Saturday, February 28, 2009
I've recently read about a technique in running called "ChiRunning". Developed from Tai Chi practice, it involves leaning forward while running and allowing gravity to help propel you in an effortless way. The runner is supposed to be loose and relaxed while running and it makes running effortless.
It sounds like common sense, but any pain that occurs while running should not be ignored as it is your body telling you that there is something wrong with your technique. Shin splints, plantar fasciitis, iliotibial band pain, back pain can all be helped by changing the biomechanics and posture when running.
In ChiRunning, they focus on the feet being hip width apart and toes pointing forward (not angled outward). They are also mindful of softening the knees and making sure the weight is not on the ball of the foot or the heels, but in the midfoot.
For the chi runners, practicing the form is what makes it work. Running slow at first and making sure you are in alignment and mindful of posture seems to be the key.
There are a number of youtube videos on ChiRunning for you recreational runners.
Posted by Toni Brayer, MD at 10:56 PM
Friday, February 27, 2009
The answer to the NEJM challenge is #2. Angiotensin Converting Enzyme.
Lupus pernio is a skin manifestation of sarcoidosis that involves the nasal bridge and cheeks. Serum levels of the angiotensin-converting enzyme are elevated in the majority of patients with untreated sarcoidosis.
Sarcoidosis is an autoimmune disease that causes inflammatory cells to clump in various parts of the body, commonly the lungs, lymph nodes, eyes and skin. It can develop slowly over years or it can appear suddenly and then disappear.
Black Americans have a higher incidence of sarcoidosis and black women develop it twice as often as black men. It usually develops between the ages of 20-40. Treatment involves immune suppressive drugs like hydrocortisone.
Now see how smart you are?
Posted by Toni Brayer, MD at 9:11 PM
Thursday, February 26, 2009
EverythingHealth loves to give free things away! Because we couldn't decide amongst all of the great entries, a random drawing was held and the winner is...(drumroll).... SUSAN.
Congratulations, Susan. Please contact me with your mailing address to receive your case of healthy, yummy POM. Thanks to everyone who wrote great comments. I'll try to have other contests in the future so everyone can win.
Posted by Toni Brayer, MD at 6:39 PM
The New England Journal of Medicine diagnostic challenge is aimed at physicians but anyone can play. This patient has skin lesions (click on image for a better view) that are non-tender, non-itchy and slowly growing. What lab test would cinch the diagnosis?
2. Angiotensin-converting enzyme
3. Anti-tissue transglutaminase antibody
5. Vitamin B6
The answer will be posed on Friday.
Posted by Toni Brayer, MD at 4:15 PM
Wednesday, February 25, 2009
As a comprehensive internist, I hear lots of stories from my patients about their experiences with other doctors. Some are real shockers like this one..(used with permission):
Beverly had several weeks of rectal bleeding and pain. She mentioned it at her gynecologist visit and that doctor did an exam and thought she felt hemorrhoids so she referred her to a gastrointestinal (GI) specialist for treatment and possible colonoscopy. (The patient is 50 and is due for a screening exam anyway).
Beverly saw the GI doctor who...get this...never undressed her, did no exam at all but just talked to her and told her he didn't deal with problems "below the waist". He referred her to his friend the colo-rectal surgeon. Despite no exam he gave her a prescription for nitroglycerin cream and said once her hemorrhoids were cleared up he would be happy to do a colonoscopy. She got a bill for a 99243 "consult" for $275.00. This was for no exam and him just accepting a second hand opinion that she had hemorrhoids! He didn't even weigh her but just wrote down the weight she said she was.
I saw her, did my own exam of course, and the diagnosis is a rectal fissure (a small tear), no active hemorrhoids and the treatment is different. She still needs a screening colonoscopy (per her age) but I guarantee it won't be done by the GI physician. I would block the door myself to keep her away from him.
I hate hearing these types of stories and there are 100 excellent doctors for every lousy one. This is one reason the "rate your doctor" websites are catching on!
Posted by Toni Brayer, MD at 8:32 PM
Tuesday, February 24, 2009
Dear Dr. Toni,
I have been stripping lead based paint off of old (very old) wood planks for a project I am doing. Now I'm worried about lead poisoning. Can I get it from breathing in fumes and paint dust? How can I know?
Yes, lead poisoning occurs after exposure in the environment and lead is not biodegradable. Old paints, water pipes and even dishes can contain lead and may pose a health hazard from breathing in lead dust, drinking water from lead based pipes or ingesting it. The accumulation of lead is gradual and symptoms might include muscle weakness, headache, memory loss, pain or tingling of the extremities and digestive problems. Children are more susceptible and can have weight loss, irritability, anemia and vomiting.
Since you are working with old paint on your project, you should have a blood test to detect lead poisoning. Levels are measured in micrograms per deciliter (mcg/dL) and any level of 10 or higher is a problem. Higher levels (can go above 70) can be a medical emergency.
The first treatment for mild lead poisoning is to stop the exposure. Don't remove lead paint by sanding because it creates small particles that can be ingested or inhaled. Heat guns or open flame torches create the same problem. Don't eat where lead dust might be present and wear protective clothing and leave the clothes at the job site.
For high levels or symptoms, the treatment is chelation therapy, which binds with the heavy metal and removes it through the urine. Multiple treatments may be needed and therapy might not reverse damage that has already occurred so go get that blood test and see where you stand.
Posted by Toni Brayer, MD at 11:14 PM
Everythinghealth loves President Obama and was impressed and inspired by his speech tonight. Some random thoughts:
- He has a beautiful smile and is like a Rock Star
- It seemed both Republicans and Dems gave standing ovations - no divided house (at least in public)
- He was upbeat and hopeful
- He loves Michelle and acknowledged her
- He seemed to be the youngest person in the room
- Pale, male and stale (don't those guys ever retire?)
- He promised a lot - hope he didn't over promise and under deliver
- He looks good with a red striped tie
- He didn't equivocate on reforming healthcare...but how?
- Does anyone believe a word from Ben Bernanke? The stock market rallied.
- "If you earn less than 250K/year, your taxes will not increase one single dime"
- He talked about a lot of new programs and also pledged to cut the national debt by 50% in his first term. Sounds good..maybe too good?
- I could listen to him talk all night.
Posted by Toni Brayer, MD at 8:04 PM
Monday, February 23, 2009
Biodiesel fuel is considered to be more environmentally friendly than gasoline and different sources such as algae, beef tallow and corn have been tied as an alternative form of fuel.
Dr. Craig Alan Bittner, a Beverly Hills cosmetic surgeon found a new form of fuel right in his practice. Liposuction fat! He made fuel for his girlfriend's SUV from the extracted fat of patients. Apparently he had more fat than he could use.
This doctor is under investigation by the California Department of Public Health because it is against the law to use human waste as fuel. Who knew? His fat for fuel escapades were unveiled when he was sued by several patients for letting his unqualified girlfriend assist in operations that left patients "disfigured".
The entrepreneurial doctor has left the country for South America.
Posted by Toni Brayer, MD at 9:27 PM
Saturday, February 21, 2009
Just for fun and good health...lets have another Give-a-way, OK?
POM Wonderful is pure 100% pomegranate Juice. EverythingHealth loves that there is no sugar, preservatives, color or cheap filler juices in POM. And for you folks that want to "buy American"...it is grown right here in the good ole' USA.
We always promote getting your vitamins and antioxidants from real food and pomegranate juice is one of the most potent antioxidants in nature. Studies have shown improvement in cardiac health, erectile dysfunction and prostate health with daily POM drinkers.
So think about how your health could be improved by drinking POM and write a comment. The best reply will receive a case of POM. (within the U.S. only, sorry international readers)
I'll post the winner on Thursday, Feb 26.
Click on the comments and tell me why you want POM.
Posted by Toni Brayer, MD at 8:34 AM
Thursday, February 19, 2009
My laziness in blogging today is your win as I refer you over to Dr. Rich's Covert Rationing blog.
Dr. Rich writes a provocative piece on Cardiologists and their propensity to perform cardiac caths and place stents in patients...despite the evidence that stenting blocked coronary arteries does not prevent heart attack or prolong life.
Drug eluding (coated) stents cost from $15,000 to $30,000 to place and the data shows that medication (cholesterol lowering drugs and aspirin) are equally effective in patients who have stable blocked arteries and chest pain. So why are 70% of these patients treated with stents? Read Dr. Rich's blog for an eyeopener. It gets better as you read longer and see what patients erroneously expect the stent will do for them.
You can't blame the cardiologists...they are only responding to perverse incentives that pay them handsomely for doing more and more.
It's the American Way.
Posted by Toni Brayer, MD at 10:51 PM
Wednesday, February 18, 2009
Tip to EverythingHealth readers: Quit wasting your money on "antioxidants". The evidence is clear that Vitamin E, B-vitamins and Folic Acid do not prevent heart attack or stroke.
It's easy to see why there was a buzz about these antioxidants and why millions of people have spent $billions of dollars on these vitamins. The LDL (bad) particle of cholesterol needs to be "oxidized" to be taken up into the artery wall. People got interested in Vitamin E, which circulates in the LDL particle and thought it might be protective against oxidation. Beta Carotene also circulates so people thought it might prevent cancer and heart disease.
That lead to numerous prospective, randomized trials in both men and women in high risk and low risk populations. They took Vitamin E, Vitamin C, and beta carotene alone and in combination. There were huge trials over 5 years that showed NO BENEFIT.
We also got interested in homocysteine because high levels in the blood were associated with vascular disease. We thought that lowering homocysteine would prevent disease. B vitamins lower homocysteine so people started taking B vitamins and folic acid as a way to prevent disease. There have been at least 7 good trials that show NO BENEFIT whatsoever from taking these vitamins compared to placebo.
We can put this issue to rest now. Get vitamins from a healthy diet of fruits and vegetables. Go to farmers markets and buy organic when possible. Aim for 5 fruits and vegies a day. Save your money that you would spend on supplements. Use that money for organic foods.
Posted by Toni Brayer, MD at 8:29 AM
Tuesday, February 17, 2009
Dr. Michael Kamrava runs the West Coast IVF Clinic and is the doctor who has provided Octuplet mom, Nadya Suleman, all 14 of her children (under the age of 6!) Nadya Suleman, now on food stamps and welfare, spent $100,000 with Dr. Kamrava .
If that is not enough, we now find that same physician has another patient who is 49 years old and is 5 months pregnant with quadruplets.
The mother, who has two grown children, is already admitted to the LA County Hospital on bedrest and was transferred from Good Samaritan Hospital because she does not have adequate medical insurance.
The woman at 49 years old, is already considered high risk with one baby. Triplets would increase the risk of cerebral palsy by 47 times. Premature birth is almost certain with four babies.
I am happy to report that my California medical license dues, which support the Medical Board of California, are being used properly as the Medical Board is investigating Dr. Kamrava.
Dr. Kamrava, goes outside the American Society for Reproductive Medicine guidelines, which call for no more than two embryos to be implanted for women younger than 35. Implanting more embryos doesn't improved the odds of a successful pregnancy. All you get are more complications.
In 2006, the latest year for available documents, he performed 52 in vitro procedures and 20 were in women younger than 35. He used, on average, 3.5 embryos per procedure. He has one of the worst success rates of any fertility clinic in the nation. Fertility Clinics are largely unregulated and doctors are free to do whatever they wish.
If this isn't a case of malpractice, poor medical ethics and just plain bad doctoring, I don't know what is. Medical Board, do what you are paid to do and get this physician off the streets!
Posted by Toni Brayer, MD at 7:08 AM
Saturday, February 14, 2009
You never know if blog comments are real or not, but I choose to take them at face value. The comment from "tina" on my "I am sick" blog is worth writing about. Here's what tina said:
"hi, I have been everywhere and seen a lot of doctor's and no one can seem to help they just say it's all in my head as i continue to get worse and worse. Sometimes things are so bad i feel like i am going to pass out,my b/p goes higher and heart beats so fast i think i am going to die. The pains are so severe they knock me down and now my legs are starting too they feel like they are bruised or sunburn but they are not and my heart beats in my throat not my chest. This all started when i was 33 years old and found out i was pregnant for my last child but i am now 42 and it is worse not better they say anxiety/panic attacks but the meds did nothing except make me gain 70 pounds or more. I am lost and at my ends wits no one can help me. My symptoms included: low energy, poor stamina, sore throat, unexplained menstrual irregularity, upset stomach, abdominal pain, chest pain, rib soreness, shortness of breath, cough, heart palpitations, pulse skips, heart murmur, joint pain, joint swelling, stiffness of the joints all over my body, muscle pain and cramping, twitching of the face or other muscles, neck pinches and cracks, neck stiffness, neck pain, tingling, numbness, burning or stabbing sensations, shooting pains, skin hypersensitivity, facial paralysis, (Bell's palsy), double, blurry, increased floaters, light sensitivity, buzzing, ringing, ear pain, sound sensitivity, increased motion sickness, vertigo, major facial flushing and bizarre skin rashes, poor balance, lightheadedness, wooziness, panic attacks, anxiety, tremors, confusion, difficulty in thinking, difficulty with concentration, forgetfulness, poor short term memory, poor attention, disorientation, getting lost, going to wrong places, difficulty with speech or writing, mood swings, irritability, depression, disturbed sleep, too much sleep, too little sleep, the overwhelming need to sleep for 4 hours every afternoon, and a complete intolerance to alcohol.sore on scalp,dry mouth and lips,burning to head,pins and needles in hands and feet,pain(like charlie horses) in the legs,pain,bottom of my feet pain,IBS,gas,heartburn,no libio,sex hurts,stiffness and cramps in fingers and toes,hot flashes,chills and cold, constant urge to pee,bones crack easily,disrealization,disoriention,lightheadness,dizziness,muscle twitching,feeling like a cat is purring inside my body,pain if i push on my skin bones or anything on my body,sometimes a weird taste in mouth,rib pain,eyes pain,back pain,feelings of doom and death,quickly angered,heaviness in stomach,weight gain,no motivation,afraid to leave the house, 8 years of hell,tired alot or never goes in spans,MEAN MEAN BITCH ALOT,littlest things set me off,ear/jaw pain,type the same words over and over yet type them mixed up?,hair never grows (same length since i was 10) pale skin,NO ONE WANTING TO HELP ME!!!!!!!!!! days where i can do everything and then some days where i can move and i am dying,groin pain,itchy skin,if i open my mouth i can hear my heartbeat,headaches,depression,bi-polar,crying all the time, pain in legs,pitting,weight gain,blurry vision,stomach pain,nausea,fatigue,heartburn,stomach pain,twitching,muscle aches, 1/29/09-vomiting,diarrhea,stomach pain,heartburn,weight gain,numbness,shakes,leg cramps,high eosinophils,disoriention,bloating,sick! please if you can have a heart and try to help me i am so close to just ending it that pain is soooo bad.................god bless..tina"
Folks, tina has a LOT of issues. In fact, too many issues to be resolved in less than several months. I would suspect she has been doctor shopping and gets discouraged when a cure isn't forthcoming. Patients like tina require a lot of patience and a doctor who does not get discouraged easily either.
I advised her to pick one good Internist and one good Psychiatrist and to stick with them as they sort through her many problems. Taken as a whole, these are quality of life problems, not serious life threatening problems and they will take a long time to sort out. She should make sure she is eating only organic, healthy food and getting exercise every day. She should not use alcohol or any other drugs not prescribed by her physicians.
I've had patients like tina and they can be exhausting because of the "list". They often go from physician to physician and have test after test. Once a test is negative, that test does not need to be repeated. But healing relationships can occur and they can get their lives back if they stick with their physicians.
Posted by Toni Brayer, MD at 7:28 PM
Wednesday, February 11, 2009
Sunday, February 8, 2009
No one has been able to explain why doctors, as a profession, have the highest suicide rate of any profession. Every year, between 300-400 doctors take their own lives. In the general population, males commit suicide 4 x higher than women. But the suicide rate among male and female doctors is the same. Female doctors take their lives at a rate more than twice that of the general public.
There is really very little research done on this subject and most of it is old. The most definitive study was done in 2003 and published in JAMA. It stated that undiagnosed and untreated depression is the problem and even when physicians seek help for depression, they are not treated aggressively.
Mental illness still has a stigma in our society. Doctors realize, with good reason, that if they admit to a mental health problem they could lose respect, referrals, income and even their licenses. Doctors have access to drugs that can mask their symptoms without getting help and that may make the situation worse.
If depression is considered something shameful and secret, that can further lower the self confidence and self-worth of a professional which exacerbates the depression. Medicine is a pretty macho profession. It is rare for physicians to even admit they get a "cold" let alone a serious illness. It is a point of pride to admit you can function on little sleep or work without taking time for rest, food or friendship.
There are no easy answers to this problem, but educating medical students about depression and how to deal with their own emotional health might be a start. The American Foundation for Suicide Prevention has information and has created a documentary called "Struggling in Silence" about physician suicide.
Posted by Toni Brayer, MD at 8:48 AM
Saturday, February 7, 2009
Thursday, February 5, 2009
Do you want a free way to predict heart attack in women? Check the resting heart rate.
The British Medical Journal (love those Brits!) has published data that shows the resting heart rate (also known as "pulse") is a good way to predict heart attack in women over age 50. Women with heart rates higher than 76 beats per minute at rest were more likely to have heart attack than women with pulse rates below 62. Race was not a variable, nor was diabetes so the heart rate was an independent risk factor. The heart rate was not a factor in stroke.
Resting heart rate is an indicator of autonomic nervous system tone. High sympathetic nervous system tone may be a marker of subclinical cardiovascular disease and it might affect other known risk factors like blood pressure, glucose metabolism or plasma lipids (cholesterol).
To check it out on yourself, sit quietly for 5-10 minutes or check it before you get up in the morning. Take your pulse for 30 seconds and then multiply that number by 2. That is your resting heart rate.
Other known risk factors for heart attack are young family history, high blood lipids, diabetes, hypertension, obesity (high body mass index), smoking and sedentary lifestyle.
Posted by Toni Brayer, MD at 9:44 PM
Wednesday, February 4, 2009
It was so wonderful this week to see my Maasai friends from Kenya and have a reception for them at my home. This was the first trip away from their African village for many of them and they brought such magical good vibes, generosity and openness with them. They hug and touch for hello and goodbye and after gathering in a circle and chanting and singing, they blessed my home.
Led by Sironka, they perform and sell their wonderful beads to support female education, health clinics and improved standard of living for their tribe at home.
Posted by Toni Brayer, MD at 10:47 PM
Tuesday, February 3, 2009
Tom Daschle, the "almost" head of Obama's Health and Human Services, has suddenly pulled his nomination due to investigation into his failure to pay $140,000 in income tax when it was due. (he has since made payment). Although Pres. Obama continued supporting him, Daschle gave the usual explanation of "not wanting to be a distraction etc etc."
Poor Daschle (who would have been a good HHS chief) is feeling the effects of the light being shined on the last 4 years. He was on the payroll for a large law firm that represented Indian gaming, health care, support for ethanol and a number of other corporate interests that had business on the Hill. He also was a consultant and sold policy advice to many companies that had legislation pending in congress. He served as a director for Mayo Clinic and the clinic was able to forestall a $2.5 billion government loan that would have put a rail line next to the clinic in Rochester.
Obama has a mandate from the American people to clean up Washington. Limos, corporate jets, million dollar consulting fees and retainers for insider access into policy matters has got to stop. I know it is not illegal but that doesn't mean it is right.
Daschle would have been a good HHS chief because he understands health care reform and he does know how politics works. I wish he would have kept his nose clean. Also he wears cool glasses.
Posted by Toni Brayer, MD at 1:19 PM
Sunday, February 1, 2009
Thanks to KM for this link with the unfolding new information about the lady who had the octuplets in Southern California. It seems many involved with this story are against what she did, what the infertility physician did and the ethical questions it raises.
Posted by Toni Brayer, MD at 1:30 PM
The days of the $5 or $10 copay are leaving fast. A growing number of doctors offices are now using software programs that can tell them exactly if a deductible has been paid and what the patient needs to pay at the time of the visit. Most insurance now has a large deductible..even as much as $2500 to $5000 a year. Many healthy patients don't even meet their deductible in a year so they are responsible for first dollar payment.
From the doctor's perspective, collecting this money at the time of service is good business sense. The good old days where the doctor was paid last, is long gone with primary care and even general surgery doctors closing their doors because of financial issues. The margins are very thin in many medical offices and as practice expenses rise, the need to collect at the time of service is critical.
"Bill my insurance" is a term that is going by the wayside. Since "Bill my insurance" actually means the doctor will send several bills over several months and maybe 4 months later will receive a statement from the insurance company that says the amount billed is $135...the amount allowed is $62...and the patient has not yet completed the deductible so the payment is $0.
It costs a medical practice between 6-10% to send bills. The practice has just lost money on seeing that patient and in some practices 30% go unpaid.
It is no wonder physicians are being forced to be more businesslike and collect at the time of service. But it is painful for patients who have always layed down a $5 bill and they think this is the cost of medical care.
When patients pay out of pocket they do become better at deciding if they really need that test. They also realize up front what a rip off their insurance is. (don't get me started on the health insurance biz). I've said before that most "screening" blood tests are wasteful. Patients are now finding out just how expensive they are too, as they pay a larger part of the actual cost of care.
Now we need to get to the place where patients can find out AHEAD of time what the cost will be. You wouldn't dine in a restaurant without knowing the menu price. Patients shouldn't be forced to receive medical service or tests without knowing the menu price either. That would be one way to bring costs into line.
Posted by Toni Brayer, MD at 9:49 AM