done within two months of diagnosis. They also had a very high rate of false positive diagnoses that lead to many invasive procedures. MRI is quite accurate in showing where there is no cancer (true negatives) and the test might be useful in women who are considering a prophylactic mastectomy and would forgo this operation if she knew there was no cancer in the breast. Because MRI picks up many artifacts that are not cancer and the only way to know is to do biopsies, it is not to be considered a simple, non-invasive test.
(New England Journal of Medicine)

Cardiac Arrest

An interesting study came from Japan where researchers looked at out of hospital sudden deaths or cardiac arrest. Less than 1/3 of arrests that occur outside of a hospital receive any type of resuscitation. Many people are afraid to do mouth to mouth breathing and don't feel comfortable with Cardiopulmonary resuscitation (CPR)
They found that chest compressions only were just as effective as CPR and mouth to mouth breathing offered no extra benefit.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...