Monday, March 31, 2008

Elephant Painting

If this doesn't lift your day and perspective on life, nothing will. Enjoy!

U.S. Healthcare - Overhaul it


I think Americans that are in a Union have pretty good health insurance overall because the unions use health coverage as one of their bargaining chits for employer based coverage. If you have AFL-CIO coverage, you are probably not one of the 47 MILLION uninsured! You also don't have Medicaid.

So I was surprised to find a survey of more than 26,400 Americans, conducted by the AFL-CIO found that people are fed up with U.S. health care. Half of the respondents said they were union members, others were family members or self insured. I see this as the famous middle class. Because it was an online survey, they at least had computer access, and were working Americans. Listen up, Washington...the people have had it!

Among the findings:
  • 95% said the health care system in the U.S. needs fundamental change or overhaul
  • 46% reported spending $1000-$5000 in out-of-pocket costs over the past year
  • 48% said they or a family member stayed in a job just for the health insurance
  • Nearly 1/3 said their insurance company refused to cover a medical treatment that should have been covered.
  • 97% said they plan to vote in the upcoming election
To read the full story go here.

Wednesday, March 26, 2008

Scary Technology- At Home Paternity Test


We should have expected that this day would come and here it is. Consumers can now purchase an at home test kit for men to solve that age old question "Hey, is that funny looking kid really mine?"

A company called Identigene has developed a paternity test that is available over the counter at Rite Aid and Meijer drugstores. The test costs $29.99 and there is an additional $119 for lab fees. The kit includes swabs for the mother, child and alleged father. After the swab is taken, just slip it in the postage paid envelope for processing by a Salt Lake City lab. Voila...results in 3-5 days and then the agony can begin.

The website also offers family/marriage or genetic counselors. That is probably the most valuable aspect.

Tuesday, March 25, 2008

Gratitude


Reading medical blogs can be a real downer. We bloggers like to point out the problems with healthcare financing, training and economics. Insurance companies are a drag and being on call is like carrying around a 2 ton beeper. Talking about the pleasures and privilege of practicing medicine may not be blogworthy, but the note I carry in my handbag and read each day is my reminder of how great I have it.

When the going gets tough, I pull out the note from Karen (not her real name!). This 3X5 notecard, hand written on both sides, warms my heart and reminds me of why I am a doctor.

Karen had been my patient for a few years and we developed a relationship as we dealt with the usual easy issues healthy young working moms have. One day she brought her 48 year old husband to me because he was tired and had a nagging cough. The diagnosis was not hard to confirm. A chest X-ray followed by a biopsy revealed an unexpected and "for no damn reason" lung cancer. It was the hardest result to discuss but we dug in with the best specialists for consultation and treatment. Despite the most advanced aggressive treatment, over the next year, he died. They had a young daughter and the agony of watching him decline and knowing he would not make it was almost unbearable for all of us. This was your classic young family who exhibited bravery and humor and grace and inspired everyone who came into contact with them.

Now two years later, the hard grief was lessening and Karen was looking forward in her own life. She had her own cancer scare (thankfully not present) and at our last visit she gave me the envelope. Reading her words of thanks and her recollection of the guiding support she felt from me, touched me in deep ways. She mentioned the journey she and her husband had taken together, with me too, and it was like poetry.

This is why we do Medicine. It is for the opportunity to share private, agonizing, happy,painful, spiritual moments with others and, hopefully, make some kind of difference. It's not about money or lifestyle. It's about gratitude. Mine and hers.

Monday, March 24, 2008

Genes and the Environment - Epigenetic


How genes interact with the environment to cause disease has been a mystery to scientists. But now, the field of Epigenetics is starting to give clues that will help with cancer and other diseases.

Epigenetics can be thought of as chemical switches that can turn on and off the expression of genes in response to environmental factors. These chemical changes alter whether certain genes are expressed but they don't alter the genetic DNA sequence. The epigenetic changes occur most commonly during pregnancy, neonatal development, puberty and old age. The effects of these changes can occur years or decades later and, because the genes are altered, they can effect offspring also.

One example is shown in some cancers where tumor suppressor genes can be inactivated epigenetically in human tumors. There are now cancer therapies that aim to reverse inappropriate DNA methylation of such genes to allow them to function properly. These therapies don't replace a mutated gene with a good one, but rather they remove epigenetic marks so growth regulatory genes function properly.

There is some evidence in animal models that there may be epigenetic causes for chronic diseases, addiction and mental illness also. The effects of food supply, smoking and chemicals in plastics may mediate epigenetic changes that affect transgenerational inheritance. Pregnant mice that were exposed to BPA , a building block of polycarbonate plastics and epoxy resins used to make water bottles and dental sealants, caused changes in the mice that later became obese, diabetic and developed cancer. It is too early to say if humans behave the same way but when you see how plastics have overtaken our environment and the rise in obesity, it is a compelling theory.

The National Children's Study will follow a large nationally representative sample of children from prior to conception until they are young adults. The samples collected during this study should enable scientists to see if early developmental changes in the epigenome are linked to the development of human disease later in life.

The advances in science are never static and our ability to map the human genome has just barely opened the window of new discoveries. The field of Epigenomics is still in its infancy but the discoveries will be swift and additive. We truly do live in exciting times and I suspect in the future we will be screening and treating disease at a molecular level before it occurs, not after.

Sunday, March 23, 2008

Easter and Spring


Happy Easter-Happy Spring Equinox. No matter what you call it or how you celebrate, this time of year has been celebrated by all cultures since antiquity.

Of course Easter Sunday is a Christian celebration of Christ rising from the dead to take his place as the Son of God. But the Easter celebration has Pagan roots, long before Jesus Christ, with celebrations honoring the goddess of Spring. The Spring Equinox, when crops are fertilized and there is a balance of daylight and night, has been an important time for hundreds of centuries.

Think about it...making it through the long dark winter, when there were no lights, no convenience stores, no fresh food and no treatments for pneumonia or childbirth was a marvel. Just being alive at the end of each winter must have been a cause for celebration. Seeing the first flowers bloom and the first sprouts of food crops meant you would live. Getting together with neighbors and relatives to dance and sing and eat was a testament to life. Eggs and rabbits are a universal symbol for fertility and life.

The Christian Easter also falls near the time of the Jewish festival of Passover, one of the most important feasts in the Jewish calendar. This year, Passover will begin on April 5th.

So no matter what your religion, I wish you a happy Spring and good health and I hope you take any excuse for a day of celebration!

Thursday, March 20, 2008

Do You Need a Doctor? It better be for skin


Breaking News (that all of us in Medicine already knew)!!! Young doctors all want to be Dermatologists. Yes, there is a sudden overwhelming interest in skin, pores and hair after spending years in premed, medical school and residency. Taking care of the whole person? Doing a work up for abdominal pain and removing a sick appendix? Evaluating kidneys or hearts or thyroid glands? Arthritis, hypertension and headaches? Forget it!

It's skin that's in!

This is the week for the Residency match and the New York Times tells us that the most sought after residencies are Dermatology and Plastic Surgery. Thank heavens there are only 320 new slots to fill in Derm or there would be no doctors left for anything else. The sad thing is that the Residents who don't get their first pick will be defaulted to other specialties and will be forced to take care of all of us when we are really sick. I don't know about you, but I kind of want my doctor to WANT to do Medicine...not have that be the last option.

Why is this occurring? The answer is lifestyle, money and prestige. Certain specialties are known as the R.O.A.D. to happiness. R.adiology, O.pthalmology, A.nesthesiology and D.ermatology. These specialties are in great demand by young doctors because they make money, have limited or no call and provide a nice lifestyle. Derm, like plastic surgery, and ENT has turned into a cash cosmetic business. Patients are always happy and no insurance hassles to deal with.

Our health care system is structured to get these results. Government interference and regulations, hassles, debt, malpractice, consumer apathy and entitlements have brought us to this point in time. Although I support universal health care for all, with the current system it will just create more burden on underfunded providers and hospitals.

I'm happy for the excited new doctors in training. I just hope there will be someone to take care of me and the other boomers as we hit Medicare age.

Wednesday, March 19, 2008

Omega 3 FFA - More Good Heart Benefits


I've written before about Omega 3 FFA but I just learned some new facts that I want to share because it is so important to our longevity and health. I've always been a bit confused about the amount that is needed for proven benefit so here are some important facts:

DHA and EPA are the two omega-3 fatty acids that have shown to prevent cardiovascular disease. Two major randomized clinical trials showed significant reduced mortality and heart attacks with doses of 850mg and 1.8 g/day of DHA and EPA. Higher doses (3-4 gms) have been shown to reduce blood pressure, triglyceride levels and atrial fibrillation. These results are spectacular.

Both DHA and EPA are present in all oily fish such as salmon. One standard capsule of fish oil is equivalent to 300 mg of EPA and DHA. Two tablets of fish oil taken twice weekly provides the same amount of omega-3 fatty acids as 6 oz salmon twice weekly. Evidence for cardio vascular protection from the plant-derived omega-3 FFA, alpha-linolenic acid, is much weaker than it is for DHA and EPA but eating walnuts, flax seed, sunflower seeds and enriched omega 3 eggs can boost your overall intake.

Modest consumption of 200-500 mg/day has been associated with reduced coronary deaths. More is better!

Omega-3 FFA may be taken at any time and the oils persist in cell membranes for weeks after consumption so you can take more at once if you don't want to take it every day. That's why eating fish twice a week is equivalent to daily dosing. It doesn't interfere with any other medication.

Carnival of Human Resources Blog


Check out Wally Block's Three Star Leadership Blog
which features some great links for the human resources world (including EverythingHealth, thank you very much!). This great collection includes "Steps for figuring out your next career move", "CEO excessive pay", "How to interview" and even "How to be a green leader". But it's HR so don't spend all of your work day surfing the web or you could get fired. ha ha.

Monday, March 17, 2008

Paper or Plastic?


Thanks to my friend at Frankly Green for this great link at msnbc.com to help answer that age old question:
"Paper or Plastic?"

It is a little long to watch, but it's informative.

If you don't want to watch it...I'll give you the punchline: Take reusable bags. (Keep them in the back of your car so you always have them with you) If you are caught without a reusable bag...make your decision on which paper or plastic bag you would reuse for another task. It's not simple, but if we all used reusable bags it would go a long way toward reducing our "carbon footprint".

Saturday, March 15, 2008

Too Many Tests, Too Many Doctors


I've written often about the primary care doctor shortage and the crazy system of health care financing that we have in the United States. To get a clear example of this, check out the great op ed article in the New York Times, titled "Many Doctors, Many Tests, No Rhyme or Reason."

The writer, a medical intern, had his eyes opened when he witnessed a 50 year old man who was admitted for shortness of breath, ended up staying a month in a hospital with consults by a hematologist (blood specialist), endocrinologist (gland specialist), podiatrist (foot specialist), two cardiologist, nephrologist (kidney specialist), ID (Infectious disease), pulmonary (lung), urologist (male urinary), Gastroenterologist, nutritionist, pain specialist, two surgeons and a thoracic surgeon.

The patient underwent 12 procedures, including a pacemaker and cardiac cath. His main diagnosis (which does cause shortness of breath) was anemia.

The question to be asked is, did that extensive and mind boggling expensive work up benefit that patient? It wasn't mentioned in the article but I am pretty certain he was not paying the fee. Either an insurer (read the working guy) or Medicaid (read your taxes) coughed up the dough for the hospital, the tests and the 17 doctors.

In the "old days", when patients had a family doctor or Internist, there was someone to coordinate and manage the patient. Now, if a patient sees an Orthopedic physician for a bad knee and surgery is planned, the Ortho doc will ask for surgery clearance which can start the cascade of one specialist after another. Some of this is defensive medicine, some are thoughtless referrals, some are feeding patients to your buddies.

For example a cardiologist may find an abnormal EKG. Without an old one to compare, he may think those extra beats are worrisome and that leads to more tests and more referrals. The physician thinks they are doing the best by being "complete and comprehensive" but you end up with the scenario of multiple consults and tests that have nothing to do with the knee replacement.

Less than 20% of medical school trainees choose primary care medicine and studies show that even fewer stay in the field to practice. That means we are cranking out more and more ultra specialists. Studies show more specialists do not translate to better care and in fact, there is an inverse relationship with quality outcomes and more specialists.

Read the Op Ed. It's an eye opener and sadly very true.

Wednesday, March 12, 2008

Powerful Men and Sex


Even in the staid medical world, everyone was talking about Gov. Eliot Spitzer today and his fall from grace. What the hell was he thinking????

The big question in my mind is why would a respected, well known, powerful man...a member of the lucky gene club, risk it all for dangerous liaisons? His crazy decision to spend a reported $80K on high priced prostitutes has brought down his marriage, career and reputation. (Not to mention Hillary Clinton lost a super delegate). And there are probably many powerful men wiping their brow right now with relief that it wasn't them caught in the sting.

The answer to this unanswerable question "Why?" may be all about personality disorders. The type of man who seeks power (that includes politicians) may also have risk seeking behavior. There is some evidence that risk seekers have a lower level of monoamine oxidase A, which is a chemical that regulates the brain's level of the neurotransmitter, dopamine. They seek novel and risky situations to increase dopamine, the "pleasure" chemical. There is a thrill in seeking the dangerous and the more they get away with it, the more addictive that feeling can be.

Another personality aspect of many powerful people is narcissism. It's all about them. They view the world through their own personal needs and believe that they deserve the favors, adoration, money and attention that is bestowed upon them due to their office or job title. They are treated like they are special and they believe it. That egocentric personality that got them to the top causes them to believe they are different than the rest of us. They truly believe that they are above the law and societies norms.

We will undoubtedly learn more about Spitzer's personality and affairs as time goes on and the 22 year old escort writes her book. In time we will get tired of hearing about it and forget...until the next politician hits the front page with a new scandal.

Tuesday, March 11, 2008

Grand Rounds

The best of the medical blogs are featured in this weeks Grand Rounds, hosted by our Canadian Medicine friends. Check it out for some good reads.

Monday, March 10, 2008

Expensive Placebo Pills Work Better


An amazing study published in JAMA has shown that expensive placebo (dummy) pills work better than cheaper dummy pills. Researchers from Mass. Institute of Technology (MIT) recruited 82 healthy people. They said they were taking a new opioid pain pill that had been approved by the FDA. Instead they gave half the subjects a placebo pill that they said cost $2.50. They gave the same placebo to the other subjects but told them it cost .10 cents.

The researchers administered electric shocks (hope they got paid for this study!!!). Of the folks who took the $2.50 pill, 85% said it worked. Only 61% of the people who took the same placebo worth .10 cents said it worked.

The take home message for doctors is that we shouldn't be stressing how inexpensive medications are if we want people to improve. Generic Omeprazole has been shown to work as well as Prilosec for GERD. All of us have had patients who ask for the "Name Brand" (read expensive) because "It works better". It may work better because of its effect on the pocketbook rather than the body.

How we communicate may have more effect on healing than the drug itself.

Reduce Stress - 3 Simple Ways


EverythingHealth is happy to present a guest blog today from educator and writer, Susan Jacobs.

Keep Healthy By Reducing Stress - 3 Simple Ways

Let’s face it; life can be very stressful at times for everyone. With worries about jobs, families, friends, and much more, the average person deals with a considerable amount of stress daily. New research has shown that stress can have extremely negative effects on the health of a person. Life-threatening events such as strokes and heart attacks are often caused by stress. With that in mind, I decided that it would be a nice idea to provide information on 3 things that cause stress, and 3 ways to alleviate stress.

Top 3 Stressors

1. Relationships

This shouldn’t come as a surprise to anyone who has been in a relationship, but relationships can be downright stressful sometimes. There are a lot of issues that can occur between two people, which can cause considerable strain on any relationship. When relationships end the amount of stress can really take a toll on one’s body and mind.

2. Finances

In today’s “dog-eat-dog” world, financial stability is paramount. In other words, financial worries can cause a significant amount of stress. Bills, credit cards, mortgages, and other various debts can often take their toll on a persons overall health.

3. Time Management (Or a lack there-of)

People are simply too busy sometimes these days. With work, school, families, clubs, and various other activities, there is often little time to relax. Time management is a major cause of stress amongst people. When many things need to be accomplished, but there just seems like there’s not enough time in the day to do it all, stress levels can go through the roof.

Stress Relievers

I started with highlighting the stressors so readers can identify the source (which is half the battle). The next thing to do is get rid of the stress completely, or at least lessen it for a while. This can be accomplished in a variety of ways.

1. Working Out

Physical activity is a great stress reliever. It’s healthy, and is not terribly time consuming in order to be effective. It can also lead to higher self-esteem as those who work out regularly eventually start to get into shape. When life around the house, or work, or wherever seems to be too stressful, going to the gym and lifting a little bit, running, or any other activity can be a great stress reliever. The best thing about it is that you are adding to productivity is well, which always increased confidence.

2. Sleep, Sleep, Sleep

Too many people today go through their whole weeks without ever getting the right amount of sleep. Most people become irritable when they are tired. Being tired is likely to make you much more stressed than it’s worth. Set scheduled bed times if you have to. Give yourself time for a nap when you get home from work, or whenever you are free. Sometimes the best way to relieve stress is to simply shut your eyes for a few and relax. Not to mention, you’ll be much more mentally agile if you’ve had a full nights sleep. Remember, a lack of sleep always leads to stress.

3. Management

Time and finances are usually the most limited resources in any person’s life, which can lead to stress over anything that concerns that. If you can merely manage them both, things won’t be as stressful. For time, make use of date books, calendars, planners, and anything else you might think you need don’t over-stretch yourself and make room for relaxing time, eating, and sleeping. The busiest person I know isn’t nearly as stressed as me because she makes use of time management.

For finances, management is also a key component. If you have a credit card, don’t buy something unless you can afford to pay it off. Also, if you don’t need it, don’t get it. Too many people get credit cards and see a fountain of wealth. There are countless financial management seminars, tapes, CDs, books, etc for people who don’t know where to begin. If you’re really struggling, consult a professional. In any case, the stresses of finances shouldn’t dominate your life. You can be proactive and take control of reducing your stress.

Stress can have extremely negative effects on both the body and mind. With the constant worries many have, it may seem like too much of a daunting task to deal with everything. However, using a few simple pieces of advice can go a long way. Managing, sleeping, and working out are just a few examples of great ways to relieve stress. Remember, sometimes life gets to the best of us, but things have a habit of turning around in your favor eventually.

Susan Jacobs is a teacher, a freelance writer as well as a regular contributor for NOEDb a site helping students obtain an online nursing degree. Susan invites your questions, comments and freelancing job inquiries at her email address: susan.jacobs45@gmail.com.

Sunday, March 9, 2008

Nutrition and Childhood Allergy


The incidence of allergies in children has increased over the past several decades. Asthma has increased 160% and atopic dermatitis (eczema, rashes) has increased 2-3 fold. Peanut allergy has also doubled in the last decade.

A new report, published by the American Academy of Pediatrics in Pediatrics shows that breastfeeding for at least 4 months may help prevent allergies in high risk infants. The investigators also found that breastfeeding, compared with feeding cow milk formula protected against wheezing in early life. There was slight evidence that atopic dermatitis may be delayed or prevented by the use of partially hydrolyzed formulas compared with cow milk formulas in mothers who don't breastfeed. There was no advantage in using soy based infant formula.

The authors also found no evidence for delaying certain food groups after age 4-6 months as a protective effect. This included fish, eggs and products containing peanut protein.

All of the answers about the increased allergies in kids were not solved by this study and any time you are talking about the immune system and inflammation, there are more questions than answers.

But now Pediatricians can give solid advise to parents. "Breast feed exclusively for the first four months. If you must use formula, don't use cow milk formula. When you introduce foods, there is no evidence that certain foods trigger allergies."

Thursday, March 6, 2008

Physicians are Sleep Deprived


When patients complain about insomnia or difficulty staying asleep, I must admit I have no personal point of reference to what they are experiencing. I can fall asleep within minutes of my head hitting that nice soft pillow. I can doze off in a movie, sitting around with a group of friends or reading medical journals. The American College of Chest Physicians has now published results of a survey that shows the majority of doctors are sleep deprived.

I suspected it before. We just don't get enough sleep. Doctors reported they scrimp on sleep during the work week and catch up on weekends. Interestingly most physicians reported the lack of sleep did not adversely affect their work. However, 18% admitted they missed family or leisure activities in order to sleep. I think this may be a bit of the "Superman" syndrome. Oh sure, other humans need sleep for top level function, but not me! I'm a Doctor!

The National Sleep Foundation maintains that 8 to 9 hours of sleep for adult humans is optimal for alertness, memory and problem solving. Other studies have found that lack of sleep can more than double the risk of death from cardiovascular disease, but that too much sleep can also double the risk of death.

I would like to see this same survey broken down by age. It is a well known fact that new, young doctors have a very different view of their place in the profession and they are not willing to sacrifice their own personal needs (sleep, recreation, family, outside activities) for the profession of medicine. Work is one aspect of their life, not their entire life. I suspect that younger doctors are not sleep deprived. They have found a way for better balance.

I know for a fact that you can train yourself, over time, to get by on less sleep. I sleep less than anyone in my family or my friends. Is this a good thing? I don't know but it does allow me to indulge in blogging and reading and writing and yawn!!!! I'm tired.

Wednesday, March 5, 2008

Medicare Fraud - Or Just a Mistake?


I hate waste and fraud as much as the next guy but are "Medicare coding mistakes" really the most pressing activity for our government to go after? Private audit companies, hired by Medicare, will begin scouring mountains of medical records in doctors' offices and hospitals to see if health care providers made a mistake in coding and billing Medicare. Intent to fraudulently bill does not need to be proven...just the fact that the wrong code was used is enough for the Feds to recoup enormous fines. These "recovery audit contractors" will keep 20% of the over payments...quite an incentive to look at every code and be a Monday morning quarterback.

Just to put it in perspective, there are 1.2 billion Medicare claims filed each year and during the first 2 1/2 years of the program in Florida, California and New York (big Medicare states) the error rate was less than 0.2%. Some errors are obvious, such as billing for more than one colonoscopy in a day. But some are just nit-picky...like whether a patient has the correct diagnosis to qualify for being admitted or being sent to a rehab facility. The patient already received the medical service or hospital care. If the code for diabetes was switched to heart failure, does it really mean fraud occurred?

Have you ever tried to appeal or fight the government on taxes or parking tickets or anything where you get hung up in bureaucracy? It costs about $2000 to appeal each claim audit, not to mention the personnel costs. Many providers just don't appeal because it is not worth it.

I'm all for ferreting out Medicare and Medicaid fraud. It should be easy to find these clinics I read about, that cruise poor neighborhoods for patients and then do millions of dollars of unneeded tests on them. I say throw the book at 'em.

But coding mistakes (when there are tens of thousands of codes that change constantly) and gray areas of clinical judgment can be legitimate Medicare expenses that do not warrant repayment.

Couldn't we start investigating Haliburton and it's subsidiaries and try and find out where billions of Iraq reconstruction dollars have gone? Now that would be money well spent.

Tuesday, March 4, 2008

Antibiotics - Truths you may not like


Some blogs are so good I want to repeat it for my readers. Thanks to Distractible mind for this one. Patients don't like to hear it but here is the real truth about antibiotics and YOU:

Common myths about infections and antibiotics

Much attention has been given to the fact that antibiotics are given too often. The reason for this concern is that the overuse of antibiotics can create resistance in the bacteria a person carries, making it much harder to treat serious infections in the future.

For that reason, the physicians in our practice are trying to avoid using antibiotics unless they are necessary. The problem is that many patients come to the office already convinced that their infection requires an antibiotic and so will not be satisfied unless they get one. This puts our staff in a difficult position, as we want to practice good medicine, but also strive keep our patients happy.

To help with this problem, here is a list of common misconceptions about when antibiotics are appropriate.

  • If mucous is green, it is time for antibiotics. Almost all respiratory infections go through a stage where the mucous turns green (or darker). This is due to a large number of white blood cells, and may actually mean that your body is winning the battle against the infection.
  • When a fever starts, it is time for antibiotics. Fever is part of the body’s defense against infection. Even fevers as high as 104 can be caused by viruses (which are not killed by antibiotics).
  • Sinus pain means you need antibiotics. Sinus pain is caused by a difference in pressure between the inside of the sinuses and the outside world. This is usually caused by thick mucous, and not necessarily infection. Decongestants can help with this (although they may not be appropriate with certain heart conditions and hypertension), as can salt water spray in the nose. The pain is best treated with acetaminophen (Tylenol, etc), or ibuprofen (Advil, etc.).
  • “The last time I had this I needed antibiotics, so I wanted to catch it early this time.” Most infections that do require antibiotics start with a virus infection and then turn into bacterial infection for which antibiotics are appropriate. To treat an infection “early” means that you would treat it when it does not yet need antibiotics. This is exactly what can cause resistant bacteria. If your symptoms are that of a virus, then antibiotics are a bad choice.
  • Bronchitis requires antibiotics. While there are some cases of bacterial bronchitis, the majority of cases of bronchitis are caused by viruses. Bronchitis happens when a person has a coarse cough (loose phlegm), and does not have pneumonia (as heard by the physician on exam). Overall, bronchitis probably accounts for the biggest number of inappropriate antibiotic prescriptions.
  • “I am immune to amoxicillin.” Amoxicillin is not the strongest antibiotic. This is exactly the reason we like to use it first. The goal of antibiotic therapy is to knock the bacterial infection down to the point that a patient’s body can do the rest. Most of the time, the “weaker” antibiotics do the job just fine. Stronger antibiotics are used when:
    • A person is has just finished a course of “weaker” antibiotics. In this instance, the bacteria are more likely to be resistant. This resistance only lasts for a few months.
    • A person who is physically frail.
    • An infection that appears especially serious.
  • “Can I have antibiotics to be on the safe side?” Antibiotic resistance is much less safe than waiting to see if an antibiotic will be needed.
  • “Can you call in an antibiotic?” We usually don’t call in antibiotics. The one sure exception for this is if a family member has a documented case of strep throat. The contagiousness of this is enough that it is reasonable to call it in. Sinus infections, bronchitis, and ear infections are not something we will call in antibiotics for. Please don’t ask.
  • “When I got an antibiotic last time, I got better. That means the antibiotic made me better.” Thankfully, most illnesses get better over time. It is very possible that it would have gotten better just as fast without the antibiotic. Just because the rooster crows every morning, doesn’t mean it causes the sun to rise.

Monday, March 3, 2008

Women, Now You Can...PEE STANDING UP!



Thanks to Rich in Boston for alerting me to the fact that women can now pee ("urinate" for you purists) standing up. You might think it is gross to talk about, but for women who are tired of laying toilet paper on the seats or using their quads until they tremble with fatigue, this is a novel idea. I like the handy little cardboard. Hope it is biodegradable, just like pee.

Sunday, March 2, 2008

You're the Doctor - Answer


The patient in the photo below has Poison Oak (Rhus dermatitis). Don't feel bad if you missed it. She had 4 medical visits before it was successfully diagnosed.

Poison Oak is a form of a contact dermatitis (good work, "erp") and she actually contracted it while hiking in Point Reyes, California. Once the urushiol oil from the plant sets on the skin, an inflammatory and allergic response keeps it going, sometimes for weeks. The weeping blisters are common, as is the swelling redness. Contrary to common belief, the oozing blisters do not spread it. It is the underlying response of the body that keeps the dermatitis spreading.

She was successfully treated with topical and oral corticosteroids (Prednisone) but some scars have remained.

Thank you to K.M. for allowing her story and photo to be shared.

Saturday, March 1, 2008

You're the Doctor- Whats the Diagnosis?


This young woman developed this skin condition on her leg after a trip to the Grand Canyon. She was treated with two different antibiotics but it worsened. The winner gets a years free subscription to EverythingHealth. Oh, yea...it's already free. OK the winner gets bragging rights.
Answer will be posted tomorrow.

Ricin - what you should know


The poison Ricin was found in a Las Vegas Hotel room and one man is hospitalized and unconscious after exposure. Because it takes a deliberate act to poison with Ricin, this brings up concerns about National Security and many questions that are not yet answered.

Ricin is the "waste" mash left after Castor beans are processed into castor oil. Except for cancer research, there are no medical uses for Ricin. It is a stable structure and doesn't degrade in extreme temperatures. People can breathe in a Ricin mist or it can be swallowed in food or water or it could even be injected. As little as 500 micrograms (the size of the head of a pin) could be enough to kill an adult. It kills by getting inside the cells and preventing cells from making proteins.

Symptoms of Ricin poisoning depend upon the route of exposure and the dose. If inhaled, there would be respiratory distress, fever, cough, nausea and chest tightness within hours, leading to full respiratory collapse and death. Ingested ricin would cause vomiting and bloody diarrhea leading to major organ failure and death.

There is no antidote for ricin but supportive medical care (intensive IV fluids, respiratory support) can save people who have low exposure if started before shock sets in. There are no tests to confirm that a person has been exposed to Ricin.

In terms of bioterrorism, Ricin is easy to produce but is not considered as powerful a threat as botulinum or anthrax. Those substances can have more of a widespread effect, but are more difficult to obtain.

Hopefully this guy will live so authorities can question him about why he has this dangerous substance. He's been in the hospital, probably on a respirator, for two weeks. Right now there are more questions than answers.

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