Sunday, May 31, 2009

Save the Fetus - Kill the Doctor


Dr. George Tiller, age 67, was shot and killed today IN HIS CHURCH in Wichita. Dr. Tiller performs late term abortions and his clinic was the site of many anti-abortion protesters over the years. He was shot in both arm in 1993 and recovered. His clinic has been severely vandalized with protesters cutting through the roof and inflicting water damage. He has been sued and harassed. Now he is dead.

Dr. Tiller's website states "Women and families are intellectually, emotionally, spiritually and ethically competent to struggle with complex health inssues--including abortion--and come to decisions that are appropriate for themselves".

Will someone please explain to me why it is wrong to abort a fetus but it is OK to kill someone in cold blood? Here are some hateful comments made by those who celebrate his murder:
"Don't ask God to have mercy on this man. His soul belongs in Hell", "Sorry but it's a little hard to work up a lot of sympathy for him. Maybe a few more babies will see the light of day now." "Payback is a bitch".

I'm really scratching my head over this one. I just don't get it at all.

Thursday, May 28, 2009

Cervical spine and neck pain

I saw three patients in one day with neck pain. There is a common phenomena in medicine that things come in "3s" and it certainly happened today. This cool vid shows the bony anatomy but doesn't show the muscles and ligaments, which is usually the cause of the pain. The neck, scalp and shoulders can all be affected and painful muscle spasm is pretty common, leading to headache and shoulder pain.

Wednesday, May 27, 2009

Best Countries for Life Expectancy


If you have a choice of where to live to live the longest...choose Japan. The World Health organization has issued stats that show a life expectancy of 83 for living in Japan. Compare that to the lowest life expectancy in Sierra Leone, which is 41 years.

The 14 countries that had life expectancies of at least 81 years were: Japan, Australia, Iceland, Italy, San Marino, Andorra (that one is sending me to google!), France, Israel, Monaco, New Zealand, Norway, Singapore, Spain and Sweden.

The mid range countries have a life expectancy of 78 years: the United States, Chile, Cuba, Denmark, Kuwait, Slovenia and the United Arab Emirates.

Avoid these countries if you want to live a long and healthy life. They are all below 50 years:
Sierra Leone, Afghanistan, Lesotho, Zimbabwe, Chad, Zambia, Central African Republic, Guinea-Bissau, Mozambique, Swaziland, Uganda, Burkina Faso (Google again!), Burundi, Male and Nigeria.

Children younger than 5 account for nearly 20% of the world's deaths and child mortality is the reason for the wide ranges in these countries. The United States ranks 29th globally for infant mortality and we are tied with Poland and Slovakia.

That doesn't sound so good to me.

Tuesday, May 26, 2009

Origins of H1N1 (Swine flu) Virus


The Influenza Division at the Centers for Disease Control (CDC) reported in Science that the genes found in the H1N1 (Swine flu) genome have been circulating in the environment for an extended period of time but have now combined in a new way to cause infection.

By sequencing full or partial genomes of isolates of the virus found in Mexico and the United States, the researchers found combinations of 8 influenza gene segments that had not been previously described in either human or swine viruses.

The scientists found that all segments had originated in avian (bird) hosts and then entered into the swine (pig) population sometime between 1918 and 1998. Two of the segments were derived from Eurasian swine viruses that had not been detected previously outside Eurasia. The other six segments included DNA from human, swine and avian sources that had been circulating since 1998.

Where and how these various segments came together is not clear. They do know that the event lead to the genesis of the novel H1N1 virus that has antigenic properties that are distinct from seasonal human influenza but are similar to other swine-origin influenza viruses.

The CDC reports 6764 probable and confirmed cases of H1N1 in the United States. There have been 10 fatalities to date in the U.S.

Monday, May 25, 2009

Birth as a Health Hazzard



Two different articles in the New York Times today show the vast difference between women in third world countries and western nations. One article talks about the return of the birth control sponge. The contraceptive sponge was not available for awhile due to bankruptcy of the company but it is now being distributed by Mayer Laboratories (they also make Kimono brand of condoms) and the women who like the sponge as a form of birth control will be happy to have it back.

For those women who don't want to use a sponge, no worries! There are many other choices including condoms, oral contraceptives, IUDs, diaphragms and Plan B (the morning after pill). Modern women can get pregnant when they want and avoid pregnancy with a little effort.

Contrast that to women of Africa where childbirth is the most common cause of death in young women. The World Health Organization reports pregnancy and childbirth kill more than 536,000 women a year. For every women who dies, 20 more suffer severe complications like fistulas and infection.

In Afghanistan, women experience a catastrophic death rate from pregnancy and childbirth. Most of these women have never seen a doctor, nurse or paramedic. In some areas only 4% of the women are literate. Even if clinics were available, women in repressive Muslim countries are not allowed to go out alone or even be in the company (let alone examined) by a male doctor so health care is not an option.

Millions of women around the world have no access to information about reproductive health, family planning or skilled care during pregnancy and childbirth. There are no choices for birth control and getting pregnant can be a death sentence.

How can the human experience be so wide? The contrast between many birth control options and baby showers, jog strollers and high tech, safe childbirth contrasted with women who live on less than a dollar a day and have no knowledge of how they can protect their own lives and the lives of their children.

Saturday, May 23, 2009

Doctors as Good Samaritans


As a physician, I took an oath and I believe it is my duty to render aid if I can in just about any situation. I am not particularly "risk adverse" but I can understand when other physicians feel it is just not worth the risk. A malpractice suit can be a disaster.

When EMTs arrive, I give a report to them and back off as they have the tools and training to transport the victim for more advanced care. It happens all the time. A woman faints at a wedding. A child collides at a soccer game and the coaches rush the field. A man has chest pain while 20,000 feet in the air on Jet Blue. A motorcycle spins out of control and throws the rider, right in front of my car. A runner collapses at the Bay to Breakers race in San Francisco. When this happens a little bell goes off in my head before anyone even has to say "Is there a doctor in the house?" So I rush in to provide service.

I never stopped to think about the liability I was incurring by being a "good samaritan". Good Samaritan Laws are meant to protect bystanders from being prosecuted when they help a victim in distress. I was under the impression that Good Samaritan Laws protected everyone who renders aid in an emergency. Upon research, however, I found the statutes are different in every state and have loopholes big enough to drive a truck through. The laws are cumbersome and difficult to interpret and the California Supreme Court recently upheld a victims right to sue after a bystander pulled her from a wreck and she suffered a spinal cord injury from being moved. The court ruled there was not "immediate peril". Other laws only protect the first responder.

With websites like "WhoCanISue.com" and "SueEasy.com" (no I am not providing a link!), it is obvious that anyone can sue for anything. Doctors are prime targets, of course, because we carry malpractice coverage and are juicy deep pockets for trial attorneys.

Because of my training and expertise and comfort in disaster situations, I believe it is my duty to render aid no matter where there is a need. I am not particularly "risk adverse" but I can now understand when other physicians feel it is just not worth the risk to get involved. A malpractice suit can be a disaster.

What do you readers think?

Thursday, May 21, 2009

What is CRP?


C-Reactive Protein (CRP) is a protein found in the blood that indicates "inflammation". It is produced in the liver and during infection, and with some forms of cancer and inflammatory diseases (rheumatoid arthritis, lupus) it can be elevated in a blood test. CRP can also be elevated when there is inflammation in the arteries of the heart and is a "marker" for coronary artery disease.

High sensitivity CRP (hsCRP) is a common test that is done to assess the risk of heart disease, stroke and diabetes. Like high cholesterol, it is not the disease in itself, but high levels (over 3.0) that indicate a higher risk. Scientists don't know if it is a marker or is a cause of heart disease, but we do know that inflammation of the heart blood vessel walls is always present in heart attack victims. Inflammation is the body's defense against injury or infection and unstable plaques in the coronary artery can rupture and the inflammatory cells rush in to repair. Even people with low cholesterol can have high CRP indicating inflammation.

There have been numerous studies of CRP in large populations of people, and it's role as a risk for heart attack is well established. Some believe it is even a better predictor than high LDL cholesterol.

What should be done for people who test high with hsCRP? Lowing other risks (smoking, diabetes control, weight, exercise, high cholesterol) is critical. Aspirin is given as an anti-inflammatory drug and to prevent clotting. Statins (Lipitor, Crestor, Zocor, Pravachol, Mevacor) are potent anti-inflammatory drugs as well as lowering cholesterol. The Jupitor Study, published in the New England Journal of Medicine, showed a reduction in heart attacks in people with high CRP and low cholesterol who were treated with the statin, Crestor.

Among cardiologists and scientists, the benefits of statin drugs in preventing heart attacks is not a controversy. The Internet is filled with blogs that "Big-Pharma" is out to addict us all but science, not emotion, should be our guide.

Monday, May 18, 2009

Talking with Health Plans Costs Big Bucks


Does anyone NOT think we need health care reform? A study published in Health Affairs and funded by the Commonwealth fund and the Robert Woods Johnson Foundation found that physician practices spend $31 billion annually just "interacting" with Insurance plans.

As one who as been on the "interaction" side for most of my professional life, I can tell you those numbers are probably underestimates. The time spent on prior authorizations, pharmaceutical formularies, claims, billing, contracting, collecting data and just being on hold is what has killed primary care in the United States. Doctors are bailing out by leaving patient care, going concierge (retainer) or not taking insurance at all.

This leaves more patients footing the entire bill or not able to find a primary care doctor at all.

This is a system that is entirely out of wack. By forcing physicians to deal with multiple insurance carriers, each with their own payment schedules, formularies, credentialing and claim forms, we are perpetuating waste and inefficiency and it does nothing to advance the health of Americans.

Health care reform must address insurance related administration activities. Single payer is looking better and better.

Screening Tests for Cancer often Wrong


A study has been published in the Archives of Internal Medicine that shows there is a high incidence of "false-positive" tests when adults undergo the usual screening tests for cancer.
Keep in mind that these are not tests that are done to diagnose specific symptoms or concerns, but the tests that are part of health maintenance and screening.

The researchers found that for men receiving these tests: chest X-ray, flexible sigmoidoscopy, digital rectal exam and serum prostate-specific antigen (PSA), the false positive rate (no cancer) after undergoing all four exams for 3 years was 60.4%. Of these men, 28.5% would go on to have an invasive procedure.

For women the false positive rate was 48.8% for these tests: CA-125, transvaginal sonograms, Chest X-ray and flexible sigmoidoscopy. 22.1% of these women would undergo an invasive procedure to further work up the false abnormality.

They did not include mammograms for women, but they calculated that after 3 examinations the incidence of a false positive rate would be 18%.

I found these results rather surprising and there are some important facts here. First of all, we do not recommend screening chest X-rays (for lung cancer) or Ca-125 tests (for ovarian cancer) for these very reasons. They are not good screening tools and are not specific enough to give us valid information that saves lives. The key word here is SCREENING. If a patient has symptoms or genetic risk factors, that changes the decision of which tests to use.

The ability to detect cancer early and cure it has been advanced by the recommended screening tools. This is why doctors harp on patients to get these tests at the recommended ages. Patients often think we can detect all forms of cancer early with tests and that, unfortunately, is not the case. But mammography, colonoscopy and pap tests are proven to save lives.

It is important, however, to know that all tests come with a risk of false positives and the need to do further testing, sometimes invasive, to determine if it is really cancer or just a benign abnormality that will not affect the patient's health.

Friday, May 15, 2009

Depression and TV in Young Adults


The Archives of General Psychiatry reported television exposure and total media exposure in adolescence are associated with increased odds of depression in young adulthood, especially in men.


The researchers studied 4142 participants who were not depressed at baseline. They followed them for 7 years and used the same depression rating tool. They found that the people who reported more TV exposure had more depression and it correlated with each additional hour of daily use.


Interestingly, they did not find a relationship between development of depression and exposure to videos, computer games or radio. Compared with the young men, young women were less likely to develop depression given the same total media exposure.


What can this mean? Computer games and videos require some interaction and engagement. TV is quite passive and time spent isolated in front of a TV is time that is not spent exercising, working, reading or engaging with others. Perhaps the depression came first and the TV watching was a way of coping and isolating.


This is another interesting study that supports limiting TV watching in young (and old) people is good for mental health.

Thursday, May 14, 2009

Down With The Gown


I've never met anyone who thinks the hospital gown is a fine piece of clothing. With it's little ties and completely open in the back, it has to be held shut when you walk and makes the patient feel exposed. The Wall Street Journal even addressed this issue and noted the same style has been used since the 1920s.

Patient gowns are a $76 million dollar industry. I would have thought even higher but since they are durable and can be washed and reused many times, it is actually pretty economical for hospitals. Most clinics use paper gowns that are disposable. The paper gowns make the hospital cloth gowns look like designer couture.

Thanks to the Robert Wood Johnson Foundation, a $250,000 grant was given to the College of Textiles (who knew there was a college of textiles?) to develop a new gown design. Six focus groups have been working on the problem and, despite the universal dislike of the current design, creating a new one has not been easy.

Fancy fabric designs (designer Nicole Miller) just raise the price and don't change the underlying style. Velcro closures don't hold up in the wash. Snaps are difficult for elderly fingers to manipulate and they tear. Floor length sarongs worked for some people but not everyone.

The designers even tried a kimono-type wrap that fits the body. It offered modest protection and looked a little stylish but didn't really work for patients who couldn't be moved. If you are in a hospital with a broken bone or trauma or post op...you aren't able to stand and wrap a form fitting kimono around your body. Fail!

The old saying "Form follows function" seems to apply here. If you have any ideas, the College of Textiles in would be happy to hear from you. The next challenge for "Fashion Runway", perhaps?

Sunday, May 10, 2009

Pepsi Scam Warning


EverythingHealth is warning readers about a scam that could easily cost you money if you are trapped by it.

I received a very official appearing letter from "Pepsi Co." with the Pepsi and ABC logo on the stationary. The letter is on good stock paper with an official appearing bar code and it informs me that I have won One Million Dollars in the "Play for a Billion" contest in partnership with Pepsi and ABC Network. I will also appear on the ABC network for a chance to win one billion dollars.

The letter goes on to say all the arrangements are being made for me to receive my prize and a check for $5,400.00 is included to cover outstanding fees. The check is appears authentic and is from Mountain West Bank, made out to me.

There are other official appearing details, with a toll free number to call.

Of course I knew immediately this was a scam. But I could see how easy it would be to dupe other people into thinking they had won. The letter and envelope look very real. I am going to try and deposit the check. I suspect it will go through and will only be returned a few days after I have forwarded some amount of money less than $5,400 to cover some unknown fee to the scammers.

So let your elderly loved ones know about this and never, never believe you would really get a real check in the mail for a contest like this.

Moms Rock

Happy Mothers Day to all mothers and daughters around the globe from EverythingHealth.

Saturday, May 9, 2009

3D Medical Animation: Heart Attack from Atherosclerosis

A heart attack is really complicated physiology. This video shows the interactions of high cholesterol, inflammation and high blood pressure and how they work together to cause a myocardial infarction.

Friday, May 8, 2009

Warnings on Testosterone Gel


The FDA is requiring warnings to go on two prescription testosterone gels. AndroGel and Testim are testosterone creams that are used for men who have low levels of testosterone. Eight children (ages 9 months to 5 years) have been inadvertently exposed to the gel by skin-to-skin contact with the people using the product.

Testosterone causes early puberty in children and to minimize the risk the FDA is recommending:
  • Users wash their hands after applying
  • Cover the application area with clothing after the gel has dried
  • Wash the area immediately when skin-to-skin contact is expected

Thursday, May 7, 2009

Cracked Corners of Lips - Cheilitis


Q. Dr. Brayer, I have cracking and soreness at the corners of my mouth. Someone told me it is Vitamin B deficiency. What can I do about it?

A. You have a common condition called Angular Cheilitis and it is rarely caused by vitamin deficiency. The usual cause is moisture and saliva that builds up from lip licking, poor fitting dentures or drooling at night. The chronic moisture can lead to a bacterial infection or candida (yeast) infection. Cracking and fissuring at the corners of the mouth can be painful and more licking just keeps it going.

Usually it an be cleared up with a combo of an anti-fungal and steroid cream.

Top 10 Drug Reactions


Many drugs affect the action of other drugs or are implicated in allergies, causing side effects. These drug reactions can be mild and barely noticed by the patient, or they can be severe enough to send a patient to the emergency department. To make matters even more confusing, drug interactions do not happen to everyone. It may depend upon the genetics of a person, the dosage taken or other factors like underlying health problems (kidney or heart disease).

It has become impossible for a physician to know every potential drug interaction given the thousands of different medications and the infinite genetic differences in patients. One of the promises of the electronic health record (eHR) is the ability to provide alerts and "decision support" to physicians at the time they are writing prescriptions or ordering medication in the hospital.

Since we cant be "alerted" for the potential millions of interactions, focusing on the top drugs that cause most adverse events is where we begin. The top 10 adverse reactions and medication errors noted in the United States Pharmacopeia are:

1. Insulin
2. Morphine
3. Potassium Chloride
4. Albuterol
5. Heparin
6. Vancomycin
7. Cefazolin
8. Acetaminophen
9. Warfarin (Coumadin)
10 Furosemide (Lasix)

Other drugs listed in the top ten from the American Pharmacist Association are:
  • Aspirin
  • Trimethoprim-sulfamethoxazole (Bactrim, Septra)
  • Ibuprofen (Motrin, Advil)
  • Penicillin
  • Hydrocodone/acetaminophen (Vicodin)
I bet most readers have taken one or more of these medications.

Wednesday, May 6, 2009

The First U.S. Face Transplant


In 2004, Connie Culp looked like this photo (below). Her husband shot her in the face and then shot himself (and lived) with the same gun. Her nose, cheeks, eye and mouth were shattered and she was in the ICU clinging to life. She received over 30 operations on her face at the Cleveland Clinic. See the before photo which shows her after countless grafts and pieces of bone were reconstructed. But she was still unable to eat solid food and she has a tracheotomy for breathing.

On December 10 she underwent a 22 hour operation, the fourth face transplant in the world as doctors used the face of a woman who had just died to replace bone, muscles, nerves, skin and blood vessels.

It is a joy to be a small part of medicine and healing. Read more about this amazing story here.

Tuesday, May 5, 2009

Vitamin C and Gout


I've reported before about the link between high fructose corn syrup and increased incidence of gout. New research shows that Vitamin C supplements may prevent gout.

The study, reported in the Archives of Internal Medicine, looked at men between the ages of 40 and 75 years that did not have gout. The researchers adjusted to account for age, energy intake, alcohol use, body mass index, use of diuretics and hypertension or chronic kidney disease. All of the above influence development of gout.

The men who consumed more Vitamin C had a reduced incidence of gout. Each 500mg increase in supplemental Vitamin C reduced the risk of gout by 15%. The researchers concluded that Vitamin C may lower serum levels of uric acid through a number of physiologic means. Reduced uric acid leads to lower incidence of gout.

The take home message here is if you have had gout or have a family history of gout, supplements of Vitamin C (1000-1500mg/day) and avoiding high fructose corn syrup may be beneficial for reducing gout attacks.

Monday, May 4, 2009

FDA Warns Against Hydroxycut



Hydroxycut is the brand of a number of weight loss supplements that are sold in over 70 countries in the world and are taken by millions of Americans. Open most any magazine and you will see very compelling weight loss ads from Hydroxycut. It shows a men and women before and after using Hydroxycut products with six-pack abs and bikini ready figures. Hydroxycut is sold in grocery stores, pharmacies, GNC stores and over the internet. The company is based in Canada and has U.S. distributors near Buffalo, N.Y.

The Food and Drug Administration has warned dieters and body builders to immediately stop using Hydroxycut products because of 23 reports of liver problems, including one death of a teenager who died of liver disease after using the product. Another patient received a liver transplant and others are on the waiting list for a new liver.

The company that distributes Hydroxycut has voluntarily recalled 14 of its products after the announcement by the FDA.

The FDA does not regulate dietary supplements and manufacturers don't need to prove that their products or safe or effective before they sell them to consumers. The FDA relies on voluntary reports to detect any problems and many cases are never reported.

If you look at the ingredients in Hydroxycut (and many other supplements), they are filled with names that are meaningless to most physicians and patients. What is deanol bitartrate, Xanthinol nicotinate, Unula racemosa extract (root), Cridium monnieri extract (seed), cisus quadrangularis extract and about 17 others that sound the same? The consumer is advised to take 3 capsules with water two times daily before meals.

Now that the FDA has issued this advisory you can expect to see attorney ads replace the Hydroxycut ads. Within 24 hours, "The Orlando Firm" is willing to "Help Hydroxycut victims across America". That didn't take long, did it?

Saturday, May 2, 2009

The Politics of Influenza


Now that it looks like the H1N1 (Swine) flu is starting to wane and may not be the global disaster it could have been, I can't help but reflect on how political a public health emergency can be. Here is what I observed over the past week of flu-mania:

Kathleen Sebelius was sworn in as U.S. Health Secretary on Tuesday just hours after the Senate finally confirmed her nomination. The week before, the Republicans opposed her because of her support for abortion rights. It looked like it would be a long, ugly partisan fight with investigations into campaign contributions from a doctor who performs abortions but-BINGO- a flu epidemic with no Health Secretary didn't look too good. Now we have another cabinet member.

The anti-immigration folks also had a field day. Right wing talk radio pegged immigrants from the South as "infected parasites, rushing the border to escape death and receive free flu care in the United States." Nationally syndicated radio host Michael Savage led the pack last Friday, saying: “Make no mistake about it: Illegal aliens are the carriers of the new strain of human-swine avian flu from Mexico." And, Of course, Homeland Security Janet Napolitano would do nothing to protect our borders from these infected terrorists. The Swine flu became a perfect platform for immigration haters.

Another event that had nothing to do with science and everything to do with ideology was the Egyptian government slaughter of 30,000 pigs as a precaution against the swine flu. The World Health Organization said there was no evidence that pigs were transmitting the virus and there were no cases of flu in Egypt. Despite that, the pigs were killed. Pig-farming and pork consumption is limited to Egypt's Christian minority, which is about 10 percent of the population.

It is too bad that in the real world, public health is never just about human welfare. While science should be driving the discussion, politics and ideology are never far behind.

Friday, May 1, 2009

Answer to Eye Bump Quiz


Thanks for the guesses and even doctors can get it wrong.

The answer is #3 Syringoma. These are non-cancerous (benign) bumps that are caused by the overgrowth of cells from sweat glands. They most often cluster around the eye, but they can be found on other parts of the body like the upper chest, armpits, vulva, and face. They are more common in women than men. They can be treated with laser or electrosurgery for cosmetic reasons only.

Swine Flu in 1976

Swine flu isn't new. Check out this ad from Uncle Sam in the 1970's. I especially like the cheerful "stewardess", now sanely called "flight attendants". And is that guy at the beginning really 55? No way!


Hat tip to LOTD

Swine Flu Seems to be Slowing Down


As cities across the globe are preparing for the new H1N1 Swine flu, it appears the incidence of new infections is slowing down and the virulence (severity) has not increased.

The Centers for Disease Control (CDC) reports the number of confirmed cases in the United States is 109 with one death.

The largest cluster (50 confirmed) is in New York City where it rapidly spread through a NYC high school. Forty-four of the NYC confirmed cases are from this high school which was temporarily closed on Monday, April 27. Five of the students had traveled outside the U.S. the week before, although none had visited Mexico, California or Texas. All of the confirmed cases were mild.

To date, this New York school-based outbreak is the largest cluster of swine flu cases reported in the United States . The findings from this investigation indicate that symptoms appear to be similar to those of seasonal influenza . Additional assessment of the extent of illness in NYC is ongoing.

The recommendations from the CDC for avoiding flu have not changed. Fortunately, they are simple:

1. Wash your hands frequently

2. Cover your nose and mouth if you cough or sneeze and toss the tissue immediately.

3. Avoid contact with anyone who is coughing or sick

4. Stay home if you are sick


Probiotics - What and When?

Probiotics contain microorganisms that are similar to the beneficial bacterial that occur naturally in our intestinal tract.  There is so...