Answer to Medical Quiz

The answer is # 5:
Black hairy tongue (lingua villosa nigra) may be associated with the presence of chromogenic organisms (e.g., C. albicans) and the use of certain medications (e.g., doxycycline and bismuth). The pathophysiology is thought to be due to proliferation of the filiform papillae of the tongue, which stain black with porphyrin-producing chromogenic bacteria or yeast.

I take exception to the statement from New England Journal of Medicine, however, that this photo is "commonly associated" with Candida. I have treated thousands of C. albicans mouth infections ("thrush") and have never seen a condition that looked like this from Candida. The staining comes from the medications used with it.

Medical Quiz - How Smart Are you?

Which condition could cause this type of finding in the mouth? (Click on illustration to get a close up view ). Answer will be posted tomorrow.

Grand Rounds

This weeks "Grand Rounds" of medical blogs is being hosted by Prudence, MD.
I'm happy to report she found EverythingHealth worth a mention in her review of the weeks best blogs. Check her out for great blogging links

Germs- A Traveler's Companion

I read an article about the top places to find "germs" and travel is a big exposure.

I am not afraid of germs because I know they are ubiquitous and there is no way to eradicate bacteria, but having just returned from an overnight in a Hotel...I realize I have been in the midst of a virtual hothouse of germs. Think about these bacteria and virus infested environments:

• Hotel room remote control: The first thing I grab when I get to a hotel is the remote control and I check out the TV. Guess what? Hundreds of other travelers have done the same thing and the buttons are never cleaned. A travelers pack of alcohol wipes can save the day. Wipe the phone, remote, door handles and light switches to remove traces of that guy with the cold that checked out before you arrived.

• ATM buttons - Who doesn't get cash from an ATM? That's the point. Everyone has touched those buttons and they are never cleaned. A small container of alcohol based hand gel will kill the viruses and bacteria on my hands after using the ATM.
  

• Airplane bathrooms - Don't you always feel a little grubby in the airport or airplane bathroom? They are cramped, overused and experts have found excess amounts of E. coli and other bacteria on the surfaces. This is another place for the alcohol hand cleaner. Also try to flush the toilet with the lid down to avoid the volcanic flush. Get out as soon as possible.

• Hotel bedspreads -If you are lucky enough to stay at a 4 or 5 star hotel, they have wonderful washable duvet covers and have dispensed with those nasty bedspreads. Bedspreads have been found to have semen (ick) and bacteria on them because they are not washed between guests. Peal those bed spreads off. Don't sit or lay on them and whenever possible stay in a 5 star hotel.

The worst place to find germs is right at home in your own kitchen. That sponge that you use over and over is a bacteria growing farm. Put the sponge in your dishwasher and let the 150 degree temp do its magic. Fill a spray bottle with 1/4 bleach and 3/4 water and use that to clean your surfaces. Congratulations! You have just reduced germs by a significant amount.

There is no need to be paranoid about germs. A little common sense and good hand washing with soap will usually protect us.

High Intensity Interval Training

Now that the big feast is over, many people turn to exercise to try and burn off those extra calories. High-Intensity Interval Training (HIT) is one way to rev up your metabolism and get aerobic benefit in short bursts of time.

HIT is repeated sessions of relatively brief, intermittent exercise that is done with "all out" effort. A single HIT can last from a few seconds to several minutes, followed by a few minutes of rest or just movement. This basic concept is advantageous because it can be applied to almost any level of initial fitness. There is no need to maintain a certain heart rate or speed.

Even though the time of the exercise is small, a few brief sessions of intervals can benefit you as much as prolonged periods of continuous moderate exercise. You can do HIT every other day and reduce the training time.

The good news about HIT is that it dispels the myths that you must reach a "fat burning zone" that only occurs after the first 30 minutes. With HIT the energy expenditure continues even during the rest cycles and studies have shown that only seven sessions of high-intensity
interval training over two weeks increased fat burning during exercise by more than 30%.

Here is an example of a HIT program for a beginner:

• Warm up: five minutes of walking at 3.5 mph
  
• Speed up and walk at 4.0 mph for 60 seconds
• Slow down and stroll at 3.0 mph for 75 seconds
• Repeat steps 2 & 3 five more times
• Finish with 5 minutes of walking at a comfortable pace to cool down.

For the advanced athlete you can substitute running or cycling at all 80-90% of out effort for 60 seconds. Slow down to 30% of effort and repeat as above.

HIT is not better than traditional endurance exercise, but as an alternative or just a way to start exercising when you have been putting it off, it can get the metabolism and muscle strength going.
(Summarized from Martin Gibala, Phd, McMaster University, Ontario Canada)

Dennis Quaid's Twins-Preventable Error

Hollywood and the tabloids were rocked this week with the report of actor Dennis Quaid's two week old twins receiving a lethal dose of Heparin at the prestigious Cedars-Sinai Medical Center in Los Angeles.

It shows that VIPS are not immune to preventable hospital errors, no matter how much staff attention, privacy and spa-like treatment they receive from hospitals (and they do!)

This case is not unusual. Heparin is a blood thinner. The nurse accidentally cleared the line with a solution of 10,000U/ml rather than 10U/ml. A neonatal unit should not even have the stronger solution on the med cart, so the error was in having the dose stored in the wrong place as well as the nurse not double checking the label.
To the credit of Cedar-Sinai Hospital, they recognized the error and quickly administered protamine sulfate - a drug that reverses the effects of Heparin. There should be no long term bad effects once the drug is reversed completely.

Heparin is one of the top 5 drugs commonly associated with errors in hospitals. The others are Insulin, Morphine, Potassium chloride, and Warfarin (another blood thinner). These five account for 28% of all drug errors and have a high risk of injury if administered incorrectly.

The way to prevent these errors and "near-misses" is to put processes into place in health care like we do in aviation safety. Make it hard to do the wrong thing. Labels should have "red alerts" to show different strengths. The background colors on the bottles should be different and the font size needs to be increased. Look alike drug names should be differentiated by using TALL LETTERS. (glipIZIDE vs. glyBURIDE). The bottles should look completely different so it is obvious to every care giver...whether stocking a med cart or administering a medication.

I trust the Quaid twins will be fine. The high profile cases such as this show us we have a long way to go in providing safe care for all patients.

Thanksgiving Day Relaxing Medical Trivia

Here is more EverythingHealth trivia to read, marvel at, and appreciate just how wacky and wonderful our world is:

• You have 10 quadrillion cells inside your body. The mitochondria in each cell are so tiny that you can pack a billion into a grain of sand.
  

• Given an adequate supply of nutrients - a single bacterium could produce 280,000 billion offspring in a day. (Wash your hands please)

• If you compare your genes with any other human being, they will be about 99.9% the same. It's the endless recombination of genes that make us what we are!

• How fast a man's beard grows is partly a function of how much he thinks about sex. (Because thinking about sex causes a testosterone surge)

• The average distance between stars is 20 million million miles.

• Americans drink 17.5 ounces of sugary beverages a day. (No wonder we are fat. Stop it!)

• 79% of Americans feel that current American culture makes it hard to exercise regularly and maintain a healthy lifestyle.

• $10,402 is the average cost of a broken leg. (Make sure you don't lose your health insurance)

• Netflix mails out 1.6 million DVDs a day (I'll be watching all weekend!)

I give thanks to "A short History of Nearly Everything" by Bill Bryson for many of these interesting facts.

I also appreciate all the readers and comments for EverythingHealth because writing this blog keeps me on my toes and prevents Alzheimer's by making me think!

If you are reading this from another country...you aren't celebrating the pilgrims and turkey, but give thanks anyway for something wonderful in your life.

Grand Rounds is Up

The Medical Blog Carnival, "Grand Rounds" is hosted this week by Mexico Med Student and EverythingHealth was a featured blog. Check it out for good medical links!

China - Recycled Condoms

It's amazing what dangers and weirdness one can find on the world wide web! The latest comes from China Daily and New Express Daily which reports used condoms are being reprocessed into rubber bands and hair ties. They are being sold at local bazaars and even beauty salons.

First we have poisoned dog food, followed by "date rape" tainted kids toys and now used condoms? It goes without saying that this is a serious public health risk from viruses, HIV and Hepatitis. It's both disgusting and dangerous.

I'm happy to report that "an official from the Guangzhou administration of industry and commerce said it was against the law to make or sell goods from used condoms." That is reassuring.

China better get it together before the Olympics. When hair twisties are dangerous, there isn't much left.

Christmas - Too Early for Joy

It makes me a little crazy to see Christmas ornaments and music before Thanksgiving. Way before Thanksgiving. I saw some displays before Halloween.

I like my holidays to fall sequentially. It makes me feel like there is a natural order to things. Labor day should be hot and school should start AFTER Labor day. Our kids schools start the Wednesday (can you believe they start school on a Wednesday?) BEFORE Labor day. That means no family travel on that last long weekend. It means using that week to buy school supplies and make sure the kid has closed toed shoes. It's obscene.

Halloween should be all about the kids and crazy costumes and high fructose corn syrup..I mean candy. I'm OK with the commercial Halloween shops and scary decorations and it is a time that grownups can "get their freak" on also.

But when I see Santa and the reindeer right behind the pumpkin display, it is disorienting. Is it not enough to receive 20 catalogues a day to stimulate the buying frenzy? Do we have to double up on our commercial holidays just to squeeze another credit card buy from the consumer?

The fake snow and "Happy Holidays" are turning me off. I'm not ready for glitter or sparkly lights or Santa. There should be a natural progression that goes with seasonal and emotional changes.

I refuse to partake in the frenzy and the fake.

Cardiac Rehab - Proven but Underused

Cardiac rehabilitation for patients who have had a heart attack or procedure is proven to reduce new cardiovascular complications just as well as medication. Published guidelines since 1995 have recommended a comprehensive approach to cardiac rehab, including exercise training and lifestyle interventions. Despite this benefit, less than 30% of eligible patients are referred to cardiac rehab programs by their doctors. Under 14% of patients over age 65 who have had a heart attack have rehab. What is going on?

Somehow, physician awareness lags behind the evidence. Marjorie King, MD, the coauthor of the cardiovascular performance guidelines published this month in Circulation was quoted in JAMA : "The biggest factor is that physicians just plain don't think about it-we're detailed by drug companies all the time; we're not detailed by rehab clinics. It's just not part of the algorithm for treatment."
("Detailing" is when drug reps pitch their drug to doctors)

Other barriers to patients getting needed cardiac rehabilitation are that Medicare only pays about $20 per session so hospitals aren't eager to offer or expand this service. It is good for patients and good for public relations, but they can't break even on it.

Researchers found that these are the patients that would benefit from cardiac rehabilitation:

• Acute Myocardial Infarction (heart attack)
• Coronary Artery Bypass
• Heart valve or heart transplantation surgery
• Stent placement or any coronary intervention

The recent findings of low usage should act as a wake up call for clinicians as well as create awareness of the need for rehab by patients who have had a coronary event.


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SCHIP - Nasty Politics Affect Our Children

I say "our children" because we should all care about providing health care for the youngest, most helpless members of our society. It's not "them"...it is "us".

SCHIP (State Childrens Health Insurance Program) is a Federal and State government program that provides health insurance for families who earn too much for Medicaid but are near the poverty level and cannot begin to afford health insurance. Each State can determine the design, eligibility, benefit package and payment levels for coverage. Some States cover pregnant women or families and some have gone above the 200% of poverty level for a family of four ($37,700)

The bipartisan congressional bill to expand SCHIP to cover 4 million more children by 2012 was vetoed by George Bush who believed it would "Federalize Health Care". Despite SCHIP, which was started in 1997, the number of uninsured children continues to rise and 68.7% of new kids without health insurance came from families who are above the 200% of poverty level. We all know what has happened over the past 10 years with rising insurance costs and employers dropping coverage. Just saying "no" hurts families and children in America. Have you priced health insurance lately? A family of 4 would pay a minimum of $600/month if they could even get coverage! It's an impossible situation.

I was at a meeting this week where physician leaders of medical groups were discussing the SCHIP veto and how they would handle children in their practices who will lose coverage. They wanted to develop a policy of continuing to provide free care, even though there would be no reimbursement. It brought tears to my eyes to hear them discuss in earnest how they could do this...especially when they are already providing care for Medicaid children at a financial loss. Government programs (Medicare and Medicaid) are a form of "charity care" for most physicians who lose money on these patients. The physicians were determined to do whatever they could to prevent children from having no medical home.

As a practicing physician, I hear the stories and see the faces of people that are struggling to make ends meet. On the ground it is not a statistic, but a child with asthma or a broken leg or needing immunizations. Americans are not opposed to seeing their tax dollar used for health or education. We all hate waste and incompetence and fraud and SCHIP is none of those. SCHIP was originally started by a bipartisan republican congress and has been a successful program that helps our neediest citizens. What a shame that our Country cannot find the will and the resources in 2007 to cover poor children and pregnant moms and (oh gasp!) even poor parents.

Grand Rounds

A nod and thank you goes out to Dr. Anonymous for featuring EverythingHealth in this weeks Grand Rounds for outstanding health blogging. Check it out for lots of good health links.

Testicular Cancer- Basics to Know

Testicular cancer is rare but curable when diagnosed early so there are a few facts everyone with an adolescent son or relative should know.

It is the most common cancer in young adult men between age 15-35. It is very rare in African American men and is more common in men who have an undescended testicle. Testicular cancer is almost always detected by the patient himself. Young men entering adolescents should be taught how to examine their own testicles just like women learn breast exam.

Testicles are smooth and easy to examine, unlike breasts that change with menstrual cycles. The self-exam is best performed after a shower when the scrotum is relaxed and easy to palpate. Men should be alert for nodules, swelling, enlargement or tenderness. Pain is only present 50% of the time so a painless lump should be seen by the doctor.

Testicular cancer has three stages. Stage 1 involves just the testes. Stage 2 patients have disease that has spread through lymphatics but remains close to the pelvis. Stage 3 patients have disease that has spread to other organs or distant lymph nodes. Even Stage 3 patients have a good chance of cure with modern treatment of orchiectomy (testicle removal), radiation and chemotherapy.

The take home message for testicular cancer early detection is to educate young men about self exam just like we educate young women. Most testes nodules are NOT cancer but every change from smooth should be promptly evaluated by a physician. It is a highly curable disease and one of the successes of modern medicine.

By the way, for a really inspiring read, pick up "Its Not About the Bike" by Lance Armstrong.

The Purple Pill for Reflux? Choose the Cheapest

Proton Pump inhibitors (PPI) are one of the most widely prescribed medications in the world. Why are there 5 different PPIs on the market to treat acid reflux? Is one better than the other? Is the cheaper generic (Omeprazole) as good as Prevacid? or Protonics? or Aciphex? or Nexium?

With the help of The American Family Physician Journal, let me dispel the confusion. First, there are different brands of the same drug because it is a multi million dollar market and a tiny percent of that market is real $$$. It's called market share.

In reviewing the 41 studies comparing the various PPIs that were used to treat peptic ulcers or gastroesophageal reflux disease (GERD), the authors found no differences among any of the drugs.

Let's look at the monthly price differential between these products:
Nexium 20mg --- $158
40mg --- $137
Prevacid 15mg --- $153
30mg --- $147
Protonics 20mg --- $128
40mg --- $125
Prilosec 10mg --- $115
20mg --- $136

Omeprazole (Generic Prilosec) 10mg ---$27
20mg ---$21

In summary: All PPIs are effective in equipotent doses. Go for the least expensive!

Professional Freedom Beckons

I have now received three amazing solicitations from MDVIP. This is the Boca Raton corporation that will set a doctor up to do concierge, retainer medicine. The letters invite me to join a few exceptional physicians who seek "professional freedom, personal freedom and financial freedom". One invite came in a bottle with sand and seashells inside, inviting me and my guest to all expense paid trip to Florida. This week, I am invited to California and they will feed me and my guest, treat us to museum exhibits and pay me an honorarium.

The invitations are sexy, appealing and seem to be coming at a rapid clip. MDVIP is one of a handful of companies that know primary care physicians are in demand and they know patients are fed up with the long waits, quick visits and difficulty in even seeing the doctor. They know the doctor is burned out, disgusted with the hassles of insurance paperwork and discount rates. The dream of caring for the patient has turned into the nightmare of patient "panels" of 2500 people.

The solution? The patient pays a retainer ($200-1500/month) and the physician limits her practice and is available to see the patient and spend more time with each patient. Prompt phone calls and email communication is part of the deal. Usually the retainer fee covers the primary care visit also so there is no insurance billing or hassle. Labs, referrals to specialists, Xrays, hospitalization and procedures are usually not included. For those services, the patient's regular insurance applies.

Concierge medicine is taking off in Urban areas where affluent patients meet up with frustrated physicians. MDVIP helps the doctor make the transition into the new mode of practice. They take a cut and everyone is happy.

I get it. I understand it. I have many friends and colleagues who are now concierge physicians and they are rested, happy, fulfilled and off the treadmill.
It is not the answer for what ails health care and it further worsens the doctor shortage, but at this time, I'm sure MDVIP has many takers. It represents the free market at work and doctors are just saying "enough" with the patients who are saying "enough" right along with them.

Costs Rise Faster than Revenue

The Medical Group Management Association (MGMA) does an annual cost survey of medical offices. It won't be a surprise to any practicing physician who runs an office that practice costs increased by 7.4% while revenue rose only 1.8%. Family practice, cardiology and general surgery fared the worst with even lower revenue gains against losses from last year. Pediatrics and orthopedic surgery were among the specialties with a positive picture of revenue to cost. The MGMA cost survey is based on data submitted by more than 38,460 providers.

I can tell you that receptionists, filers and medical assistants want raises each year. The cost of insurance and rent goes up annually. The answering service is charging more. Supply cost goes up, even though we try to use various vendors and get the best price. I won't even mention the fact that our exam tables are looking pretty shabby and should be replaced. We bought new computers this year...ouch!

In the meantime, Wellpoint, Aetna, UnitedHealth and HealthNet are posting record profits for their investors. They are the wall street darlings which tells me that the medical cost ratio is low. According to Wikipedia the "Medical cost ratio (MCR) is a metric used in managed health care to measure medical costs as a percentage of premium revenues. It is calculated by dividing those premiums allocated for fully insured or self-funded health care coverage into the total expenses for inpatient, professional (physicians and other licensed providers), outpatient, and pharmacy. (Briefly, MCR = Costs/Premiums.)"

Lest you think I am picking on the big for-profit insurers...Medicare is a huge issue also. The waste and bureaucracy create expensive hoops that physicians must jump through just to get paid a rate that doesn't cover the cost of business.

Physicians are at the losing end of the MCR. When physicians lose, so do the patients. Note my prior post on the looming shortage of physicians. When practice costs increase faster than revenue, we have a situation that cannot continue.

Perhaps many readers of EverythingHealth are business people. You get it, right?

The Doctor Shortage

Merritt and Hawkins is one of the largest healthcare recruiting firm in the U.S. They published the results of a study that showed 48% of the physicians age 50-65 years of age are planning to cut back their office hours or retire within the next 1-3 years. The disturbing fact is that 1/3 of ALL physicians are in this age group.

To prepare for the physician shortage, new medical schools have opened and there is a small increases in the number of medical students in training. But there is a 8-12 year lag between training and practice and with the aging population it isn't hard to see what is around the corner. At a time when people want and need more medical care, there will be a serious shortage. Universal health coverage won't matter if there isn't anyone to take care of you. Having insurance and having access are not the same thing. Ask anyone on Medicaid or people who live in rural communities.

There is already a near crisis in California to find doctors to cover the Emergency Room. A wealthy community in Northern California cannot find a surgeon to be on call. Neurosurgery, ortho, ENT, opthalmology are all in short supply for ER call. Hospitals are paying large fees to doctors just to be available. It is traditionally younger, eager physicians who take ER call but there are no young, eager doctors in many places. According to this study we won't have any old tired ones either.

The largest decline in physicians is the primary care specialties (General Internal Medicine, Family Medicine, Pediatrics). I have written before about these specialties being grossly undervalued in our society. At the very least, it is time to recognize this and ensure that primary care specialties, with the the cognitive and coordinating value they bring, are reimbursed on par with procedural specialties. This is the only way young doctors will choose these specialties. THE ONLY WAY!

The unintended consequence of ignoring these facts will adversely affect our nations healthcare for decades to come.

Worst Health Care Scams

Open any magazine and you will see them. A miracle product that will make you thinner, sexier, healthier, live longer, more virile or more beautiful. Here is my vote for the years Worst Health Scams. They have no scientific merit but are great examples of compelling advertising.

1. Hoodia (Hoodia Gordonii) - When they say "As mentioned on Oprah" a red flag should go up. I don't know if this rare plant from Africa works when boiled down, but the capsules are definitely a scam. My favorite Hoodia ads say "Don't believe the scam..we have the real Hoodia". If Hoodia worked, we wouldn't be so fat.

2. Cellulite Creams - Rubbing creams or herbs on the skin does not break down cellulite (darn!!)
Cellulite is fat. You can't rub fat away.

3. Blue Green Algae - This swamp weed doesn't give you energy, cure allergies, cut sugar craving or cure your cat of leukemia. Trust me.

4. Colon Cleansers - I have good news for you. Your colon is not "toxic". Your colon does not have huge worms living inside. Your fecal matter is not stuck to the colon for months or years. If you want your GI tract to work well, eat more fiber and natural food. Period.

5. Penis Enlargements - Here is the truth. None of them work.

6. Breast Enlargement Cream - Here is the truth. None of them work. (But ladies, we can have an advantage here with surgery, unlike the guys. Sorry guys!)

7. Royal Jelly - This has been around for decades. I have always wondered how you would ever know it is "Royal" from the queen bee. It doesn't matter. There is no evidence that it does anything except cost a lot.

There are hundreds of scams out there. Save your money for a massage and a glass of wine. That is something that DOES work.

Medical Quiz

The answer is Cocaine. The hole you are looking at is on the hard palate which is the floor of the nasal passage. Excessive cocaine snorting has created this perforation, which is permanent.

Drug Quiz- How Smart Are You?

This quiz from New England Journal of Medicine will test your knowledge of adverse drug effects. What is your answer? Check in tomorrow for the correct answer.