Thursday, May 29, 2008

Positional Vertigo - Common and Treatable

One of the most common ailments I treat is Benign Positional Vertigo. The patient usually feels awful, off balance and with the room spinning for no reason. It can occur suddenly and dramatically when he gets out of bed and cause vomiting and unsteadiness when walking. The episodes can be continuous or in brief episodes that are worse as the head is moved. A good neurologic exam and absence of any one sided weakness or facial droop can cinch the diagnosis without expensive testing or scans. I look for nystagmus ( rapid involuntary movement of the eyeball) when I turn the patients head from side to side. Over time the nystagmus stops.

You would think that treatment for such a common and miserable condition would be taught in medical school. There are very effective office treatments called canalith repositioning procedure or Dix-Hallpike maneuver or Eply maneuver. Each has slight variation and involves a series of specific and timed positions for the head that restores the equilibrium in the inner ear with good effectiveness for the majority of patients.

Why don't more physicians know how to do this simple treatment? Many patients end up in the Emergency Department, yet the majority of ED physicians don't know how to do it. I thought the Ear-Nose and Throat (ENT) doctors would be the experts but after referring several patients, I realized they didn't do it. By default, I taught myself how to do it and have been helping patients leave the office symptom free ever since.

I was talking with a physician friend today about all of the simple, low tech things we can do for patients that have great benefit. They are the toolkit for primary care. They are not sexy and get little attention, no extra reimbursement and most physicians learn them themselves after years of practice...not in medical school.

The PET scans and MRIs and cardiac imaging studies get the attention and the big bucks but it is sometimes the simple, cheap methods that make life more pleasant.

Wednesday, May 28, 2008

A Cup of Cocoa Helps Diabetes

Time for health news that is warm and fuzzy!

A new study reported in the Journal of American College of Cardiology shows that a big mug of hot cocoa can reverse vascular dysfunction in patients with diabetes, suggesting a therapeutic potential of cocoa in this patient population.

Prior studies have shown that flavanol-containing foods, including cocoa, certain fruits and vegetables, tea, and red wine, have beneficial effects on LDL oxidation, platelet aggregation, insulin sensitivity, endothelial function, and blood pressure. These researchers show that the reversal of diabetic endothelial dysfunction with cocoa is comparable to intermediate- and long-term interventions using exercise and various medications, including insulin, pioglitazone, ACE inhibitors, and statins. They also found that over time the good effects persisted. Even if cocoa could enhance lifestyle and medication benefits in diabetics, it would be significant in how we approach this diabetes epidemic.

This study was not designed to determine the molecular mechanism of action but there is an indigenous population in Panama (Kuna Indians) that consumes a large amount of cocoa rich in flavanols. Despite their diet that also has a large amount of salt, they have a very low prevalence of heart disease, stroke, diabetes, and cancer compared with Kuna Indians living in Panama City.

It is important to know that the doses of flavanol in the cocoa were much higher than what we are drinking. The high-flavanol cocoa used in this study--which provides much more flavanol than the typical US dietary intake of 20 to 100 mg daily--is not sold in the supermarket.

It looks like an opportunity for a Mars or Hersheys manufacturer to me.

Sunday, May 25, 2008

Our Rights as Americans

This is the opposite of EverythingHealth. Why anyone would need this object of destruction is a mystery to me. Coming soon to a gun show near you! (Hat tip to Ray B. for this)

Saturday, May 24, 2008

Popular Music Influence

I like popular music, along with all genres like R&B, hip-hop, classical and golden oldies. The pre-teens and adolescents that I know are fixated on Rap and don't listen to much else. The influence of Rap music is world-wide, not just the United States, and the entire rap subculture has permeated the world.

The Archives of Pediatrics and Adolescent Medicine published a study that looked at popular music and references to substance abuse. I am not surprised at all by their findings but seeing it in print was a bit of a wake-up.

The authors analysed 279 of the most popular songs of 2005 according to Billboard magazine. They used coders (funny to read about coders for anything other than medicine) who collected portrayals of substance abuse.

Of the 279 songs, 33.3% portrayed substance abuse with an average of 35.2 references per song-hour. The rap songs had the most references at 77%. Pop music had 9%.
Surprisingly, country songs talked about substance abuse with 36% references. R&B/hip hop songs had 20% references to substance abuse.

The references to substance abuse were most often connected with social pressure, partying, sex and violence. Only 4 songs (4%) contained explicit antiuse messages and none talked about substance refusal. The songs portrayed more positive than negative consequences; like social, sexual, financial or emotional.

So what does all of this mean? Well, the average adolescent is exposed to approximately 84 references to explicit substance use daily in popular songs and these songs link drug use in a favorable way.

I am not on a bandwagon to ban music or burn iPods, but studies like these can make us acutely aware of just one of the many negative influences our kids face as they try to grow up.
I know my son is fascinated by, and loves gangster rap. I will use this study as yet another "talking opportunity" about forces that are not healthy for mind or body.

Friday, May 23, 2008

Bloggers Love Comments

Happy Memorial Day Weekend to readers of EverythingHealth. If you are from another country, I wish you a wonderful weekend also and hope you are having nice weather!

We bloggers love comments. It tells me that you are reading the blog and that what I have written stimulates you in some way...either good or bad. It is also a way for readers to add information or share an idea.

Due to recent spam in my comment section, I have added a word verification to cut down on electronic spam. I think it is pretty easy to use (I've done it on other blogs when I comment) so give it a try by commenting on this. Don't worry, your comments cannot generate spam to you.
Thanks for reading and please visit again soon.

Exercise Your Brain

(Homer Simpson's brain)

I have a big birthday coming up so aging is on my mind. Having things "on your mind" is good because the brain benefits from being stimulated.

The story that you are born with all of your brain cells and you use only 11% of your brain throughout your life is wrong, wrong, wrong. Brain imaging research with PET scans and fMRI scans show all areas of the brain are stimulated with different activity. The entire brain is used in an active person.

We also generate new nerve cells (neurogenesis) throughout our lives and maintaining mental acuity is what we all strive for, right? One question scientists are asking is "Are mentally sharp people more engaged socially and with more stimulating activities, or does staying involved create better functioning brains?" What comes first? Studies have shown that people who exercise have improved cognitive function. It may be the result of improved blood flow, neuro hormones and neurogenesis from exercise stimulated growth factors. Perhaps exercise cuts down on other diseases that affect the brain like diabetes.

Stimulating the brain with new inputs like travel, language, music and engaging with interesting people also has been shown to increase memory and cognition. Trying new things, not getting stuck in a rut, staying engaged and involved with all aspects of life are important for brain power. Unfortunately, none of this will reverse or stop the dread disease, Alzheimers.

As my birthday approaches, I am comforted to know that I have a condition that affects 100% of people...aging. There is no stopping it and all of the growth hormones, supplements, antioxidants, plastic surgery, Viagra and push up bras are ineffective at halting the relentless aging process.

But what is better than a prescription to eat a Mediterranean diet (yum...olive oil, wine, vegies, fish and nuts), play with interesting and fun friends, travel, read, have sex and embrace learning new things? If that is the prescription for having a healthy brain, sign me up.

Wednesday, May 21, 2008

Suicide by Self Burning

The New England Journal of Medicine reported on the tragic plight of women in Afghanistan that causes women to burn themselves as a means of suicide. The United Nations Development Fund for Women reports that 70-80% of female Afghanis are forced into marriages and more than half are married before they are 16 years of age. Women have an 84% illiteracy rate and average 7.5 births per mother. Only 14% of those childbirths have a skilled attendant present and the country's maternal mortality is 2nd in the world.

Afghan women are forced into early marriage to settle conflict between families or tribes and it is routine that these women suffer abuse from their husbands and in-laws. There is no recourse for women who are abused by their husbands and suicide, by pouring gasoline over themselves and lighting a match, is an act of desperation. According to the authors, "women and girls see this horrifying act as a means of both escaping from intolerable conditions and speaking out against abuse, since their actual voices do not bring about changes that would allow them to lead safe and secure lives."

The number of women who committed suicide by lighting themselves on fire more than doubled between 2005 - 2006 in Afghanistan.

I am trying to imagine a life like these women live. I will be thinking of it tomorrow as I drink my latte and get my son off to school in the morning. I will be thinking of it when I pick roses or run to the grocery store to pick up a forgotten item. I will think about it when I get a manicure or drop of clothes at the dry cleaner.

I urge anyone who cares about women to click on Women for Women International. A contribution will go a long way toward helping disadvantaged women in war torn countries. When women are strong and healthy, the society is strong and healthy.

Tuesday, May 20, 2008

Ted Kennedy - Brain Tumor

I wrote about Senator Kennedy's seizure yesterday and now the results of a biopsy show he has a malignant brain tumor. Unfortunately he has a glioma in the left upper part of his brain, the parietal lobe. At age 76, Senator Kennedy's prognosis is poor because gliomas, particularly in the parietal lobe are difficult to treat.

The cause of glioma brain cancer is unknown and it is not linked to smoking or alcohol. Most gliomas present with a seizure or headaches. These are fast growing malignancies and they don't spread to other parts of the body.

Google Health-a review

Google Health is officially open for business after much pre-development fanfare. It is an on-line medical record that can be added to and accessed by the patient and any entity he/she authorizes. Since the Electronic Medical Record is such a big deal, many people think Google Health will solve the problem that medical groups and hospitals have been struggling with for decades.

I checked out Google Health to see how it functions. It has good privacy policies and the patient is the only one who can authorize access. They promise not to share information with anyone else (except when required by law...remember the illegal wire taps!). It appears to be a secure site.

Information is entered easily by the patient. They have a "conditions" list that was easy for me to use but I am not sure all patients will know the medical names of their conditions. You can, however, type in the name of your condition. For example the pull down list says hypercholesterolemia but if you don't know that word you can say "high cholesterol" and that works.

You can populate the record with conditions, medications, allergies, procedures, test results and immunizations, along with your profile details like age, sex, height, weight. There are also links to "import medical records" and they have links to Walgreens, medco (mail order pharmacy), Cleveland Clinic and other select providers and Quest diagnostics. I suspect as time goes on, the link list will increase and it will be easy to have pharmacy and lab data get into the record.

Other features are "Explore health services" (which is simply links to their partner sites) and "Find a doctor". There are no ratings or quality metrics provided here...just the names and addresses in your area. It would be far more helpful if a patient could see who is accepting new patients, what languages they speak and what insurance they carry. You won't get that on Google Health at this time.

One nice feature is "drug interactions"...which gives you info after you enter your medications.

In summary, the site is easy to use, but requires a bit of computer sophistication and a lot of work for the patient to get it populated with information. It would be a good and easy way for patients to keep track of their screening tests, immunizations and drugs without having to carry around little pieces of paper. It has a really clean look, just like the Google Search Site. There are no ads (hurray!!)

I don't anticipate many doctors using this and it should not be confused with a robust "Electronic Medical Record" (eHR) . A good eHR has real time data that can be used by everyone caring for the patient and includes a problem list, all tests, current medications, labs, consultations and progress notes.

Google Health is a repository of health information and it is only as good as the info the patient puts in. It will need to be updated and maintained to be accurate. It is a good way, however, for patients to start getting involved in their own health maintenance.

I must admit I will probably use YouTube more than Google Health.

Sunday, May 18, 2008

Ted Kennedy's Seizure

Ted Kennedy, age 76, was rushed to Massachusetts General Hospital in Boston yesterday after suffering a seizure at his Cape Cod home. The first report was that he had suffered from a stroke, but that has been ruled out. He is reportedly doing fine and has no after-effects from the seizure, although he is still undergoing tests in the hospital.

In medicine, when I hear of a first seizure occurring in an adult, the first thing to make sure of is that it is a true seizure rather than a fainting spell (syncope). A seizure usually causes loss of consciousness and it is usually followed by a short period of confusion and feeling dazed. In contrast, a person will usually awaken clear headed after a fainting spell. I presume Ted Kennedy's episode was witnessed by family or friends and that he had some type of muscle shaking or sensation that identified it as a true seizure.

Once it has been identified as a true seizure, looking for a cause is the next order of business. Causes of seizures in adults are strokes, brain trauma, infection, medication toxicity, alcohol or drug withdrawal, or tumors (either benign or malignant). Some times an old brain injury from trauma can cause seizures many months or years later. The diagnosis of epilepsy requires two seizures, at least 24 hours apart. One third of people with a single (unprovoked) seizure will develop a second one.

Senator Kennedy will probably undergo the following tests:
  • Routine lab tests
  • Lumbar Puncture to examine his cerebrospinal fluid
  • Drug and alcohol screening
  • Electroencephalography (EEG)within the first 24 hours
  • Sleep deprived EEG if the first one is negative
  • MRI scan
The above tests should give Senator Kennedy and his physicians the answers they are looking for. There is controversy about whether to treat a single seizure with medication.

Hopefully they will find the cause and be able to determine if he needs seizure medication. He will not be able to drive for at least a year.

Friday, May 16, 2008

Acute Hepatitis C from Unsafe Injections

The CDC has concluded an investigation of a clinic in Nevada that reported an outbreak of Hepatitis C Virus (HCV) in 6 people that resulted from unsafe injection procedures. Here's what happened:

Hepatitis C is a reportable infection to the health department and when 3 people were reported in 2 days it raised concern about an outbreak. It turned out that all three persons underwent procedures at an endoscopy clinic within 35-90 days of the illness onset. Three more cases turned up from the same clinic for a total of six cases.

The incubation period for HCV is 15-160 days. Hepatitis C causes liver inflammation, jaundice, abdominal pain and elevated liver enzymes. Four of the six patients required hospitalization and four had procedures within a two day period. An additional 120 persons had procedures at the clinic during the time period and they are currently undergoing testing.

Investigators observed that improper injection practices were being done at the free-standing private endoscopy clinic that performed 50-60 colonoscopies and upper endoscopies a day. The staff members used clean needles and syringes to draw up anesthesia (propofol) medication and injected it directly into a patient 's IV catheter. If a patient required more sedation, the same syringe was used to draw more medication. Backflow from the patient's IV catheter contaminated the syringe with HCV and subsequently contaminated the vial. Medication remaining in the vial was used to sedate the next patient and on and on.

The Nevada Health Department is now contacting 40,000 patients who underwent procedures requiring anesthesia at the clinic to undergo screening for HCV, Hepatitis B and HIV infections from March 1. 2004 until the practice was stopped on Jan 11, 2008.

For Health Care Professionals:
  • Never administer medications from the same syringe to more than one patient, even if the needle is changed
  • Do not enter a vial with a used syringe or needle.
  • Never use medications packaged as single-use vials for more than one patient
  • Do not use bags or bottles of IV solution as a common source of supply for more than one patient
  • Follow proper infection-control practices during the preparation and administration of injected medication
Adapted from Centers for Disease Control

Answer to Medical Quiz

The answer is #1 - Hyphema. This is a common condition and it looks worse than it is. Blood (from a broken vessel or trauma) layers in the front of the eye. If it pools over the sclera (white part of the eye) it looks like a bloody blotch and can be quite frightening. Like a bruise, it resolves without treatment.

For the other players - Hypopyon refers to pus. Iridocyclitis refers to inflammation of the iris (the round colored part of the eye). Iridodonesis is a quivering of the iris when the patient moves the eye. Synechia is an adhesion between the iris and the cornea.

Thursday, May 15, 2008

What's the Diagnosis? Medical Quiz

Here is today's Medical Quiz compliments of the New England Journal of Medicine. This patient awoke with a very red eye that looked like blood. There was no pain and it did not affect his vision. What is the diagnosis? Click on the image for a better view.

The answer will be posted tomorrow.

Thursday, May 8, 2008

I'm Off To The Big Apple

EverythingHealth will be taking a little break for the next few days as I will be in New York City. It will be a thrill to be on the East Coast and experience the great New York. For your reading pleasure, check out my favorite blogs on the right side. You will find plenty to keep you occupied until I return next week.

Answer to Medical Quiz

This was a hard one. The answer is number 5 - Keratoderma blennorrhagicum.
These foot lesions are a feature of Reiters Syndrome, which is a reactive arthritis that is often the result of a sexually transmitted disease or a gastrointestinal infection. The foot lesions occur in about 20% of people with Reiters Syndrome.

Wednesday, May 7, 2008

Medical Quiz - What's the Diagnosis?

This patient is a young man with abdominal pain, diarrhea and these non-itchy lesions on his feet. What is the diagnosis?
1. Dermatopathia pigmentosa reticularis
2. Lichen planus
2. Psoriasis
4. Rubella
5. Keratoderma blennorrhagicum

Click on the image for a better view. The answer will be posted tomorrow.

Tuesday, May 6, 2008

Screening Blood Panels - Overused, Overtested

The Annals of Internal Medicine has reported that "frequent cholesterol measurement may be misleading." There are normal variations and fluctuations in any blood test that give erroneous information and frequent checking (even annually), when a person is stable on a cholesterol lowering drug, is pointless.

Other studies have shown that the "routine" blood tests we Internists and Family Doctors order on patients are worthless. Few diseases are discovered by a blood test if the patient doesn't have any symptoms. Yet it is almost impossible to practice medicine and be seen as credible by patients if you don't order a ton of tests. Many patients would rather have the blood test and forgo the doctor visit.

This is all backwards. Somehow we have sold the public a bill of goods. Over years, medical experts have convinced patients that we can detect early disease and save their lives if only we will "do everything" possible with screening tests. We have lots of blood panels (CBC, Chem 24, CRP, TSH, urinalysis, Lipids, ANA, RF, Thyroid panels, hair analysis, hormone levels, PSA and on and on) that we can run along with chest Xrays, bone density tests, cardiac stress tests, body scans, ultrasounds and mammograms.

Of these, the only ones that have been proven to potentially prolong life are:

  • Mammogram

  • Colon screening

  • Abdominal ultrasound in men over age 60 with a history of smoking or hypertension

What if primary care doctors stopped doing all of the expensive and worthless screening tests and used that time to sit with a patient and really work out a focused and preventative lifestyle that would improve health. With the use of technology, patients and doctors could monitor changes together. It would take time and effort for both the patient and doctor and need to be valued and compensated . We could use the expensive testing $$$ to pay the doctor, nutritionist and others on the team and there would probably be money left over.

Now that would be health reform that was meaningful.

We Love Big Cars

Monday, May 5, 2008

Denial - Not a River in Egypt

It amazes me how people can justify just about anything...despite all the evidence to the contrary. As they say "De-Nial is not a River in Egypt."

A guy I know came up to me at an event, reeking of tobacco smoke. Seriously, I had to take a few steps backward because of the odor. Because I am a doctor, he launched into a story about a study he is in at Stanford, where they are testing him for some health factors. I couldn't quite follow what the study was assessing.

What was remarkable was that they said he is so healthy that they told him not to quit smoking because if he quit, his health might go downhill. Yes, he heard them say that being a smoker has helped his health.

It is hard for me to believe the doctors at Stanford advised him to continue chain smoking. He doesn't look particularly healthy, has a smokers voice and unhealthy smokers skin. Of course I do not know his underlying health status.

We can fool ourselves about most anything if we want to. But 10,000 studies don't lie and believe me, smoking is about the worst thing you can do to your body.

Sunday, May 4, 2008

Women's Choice

I came across a blog that I want to share with the readers of EverythingHealth. This New York gynecologist wrote a compelling blog on why she chose her specialty. It's worth a read here at The Blog That Ate Manhattan.

Friday, May 2, 2008

McCain's Health Plan - seriously flawed

Candidate John McCain has proposed a health policy reform that will not work, and would worsen the uninsured problem in the United States. Let's take a look:

Seventy-one percent of insured people are now covered (in some fashion) by their employers. McCain proposes eliminating employer sponsored health insurance and giving tax credits to people to buy their own insurance. A family would receive a $5000 tax credit but the typical family premium is $12,000. The consumer can pay the extra $7K or go without insurance. Essentially it would remove the employer from the insurance game and let Americans fend for themselves. Have you enjoyed dealing with your insurance company thus far? How responsive are they to your phone calls or concerns about coverage? McCain says the free market would inspire competition and let those insurance companies compete for your business.

There would be no restrictions on insurers charges or coverage of preexisting conditions. Anyone who self insures today knows what happens if they have a history of cancer or diabetes or asthma or even allergies. They can expect to be penalized with exclusions or premiums that even McCain might blink at. He doesn't need to worry about his own skin cancer because he is covered by his (free) Federal plan. He proposes "high risk pools" to address pre-existing conditions, but has no real plan to ensure that these pools are funded.

McCain's plan does not include universal coverage and it allows companies to sell insurance across State lines, which would eliminate State protections that are already in force. There are no cost controls on premiums. He assumes market competition would work here.

Senator McCain's plan benefits the healthy and wealthy. It is a great windfall for American business. For everyone else, it takes us down the wrong path.

Thursday, May 1, 2008

Grand Rounds This Week

For a fun spin around the medical blogosphere check out this weeks Grand Rounds, hosted by Dr. Gurley. Lots of great and stimulating reading!

Breastfeeding New Infants

The benefits of breast feeding for at least the first six months of life have been proven over and over with scientific studies. Let's face it...nature hardly ever gets it wrong. Breast milk is a perfect nutrient, contains antibodies and is easy to digest. It is also free and readily available!

A new study by the Center for Disease Control and Prevention shows that 77% of new mothers breast-feed their babies in the United States. There has been an effort to educate women about the benefits and it seems to be paying off. The stats may be a little skewed, however, because the study gave credit even if a woman breast fed for just one day. And prior studies have shown that far fewer mothers of any age breast feed for the recommended 6 months.

So there is good news, but still not great statistics for what we know is optimal infant health. I think one of the problems is how unsupportive our society is for new mothers. A breast feeding mother cannot be in public without weird stares from people. There are few workplaces that have facilities for a mom to pump her milk. We make it a huge hassle to do what is natural. It is almost impossible to keep breast feeding once a mom returns to work. With the demands of new motherhood and the extra effort it takes for a working mom, it is amazing anyone breast feeds after returning to work.

European cultures are more tolerant and accepting of what is natural. We could learn from them and have healthier children and happier moms.

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...