Bumps Around Eyes

Patients often have skin lesions that worry them. These bumps around the eye are non tender but of concern to patients. What is the diagnosis?
1. Sebaceous hyperplasia
2. Milia
3. Syringomas
4. Seborrheic keratosis
5. Warts

Make your best guess and the answer will be posted tomorrow.

Swine Flu 101

Q: What is a pandemic?
A: When a new subtype of a virus is identified, there is little or no immunity present in the community so everyone is at risk. A global disease outbreak is a pandemic. It past flu pandemics (Spanish flu-1918, Asian flu- 1957, Hong Kong flu-1968) the virus reached around the world within 6-9 months. We are more connected now so it could be faster.


Q: Did the Swine flu come from pigs?
A: It is a new strain of influenza A H1N1, not previously seen in swine or humans. Swine influenzas are common in pigs year round but this virus is spread from human to human without pig involvement.


Q: Why is Egypt killing all the pigs?
A: There have been no cases in Egypt and killing the pigs makes no scientific sense.


Q: Why does the World Health Organization (WHO) use a rating system for a pandemic?
A: The rating system helps public health officials and hospitals prepare for a pandemic. The pandemic alert (Phase 1-6) helps to track the virus across the globe. We are now at Phase 5 which is "Spread of disease between humans is occurring in more than one country of one WHO region." Phase 6 is "community-level outbreaks in at least one additional country in a different WHO region from phase 5." That indicates a global pandemic.


Q: If I have fever and diarrhea, could it be the swine flu?
A: Influenza is a respiratory illness so it affects the lungs. If the main symptoms are in the GI tract or stomach, it is not the swine flu.


Q: I had the flu vaccine this year. Am I still at risk?
A: Because this is a new strain, the flu vaccine will not be protective. A new vaccine is being developed and is on fast track.


Q: How worried should I be?
A: You should stay informed but not worry. In the U.S. 36,000 people die from influenza each year. The swine flu is a new strain that has health officials worried because we do not have a vaccine or immunity, but there is nothing to indicate that it is more virulent than ordinary flu. Because it is new and spreading globally, there is close surveillance and reporting. If many people are sick and home with the flu it can affect public services, hospitals, schools, business, travel and the economy. Cities are preparing, but they really have no idea how the pandemic will play out.

Swine Flu Update

As expected with any flu epidemic, the confirmed cases continue to rise throughout the world. As of today, the U.S. has 94 confirmed cases. California has 14 confirmed and 7 probable cases and they are all considered "mild". Canada has 13 confirmed cases, all mild.

One 22 month old toddler has died from Swine flu in Houston, Texas. He contracted it in Mexico and came to Texas with his family for treatment. There are no other deaths in the U.S. at this time.

One of the questions the Centers for Disease Control (CDC) is attempting to answer is why do some people have mild, short symptoms and others are sicker? They are looking at immune status, age, how long they were ill and what other treatments were tried and if they took antiviral medication.

Dr. Richard Bessler, acting director of CDC, said that milder cases of swine flu A (N1H1) virus in the United States and other countries besides Mexico may be the result of the virus getting weaker as it travels from person to person. It is too early to know if that is happening and in the case of the influenza pandemic in 1918, the virus was mild and after it seemed to stop, it returned in a more virulent form.

The CDC has determined that the swine flu is treatable with the antiviral drugs, Tamiflu and Relenza. The swine flu continues to behave like Influenza A with fever, cough, muscle aching and fatigue. Anyone with these symptoms should contact their doctor to get tested and treated early with antiviral prescription medication.

Learn About Science and Spiders

After non-stop Flu, unemployment and the rising uninsured, it is time to turn our attention to fascinating experiments with spiders.

Hat tip to Happy Hospitalist.

Influenza Update

At the risk of joining the media frenzy, I want to give EverythingHealth readers an update on the Swine flu. (Scroll down for first Swine Flu post)

As of today, there are 64 confirmed cases in the United States. Mexico has confirmed 18 laboratory cases of Swine fluA H1N1 infection with more samples being tested. In response to the intensifying outbreak, the World Health Organization raised the worldwide pandemic alert level to Phase 4. A Phase 4 alert is characterized by confirmed person-to-person spread of a new influenza virus able to cause “community-level” outbreaks.”

The US cases have all been mild and there have been no deaths. It is important to remember that regular influenza, a virus, causes 36,000 deaths a year in the U.S. It is unknown if the flu shot offers any protection for this strain of Swine flu.

This flu presents like any influenza with cough, aching body, high fever and malaise. Hospitals and health clinics are geared up to do nasal swabs on people who present with flu symptoms to help identify if we are in an epidemic or not. Those patients will then be sent home with Tamiflu or Relenza to rest, drink fluids and recover.

The flu virus is effectively killed with alcohol so alcohol based gel cleansers/sanitizers should be used if you are traveling or in close contact with people (schools, nursing homes, work).

Cultural Health Literacy

Our gardener is from Honduras but he speaks excellent English as a second language and has lived in the U.S. for many years. Despite this, his understanding of medical issues is quite limited, both by language and education. Today we were talking about the Swine Flu outbreak in Mexico and I was giving him what I thought was simple education. The conversation switched to immunizations and that is where I realized even simple explanations didn't work.

Raul believes he had a vaccination for Tuberculosis at a local community clinic before he recently returned to Honduras for a visit. He also had another vaccine that he has no idea what it was. I explained the TB skin test to him and the fact that there are no vaccinations for TB. (Actually in some foreign countries they do vaccinate with a drug called BCG but it is not used in the U.S.) He insisted that he tested negative for TB but was given 8 months of pills to take as a vaccine.

I am clear what happened. Tuberculosis exposure is treated with INH (Isoniazid) pills daily for 6-8 months. He probably had a positive TB skin test and because he travels back and forth to a TB endemic area he was given INH for "latent" TB and to prevent active infection.
This is not what we know of as a vaccine. Even more worrisome is the other vaccine that he received for unknown reasons. It could have been tetanus, polio, yellow fever or measles. And we have no idea what preventive immunizations he is missing.

Very few patients, no matter where they are from, remember when and where they were vaccinated. As a comprehensive Internist, I keep a record on my patients but fewer and fewer patients have a continuity physician. Patients who are seen at various emergency rooms, urgent care, travel clinics or other community clinics have no real records to fall back on.

At the very least, patients should be given a laminated card to carry in their wallets that list immunizations and dates. This should be standardized across the U.S., much like a drivers license. Is that so hard to do?

Swine Flu

Don't panic, just be informed. The swine flu has spread through Mexico and is believed to have killed 100 people with about 1600 infected. Now there are 20 cases confirmed in the United States and the Centers for Disease Control (CDC) has determined that the strains of the virus are the same. There is concern because this flu, which is usually passed by contact with animals, is now being spread person to person.

The global flu experts are not sure how dangerous the new A (H1N1) swine flu strain is. It is also unknown if this years flu shot will protect against this strain.

The swine flu presents with a fever, body aches and a cough. The U.S. cases were confirmed in California, Kansas, Texas, New York and Ohio. All the cases seem to be with someone who has traveled to Mexico or has had contact with someone who had. I have no doubt that more cases will be identified as this virus is spread.

What can you do? The usual precautions of hand washing and avoiding people with a cough are suggested. If you know someone who has recently been to Mexico, I would avoid contact.

Flu can be differentiated from a common cold because it is more severe with higher fever. Sore throat and runny nose without high fever or body aches are likely a cold. The flu knocks you flat.

Bad Economy Hits Health Care

The nations large health insurers are losing members at a rapid rate and WellPoint, the country's largest health insurer said it lost nearly 500,000 members since December. Wellpoint analyzed the decline and said it lost to layoffs or workers otherwise opting out of employer coverage.

Kaiser estimates that of the nine million people expected to have lost employer-sponsored health coverage since December 2007, about four million of them currently are uninsured. United Health reported a 900,000 drop in the number of people enrolled since first quarter. (from Wall Street Journal)

When people get laid off, they have the option of continuing insurance for themselves and their dependents by self-paying under COBRA (Consolidated Omnibus Budget Reconciliation Act). Within 30 days they must apply for COBRA and the insurance covers for 18 months. The employee (now no longer with a job) pays the entire premium plus 2%.

The President's American Recovery and Reinvestment Act of 2009 allows a premium reduction for anyone who was laid off between September 1,2008 and December 31, 2009. Those people can pay only 35% of the premium cost for up to 9 months. (No refunds if you have been paying the full amount).

If the company went bankrupt or discontinued health coverage, there is no COBRA available.

Hospitals and physicians are all seeing more patients without insurance of any type and elective surgery and preventive doctor visits are on the decline. COBRA insurance is extremely expensive and people without an income are often unable to pay $500 - $1200 a month for health insurance. It is not a surprise that the ranks of the uninsured are rising rapidly.

The way our nation deals with health, costs, and health insurance is not sustainable and must change.

Blue Ribbon for Free Speech

Journalist Roxana Saberi has been incarcerated in Tehran's Evin Prison, where she is spending her birthday on a hunger strike. Around the world, people continue to face similar violations of their rights to freedom of expression, free speech, and a free press. Let's show the international community that we won't be silenced by intimidation and tyranny - that we won't stop believing in and fighting for these rights.

Freedom of the press is not a luxury. It lies at the heart of making this world healthier and more just. People without a voice and without a clear line of sight into the things that would threaten or corrupt their societies cannot hope for equitable growth and meaningful change.

A group of bloggers around the world are holding a blog rally in support of journalists, bloggers, students, and writers who have dared to express their thoughts freely only to be imprisoned, abused, or killed.

Please consider "wearing" a blue ribbon online this week on your blogs, websites, and facebook / myspace / twitter pages, and invite others to do the same. Get the discussion going, and keep it going!



The Universal Declaration of Human Rights states, "Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference, and impart information and ideas through any media regardless of frontiers."

Never Shake a Baby - Even on an iPhone

The folks at Apple really goofed! In the quest to have the neatest and coolest apps for their iPhone and iPodTouch, they actually approved a game where you shake a baby. The Baby Shaker iPhone app made it all the way through the Apple approval process and they released it for download. The game shows an animated baby who is crying, and you shake the iPhone until red X's appear over the baby's eyes. Whoa! They call this a game?

After angry parents and children's organizations demanded answers, Apple removed the app. This is an example of a serious lack of common sense. Maybe the Apple staff is too young to have good judgement?

Shaken Baby Syndrome is a serious health concern. Shaking a baby (also called shaken baby/shaken impact syndrome or SBS) causes a form of inflicted head trauma. Shaking a small child can kill, blind or paralyze and head trauma is the leading cause of death in child abuse cases in the United States.

Needless to say, a game like this is grossly wrong. Thankfully, there are other fun games you can play with your iPhone.

Top 10 Apple iPhone Apps

1. StickWars
2. Flight Control
3. Pocket God
4. iHunt 3D
5. ParkingLot
6. Leaf Trombone
7. Playman Track
8. Flick Fishing
9. Tweetie
10. Camera Zoom

Environmental Horror

Everything in Its Path: Mountaintop Removal

Imagine a quarter-mile strip of land stretching from Washington, DC until San Francisco: An estimated 800-1000 square miles of mountains and valleys have been eliminated from the American landscape since the launch of mountaintop removal strip mining operations in central Appalachia in 1970. Using explosives and heavy machinery, over 500 mountains in the oldest and one of the most diverse ranges on earth, have been clear cut, blown to bits and then toppled into valleys and streams with their waste since President Jimmy Carter signed the Surface Mining Control and Reclamation Act in 1977, which shamefully recognized mountaintop removal as an approved mining technique.

Mountaintop removal has not only destroyed the natural heritage; it has ripped out the roots of the Appalachian culture and depopulated the historic mountain communities in the process.

It continues today as one of the most egregious human rights and environmental violations in the nation.

From Huffinton Post

Medical Students and Cadavers

JS sent me an article from The Wall Street Journal about how medical students in Taiwan deal with the cadavers they learn from in anatomy lab. Before school begins, the students visit the families of the donors and learn about their lives. The donated bodies are treated with such reverence, the students have an elaborate farewell ceremony where they honor their donors and even write biographies and light incense in their honor. Some donor families attend the farewell ceremonies and tears are shed by all as poems are read and photos shown. After the dissection, the med students carry the donors' coffins to the crematory and mourn as a group.

This effort to foster compassion in young physicians also creates more donors, as the Chinese culture does not believe in damaging bodies before burial. Bodies are viewed as a bequeathal from their ancestors. The bodies are elaborately sewn up after the dissection labs so they are intact and donor families know that their relative will be treated with respect.

Cadaver lab is a rite of passage for all doctors in training and it is an experience every doctor remembers from early medical school.

We were in groups of 4 (two on each side) for my gross anatomy training and I can remember every aspect of that semester...the lab, the lighting, the plastic sheeting, the lessons each day, the smell of formaldehyde, the way the anatomy book got soiled and tattered, the feel of the skin and organs, and most of all the reverence for the body.

Although we had no rituals (except we did give our donated body a name - "Ben") there was an air of respect and quiet in the cadaver lab. I often worked alone late into the evening and it was a surreal experience.

I like the idea of having a formal ritual. We never knew names or histories of our cadavers so visiting with families was not an option, but we did feel gratitude to those who contributed so much, after death, to our education.

Welcome World Visitors

I get a big thrill out of seeing visitors to EverythingHealth from around the world. Just knowing we are connecting openly and freely is amazing. Hearty welcome to todays visitors from United Kingdom, Australia, Napoli Italy, Tehran Iran, Belgium, Alberta Canada, Mexico, Puerto Rico, Dominican Republic, British Columbia, Saskatchewan Canada, Aruba, Japan, Arab Emirates, Israel, China and of course, all across the United States. Someday I hope to visit each of these countries.

Infection from Pet Rats

This 6 year old girl developed an itchy rash on her cheek and she was treated for a staph infection (impetigo). Because it didn't fully resolve and more lesions developed on her arm and neck, a potassium hydroxide (KOH) test was done. It confirmed a fungal infection known as tinea corporis or "ringworm".

Tinea corporis is a pretty common infection and once it is diagnosed, it is easy to cure with a topical antifungal cream and 1 week of oral medication.

What makes this story interesting is that the child's parents revealed they had given her 2 pet rats as a Christmas present a week before the rash began. They had become attached to the rats and didn't want to get rid of them.

The story has a happy ending. They simply washed the rats with an over-the-counter ketoconazole shampoo and treated them with tiny doses of the oral medication. Everyone was cured!

I think this story grabbed me because my favorite childhood pet was a white rat named "Sniffles" and I would certainly have bathed her and medicated her if needed.

From Consultant: David Kaplan, MD, University of Kansas School of Medicine

A Pill Will Cure Everything

Driving in the early morning (6:00) and listening to AM talk radio is a fascinating experience. While surfing channels I learned so much about health.

Dr. Stewart was being "interviewed" in talk show format and told the listeners all about "C-Max" It turns out that this formula of vitamin C can add 6 years to your life. Also if you take this wonder pill, it prevents heart attacks and strokes and diabetes too. He quotes large studies from somewhere (30,000 people) that prove simple vitamin C is the elixir of health. When the "talk show host" asked "Why aren't other doctors talking about this?" He replied, "It's not their fault. They only got 2 hours of nutrition lectures in medical school. They just don't know." Thank you Dr Stewart for educating me. Channel flip...

Next I heard another "talk show" with a very energetic and knowledgeable Dr. Bond. I didn't catch the name of the formula but it contained Lutein and Co-Q10. This wonder pill does even more than Vitamin C. It turns out it prevents blindness, makes skin smooth, prevents heart attacks, strokes and cancer. He quotes studies from somewhere that show the brain needs these ingredients so it even prevents alzheimers..."order today".

Let me be clear. We do need Vitamin C, Lutein and Co-Q10 in our diets. Lutein is found in dark green leafy vegetables. Fresh spinach and broccoli are cheap and available at all markets and steamed with a little garlic will provide ample lutein. Vitamin C is easily obtained with citrus juice or fruit. Co-Q10 is a little harder to get in the diet because we don't each much mackerel. There is conflicting data on the benefits of supplementing Co-Q10 (sorry Dr. Bond) and it is an expensive supplement.

I have reported before about well controlled, large trials that debunked the benefits of antioxidant supplements (Vitamin E, beta Carotene, Vitamin C etc.) These vitamins and minerals are essential to good health but taking a pill will not get you the good health you want.

What do I take? Vitamin D, CoQ10 and Omega 3. Except for the CoQ10 (I'm hedging on that one) they have data that shows benefits. I am data driven and hate to waste money. 5 fruits and vegetables a day in the diet is the way to get the best nutrients.

The radio infomercial talk shows are quite entertaining, however.

Susan Boyle - Singer - Britains Got Talent 2009 (With Lyrics)

By now everyone must have seen the remarkable performance of this unknown Brit. But in case you haven't, check it out and be thrilled.

Obese Passengers Must Buy Two Seats

My heart goes out to huge people. There is so much "fat" discrimination in our society and now, United Airlines has announced that obese passengers will be bumped from full flights and be required to buy two tickets on the next flight or upgrade to business class. (tip from me: chose business class). Think how humiliating and expensive it is to be obese!

I do understand the need for such draconian rules and it isn't fair to other passengers if an extra large person spills over into their seat. But, lets face it, to fit comfortably into any coach airline seat you need to be under 5 feet tall and weigh, oh... about 80 lbs. The airlines have squeezed the space so narrowly passengers are already touching and it is impossible to cross your legs or crawl out.

Delta Air Lines, the world's largest carrier, tries to place overweight passengers next to empty seats. I haven't seen an empty seat on an airplane for about two years. Southwest Airlines requires a passenger who cannot lower their armrest to buy two seats also.

I don't envy the flight attendants who have to enforce the new policy. And the embarrassment of being asked to move or be bumped from a flight when you are already seated is painful to think of.

Its no wonder bariatric and lap-band surgery are two of the fastest growing elective procedures. Being fat is no fun and it is proving to be very expensive.

What Medical Specialty Are You Suited For?

Hey, I'm easing back into the blog world after a fun trip to NYC. If you are a Doctor or ever thought you'd enjoy the world of Medicine, take this quick quiz to see what specialty you are suited for.

I wish I would have had a quiz like this when I was deciding (oh so many years ago) on a specialty. Most medical students make important career decisions based on whether they had a good experience during a 4-6 week rotation. The Resident physician you serve under can make or break a rotation and, believe me, I've seen a lot of doctors that are not at all suited for the specialty they chose.

In case you are wondering, I scored highest on Orthopedic Surgery, Thoracic Surgery, OB/GYN, General Surgery and Urology. Interesting that they are all surgical specialties. Internal Medicine (my specialty) was number 25 for me. I guess it was all those questions that asked if I liked good outcomes and am decisive (yes and yes)!

See what specialty suits you.

Hat tip to Anesthesioboist for the quiz.

Spring Break in NYC

There will be a little lull in the posts on EverythingHealth while I take a break with family and visit New York City. In the meantime, please look on the right side under "My Favorite Links" and you'll fine a lot to read on the Medical blogsphere and other fun sites.

See you in a week! Come back and be a "follower" of EverythingHealth.

Goodbye Pap Test

The pap smear may become a relic of the past. File it away with blood letting and arsenic when a new DNA test is brought to market that will enable women to be tested once every 5 to 10 years to detect cervical cancer.

The annual Pap Smear has been around since the 1940s and requires a scraping of the cervix with a pathologist reading the smear and looking for abnormal cells. The new DNA test, which is being sponsored by the Bill and Melinda Gates Foundation in India, has shown a single screening beats all other methods at detecting the HPV virus that leads to cancer. At $5 a test, the cost is a fraction of the Pap test and even though it requires a cervical smear, the results are available within a few hours. If it is negative it does not need to be repeated for several years.

Cervical cancer is caused by certain strains of the human papillomavirus and it is a sexually transmitted virus. In poor countries more than 250,000 women die annually of cervical cancer.
Most women in these countries do not have access to clinics or screening for cancer. A cheap and easy test would be a major breakthrough.

I think it will be a long time before the American College of Obstetricians and Gynecologists would accept a DNA test that puts the annual pap smear out to pasture. Old habits die hard and they will probably demand years and years of studies to make sure the new test is effective. Studies already show that women with a negative pap smear can wait three years before getting another one, yet most women come yearly and insurance pays for yearly tests, which is probably a waste of money.

Will the new DNA test replace pap smears? It certainly will in developing countries. In the United States we will need to wait for more confirmatory studies and a change in habit.

Myocardial Infarction

This is a cool short video that shows how a heart attack happens.

Testosterone Levels After Menopause

One of the little mentioned effects of menopause in women is low libido. As Estrogen levels decline, sexual desire seems to fade too. Since this isn't openly discussed, women and their partners wonder what the heck has happened.

In the past it was blamed on "empty nest" or mid-life crisis but we know now that the culprit is the hormone testosterone. Yup! That male hormone, testosterone, is present in women too and serum levels of free testosterone are on a downward slope in women around menopause and after.

You would think there would be a plethora of clinical trials and studies on testosterone decline in women...especially since everyone seems to be concerned about older men and their ability to get an erection (think: Viagra, Cialis, Levitra). Unfortunately, this has been an ignored area of women's health.

One study of 814 postmenopausal women from the New England Journal of Medicine in 2008, reported women who received testosterone replacement had significant increased sexual desire and satisfying sexual encounters compared to those who received placebo. The testosterone was given in two doses, 150mcg/day and 300mcg/day.

The women who received the higher dose had a better response, but higher doses also led to more androgenic side effects like hair growth and acne (19.9% with testosterone 300mcg compared to 10.5% placebo).

Of note, this study did not include women who had used estrogen or progesterone within 3 months and the women all had stable sexual partners.

It would be nice to have more studies to look at testosterone replacement effects and potential side effects so we could advise women with sexual dysfunction after menopause. For now, it's a decision that will need to be made without a great deal of science and evidence.

Swallowing Coins

This 7 year old child was brought to the ED because she had pain when she swallowed and "stomach pain". It turns out she shook a piggy bank upside down above her head and a few coins fell out. She swallowed one of them.

The X-ray shows a coin in the stomach. Because the child and her family were going on vacation the next day, an upper endoscopy (image#1) was done and 2 coins were seen in the stomach. They were retrieved with a Roth net and the vacation proceeded.

Most coins are swallowed by children between 6 months and 3 years. The coins will usually pass through the GI tract and come out the other end without a problem.

Image from Consultant

Foxy Richard Scott Wants to Protect Us Chickens

Richard Scott was the former President of Columbia/HCA, the worlds largest health care company in the 1990s. He was ousted by his own board of directors after the company pleaded guilty to fraud against state and federal health programs. They paid $1.7 billion to settle charges. Big businessman Scott spoke out back then against non-profit hospitals (his competition) and said they were "non-taxpaying hospitals" that had no business doing hospital business.
He "retired" with his personal billions to Naples, Florida and he now owns a chain of urgent care clinics, serves on 5 large corporation boards of director and runs a private investment firm.

Richard Scott, the "Gordon Gecko" of the health care world, is using his personal money and influence on Capital Hill to form a new group, "Conservatives for Patients' Rights" to speak out against President Obama's health care plans. It doesn't matter that the President has been rather busy with the economy and has not yet outlined his health care plan...Scott is ready to oppose it no matter what.

According the the New York Times, it is rather odd that someone who led a company that defrauded the government, and also was the recipient of millions of dollars in personal profits from Medicare and Medicaid programs, is now the Republican spokesman against change and reform. Even industry groups and Republicans who opposed the Clinton health care proposals are admitting that some form of reform is necessary and inevitable.

Scott and the conservative public relations firm, CRC, who brought us the Swift Boat attacks on Senator John Kerry, have gone pubic with TV ads that star Scott ( an ego, ya think?) saying "Imagine waking up one day and all your medical decisions are made by a central, national board." He has dispatched cameras to other countries to discredit socialized medicine so we should be seeing those ads soon.

I think Americans have become a little smarter and a little less willing to listen to swindlers. Richard Scott, go crawl back under your Florida sand castle.