Thursday, December 30, 2010

New Years Resolutions for Doctors and Patients

Below is an updated re-post of a blog from a few years ago.  I liked it then and I like it now.

#1 Doctor: Resolve to let patient speak without interruption and describe their symptoms.
Patient: Resolve to focus on the problem I am seeing the doctor about and not come with a list of 10 complaints for a 15 minute visit.

#2 Doctor: Resolve to keep a pleasant tone of voice when answering night and weekend calls from the answering service, patients or nurses.
Patient: Resolve to get my prescriptions filled during office hours, not forget my medications while traveling and to use nights and weekend phone calls for emergencies only.

#3 Doctor:
Resolve to exercise a minimum of 4 times a week for better health.
Patient: Ditto

#4 Doctor: Resolve to train my staff and model excellent customer service for patients.
Resolve to understand that getting an instant referral, prescription, note for jury duty, letter to my insurance from the doctor is not my god-given right and I will stop bitching if it doesn't happen the day I request it.

#5 Doctor: Resolve to give at least one compliment a day to my office staff, child and spouse.
Patient: Ditto

#6 Doctor: Resolve to apologize when I am late seeing a patient who has been waiting.
Patient: Resolve to understand that when the doctor is late  another human being needed attention. It might me me in the future who needs extra time.

#7 Doctor: Resolve to do one new thing a month that is novel. ( a play? travel? special activity with a child or spouse? computer skill? music? see a friend?)
Patient: Ditto

#8 Doctor: Resolve to review all insurance payers and drop contracts that are not paying market rates for my skills and education. I will not go bankrupt.
Patient: Resolve to try and understand the medical economics that require my doctor to drop my insurance. If my doctor isn't worth paying a little more for the visit I will find a new doctor.

#9 Doctor: Resolve for each new prescription I write I will explain 5 things. The name of the medication. The reason for the medication. The side effects. How to take it. And how long to take it.
Patient: Once the doctor has prescribed a medication, I will take it as prescribed or let the doctor know right away if I am stopping it.

#10 Doctor: I will give thanks that I have a wonderful profession where I can help people in a special way.
Patient: I will not underestimate the many years of training and sacrifice my doctors have gone through and I will appreciate that they are trying their hardest to help me stay healthy.

Tuesday, December 28, 2010

Top 10 Articles Read by Doctors

Now that the end of the decade is near, we are hearing and reading about "the top this and that" from music to fashion to political downfalls.  Medscape has their own top 10 articles that were read by physicians on their site.  I find it interesting to see what my colleagues plug in to when they are not seeing patients.  The only surprise to me was the Brain Tumor "risk" because I thought that was settled years ago!  I'm not surprised about number 2 or 3.  Everyone I know is trying to survive in some way.

Here are the highlights from the Medscape Top 10 for physicians in 2010:
  1. Brain Tumour Risk in Relation to Mobile Telephone Use
    Is it safe to take that call?
  2. Trashed on the Internet: What Should You Do?
    Does a physician have any recourse if patients post a bad review on an Internet rating site?
  3. Six Ways to Earn Extra Income From Medical Activities
    Physicians are seeking ways to create more revenue. These activities may bring in additional profit.
  4. Physician in Whistle-Blower Case Charged by Texas Medical Board
    A nurse who had reported the physician to the Texas Medical Board in 2009 was acquitted of a felony charge of misuse of official information.
  5. FDA Issues Second Warning Against Treating Leg Cramps With Quinine
    Treating such cramps with quinine is an off-label use with potentially serious adverse effects.
  6. Berwick Appointed to Head CMS Without Senate Vote
    President Obama used his power of "recess appointment" to avoid a possible Republican filibuster of the nomination of Dr. Berwick to the CMS post.
  7. Abbott Withdraws Sibutramine From Market
    The FDA pulled the weight-loss medication from the market after data pointed to a 16% increase in the risk for serious cardiovascular events.
  8. FDA Warns of Suicide Risk for Tramadol
    The agency advised physicians that the opioid may be sought by patients with drug abuse and addiction problems or those with criminal diversion in mind.
  9. Calcium Supplements Boost Heart-Attack Risk
    A meta-analysis finds that calcium supplements increase the risk for MI.
  10. Healthcare Reform Resource Center
    The evolving debate was chronicled by Medscape throughout 2010.

Chewable Contraceptive

Just in the nick of time before this decade ends, the FDA has approved the first low-dose chewable birth control contraceptive. 

The daily chew will be marketed by Watson Pharmaceuticals, Inc.   Fred Wilkinson, executive vice president of Global Brands said "We believe this product is an important addition to the oral contraceptive category, and that its characteristics will make it a desirable choice for women."

I have to ask myself...why?

Most birth control failures occur because the woman forgets to take the pill.  Will a chewable be more reliant?  Is it aimed at gals who just love chewing gum?  I don't get the concept.

Marketing for this breakthrough will begin the in the second quarter of 2011. 

Monday, December 27, 2010

Henrietta Lacks and Her Immortal Cells

If you like science, true history and an engaging story, pick up the new book by journalist Rebecca Skloot, The Immortal Life of Henrietta Lacks and prepare for a great read.  I knew nothing about the young black woman whose cells were taken back in 1951 by a scientist at Johns Hopkins Hospital and how those cells have revolutionized modern cell biology and research.

The HeLa (named after HEnrietta LAcks) cells were taken as she lay dying on the "colored" ward at Johns Hopkins Hospital of aggressive cervical cancer at age 30. Everyone who studies basic cell biology has heard of HeLa cells because they were the first human cell line to be successfully grown in culture and they are alive today.  HeLa cells were sent to researchers all across the globe and have been used to develop the polio vaccine, viruses, cloning, gene mapping and in-vitro fertilization.  Billions of the same immortal HeLa cells are used by researchers fighting cancer, multiple sclerosis, heart disease and diabetes.

Yet few people know anything about the woman who worked as a tobacco farmer and was buried in an unmarked grave.  Author Rebecca Skloot takes the reader on a journey that starts in 1951 and takes us through the discovery of Henrietta's real identity in the 1970's.  Henrietta Lacks had a life. She had five children and brothers and a husband who knew nothing of her immortal cells and how they were changing the world.  As the author became obsessed with the story, she researched and sought out the family and her discovery changed their lives as well.

The story is somewhat shocking as the reader learns how blacks were treated by the medical establishment in the Jim Crow South.  Equally surprising is the fact that biologic tissue is being used today in the same way, with the "patient" rarely knowing.   No permission was granted for the harvesting of the HeLa cells and no information was ever given to the family until Rebecca Skloot helped them learn the true story as she learned it herself in research for the book.  The family that cannot afford health insurance has never had any benefit from the multimillion-dollar industry selling human biological materials that came from Henrietta's cells.

I couldn't put Henrietta Lacks and Her Immortal Cells down.  The author tells the Lack family story with compassion and stark reality.  It reads like fiction but is researched like investigative reporting.  The story speaks for itself.  There are no victims here.  There are no heroes.  There is only a human interest story that lives today, just like Henrietta's cells, and it is high time it is known by all.

Friday, December 24, 2010

Answer to Gory Medical Challenge.

(Scroll down to see the challenge)

The Answer to the gory image from NEJM is #2, Ischemic gangrene.

This patient had a 4 month history of progressive gangrene.  Untreated diabetes can lead to lack of blood flow to extremities which causes the tissue to die.  This foot will require amputation.  Readers of EverythingHealth are smart and many of you got the answer.

Audio of a Doctor in the Making

This 5 year old has all the makings of a good physician.  Calm, reassuring, caring, and interested in dressing well.

Wednesday, December 22, 2010

Last Gory Medical Challenge Before Christmas

If the New England Journal of Medicine can do it right before Christmas, so can EverythingHealth.  This shocking pic represents what diagnosis?
1.  Ichthyosis
2.  Ischemic gangrene
3. Necrobiosis lipoidica diabeticorum
4. Phlegmasia cerulea dolens
5. Pyoderma gangrenosum

Make your diagnosis in the comment section and check back tomorrow for the answer.
(Better yet...sign up on the right as a subscriber and you'll get a handy email alert for each post)

Tuesday, December 21, 2010

Health Care Reform Challenges

While most Republicans believe the new health law will be repealed, the Health and Human Services Secretary, Kathleen Sebelius says "there is no going back".  Reform is in turmoil after a federal judge in Virginia ruled the individual mandate unconstitutional.  Two other federal judges of equal stature have upheld it,  so confusion prevails with policywonks and the public.

The federal mandate says all Americans must maintain health insurance.  Secretary Sebelius says, "I think discussions are likely to go forward, but most Americans find the practice of saying to sick Americans or those who may be sick or those whose children are sick 'you cannot participate in the health insurance pool' really reprehensible."  

She also said, "Instead of making health insurance more available, more affordable to an estimated 32 to 35 million Americans, repeal would make sure insurance was even further out of reach and that our costs continue to skyrocket," Sebelius said.  She added, "We can't return to the days where over the last 10 years insurance charges went up 131% and people have less coverage and less options."

Many think the new health law challenges will make it all the way to the Supreme Court.

When you look at history, there are similarities with the "New Deal" from President Franklin D. Roosevelt and the Social Security Act.  He initiated it between 1933 and 1938.  In 1939 a survey of the American people asked, "Do you think the attitude of the Roosevelt administration toward business is delaying business recovery?" The American people responded "yes" by a margin of more than two-to-one and business felt even more strongly.  Legislators fought the child labor amendment, the banking reform act and the new deal relief programs as "almost the complete Communistic form of government".   New Deal opponents said "if we adopt an old age pension, we are taking another step toward destruction."

The Social Security Act was settled in a set of Supreme Court decisions that moved America toward other industrialized nations in offering old-age pensions and unemployment compensation.  We must remember how complex that bill was.  All Americans had to be issued social security numbers, taxes were withheld, field offices were set up, States had to cooperate.

Could the New Deal be accomplished in the present contentious bi-partisan climate?  Will we move forward with health reform or maintain the status quo? 

Monday, December 20, 2010

Macular Degeneration and Lifestyle

We now have another condition that may be prevented by eating a healthy diet, exercising and abstaining from smoking.  Age Related macular degeneration (AMD)!

Macular degeneration causes a loss of central vision and makes it difficult to recognize faces and read small print.  The macula degenerates with age and severe macular degeneration causes blindness.  Treatment is costly and doesn't work very well.

A new study published in the Archives of Ophthalmology looked at 1313 women aged 55-74 years.  They reviewed their diet and exercise habits.   Eating a "healthy diet" meant 3.5 servings of fruit and vegetables, 2.3 servings of dairy, 2.7 ounces of meet and 3.5 servings of grain a day.  Exercise habits and smoking history were also monitored.

They found a significant association between early AMD and diet, exercise and overall healthy habits.  Non-smokers who ate the healthiest diets and were the most active (only 5% of participants) reduced their odds for AMD by 71% compared to those with high-risk scores.

The authors noted a couple of caveats.  They studied only white females so we don't know if these results hold true for men or other ethnicities.  They also did not evaluate interrelated habits and they did not look at people with high-risk genotypes for AMD.  The authors did note, however, that having a family history of AMD did not alter the benefits of a healthy lifestyle.

So here it is...yet another reason to seize the moment and start doing the things that are proven to create better health as we age.  So far I haven't found even one study that did not extol the benefits of diet and exercise and not smoking in creating good health.

Sunday, December 19, 2010

San Francisco Gothic Merry Christmas

My uber talented friends, Martin and Brigitta Wolman created this Christmas card.  They are the best artists!!  This is a self portrait.

Thursday, December 16, 2010

Raynaud's Disease

Thanks to modern technology (iphone) a picture is worth a thousand words in diagnosing a condition.  This young woman had been exercising outside by the Golden Gate Bridge in San Francisco (temp a chilly 49ยบ F) and when she finished her hand looked like this.  It felt numb and began stinging when she ran hot water on it.

What is seen is classic Raynaud's disease.  It is a condition that causes some ares of the body like the fingers, toes, tips of nose and ears to have limited blood circulation in response to cold temperatures.  It affects women more than men and the skin can turn blue or white or purple in blotchy areas.  It is common to feel swelling and stinging as the circulation improves (such as immersing in hot water).  An attack can last several minutes to hours.

With Raynauds, there is a vasospasm of the small blood vessels that go to the digits.  This limits blood supply which causes the skin to turn pale.  Cold temperatures are most likely to trigger an attack but emotional stress can also cause it.  We think it is an inherited disorder.

Most of the time, Raynaud's does not require treatment.  Patients learn to avoid sudden cold (like refrigerators) and to wear gloves when it is cold outside.   If the attacks are frequent or severe, medications that dilate the blood vessels can be prescribed.  These are medications like nifedipine, amlodipine and felodipine.

The iphone saved her from a visit to the emergency department (where it is likely the vasoconstriction would have already resolved) or the office.

This is a form of "telemedicine". 

(Photo used with permission and gratitude)

Answer to Yesterday's Medical Quiz

The answer to the Medical Challenge was #5  Tinea.

Tinea refers to a group of infections caused by fungus. Tinea is also known as "ringworm"..even though it has nothing to do with worms.  The ringworm infection is often a well demarcated ring on the face, scalp or body.

The culture of this lesion showed Trichophyton rubrum, a common fungal species that also causes nail infection (onchomycosis) and athletes foot.  The skin infections are easily cured with 14 days of topical treatment.   Nail infections are difficult to cure.

The fungal infection "athletes foot" is also called Tinea pedis.  Topical treatment usually cures it.

Wednesday, December 15, 2010

Medical Challenge

I've been too busy to blog but not too busy to keep up with the New England Journal of Medicine.  Here is your medical quiz for the week.

What is the diagnosis for this finger lesion?  Make your best guess and the answer will be posted tomorrow.  Click on the image for a better view.

1. Anthrax
2.  Cellulitis
3.  Lichen planus
4. Psoriasis
5. Tinea

Friday, December 10, 2010

Ten Commandments For the Office Christmas Party

EverythingHealth offers sage advice to keep you healthy...both physically and mentally over the holidays.  The office or hospital Christmas party can be a treacherous place.  Observe these tips:

1.  Don't Get Toasted- A drink or two is fine and festive.  But when the booze flows freely so does the mouth and attitude.  Don't drink too much and regret (or worse yet..wonder) what you said or did with your co-workers.
2.  Don't Get Too Cozy- If you observe #1,  there will be less likelihood that you will get into trouble with that co-worker, nurse, boss, married man or make inappropriate remarks to the receptionist in the short skirt.  Remember it is still the workplace on Monday.
3.  Don't Give Bad Gifts- People will remember if your Secret Santa gift was a dud.  Do not recycle what was given to you and try to chose wisely.  It doesn't have to be expensive to be classy.  Avoid clothing and make sure you aren't giving Champagne to a Mormon.
4.  Don't Dance Crazy-  This isn't Soul Train or Dancing with the Stars.  You know what I mean.  Remember rule #1
5.  Don't Over-Eat- Make a point to hang out on the other side of the room from the buffet table.  Try to eat something first so you aren't starved and be conscious of how much you are eating.  It's easy to pack away some serious calories unconsciously.
6.  Don't Ignore People-This is the time to get to know someone you see all the time but barely know.  Mingle with people who aren't in your department and spend time with everyone, not just your pals or the bosses.
7.  Don't Wear Inappropriate Clothes-The goofy Santa tie is OK but remember it will be in every photo.  Red and Green are really awkward colors together.  Are you sure you want to wear them?
8.  Don't Dominate the Boss-Polite greetings to the boss and his/her spouse are perfect but if you are hanging with them the entire evening you will be ignoring rule #6.  Make sure the boss knows your name,  but he probably doesn't want to develop a close relationship at this party.
9.  Don't Bring Strangers as Guests - Usually these parties are for the staff and spouses.  It is quite fine to go alone and it is hard to integrate a blind date or a casual acquaintance to the office scene without making everyone uncomfortable.
10:  Don't talk about Drugs, Sex, Politics, Religion or Co-Workers -  You know why.

The Holidays are a time of celebration and relaxation.  The Office Party can be a great place to unwind and have fun.  It can also be a disaster.  Observe these commandments and make it fun.

Thursday, December 9, 2010

Women's Health Gets an F

The Oregon Health and Science University has published its 5th report card since 2000 and it grades and ranks the United States on 26 health-status indicators for women.   In 2010, not one state received an overall "satisfactory" grade for women's health and just two states (Vermont and Massachusetts) received a "satisfactory-minus" grade.  Overall, the nation is so far from meeting the goals set by the U.S. Department of Health and Human Services that it receives an overall grade of "Unsatisfactory".

The National Report Card uses status indicators to assess women's health:
  • Women's Access to Health Care Services (medically under-served area, no abortion provider, no health insurance and first trimester prenatal care)
  • Wellness  (screening mammograms, colorectal cancer, pap smears, cholesterol)
  • Prevention (leisure time physical activity, obesity, eating 5 fruits and vegies/day, binge drinking, annual dental visits, smoking)
  • Key Conditions (coronary heart disease death rate, lung cancer death, stroke death, breast cancer death)
  • Chronic Conditions (high blood pressure, diabetes, AIDS, arthritis, osteoporosis)
  • Reproductive Health (chlamydia, maternal mortality, unintended pregnancies)
  • Mental Health (days mental health was not good)
  • Violence Against Women 
  • Infant Mortality Rate
  • Life Expectancy
  • Poverty
  • High School Completion
  • Wage gap
The score on these varied status indicators fluctuated depending upon which State a woman lives.  California and New Jersey ranked highest on state health policies and Idaho and South Dakota ranked last on policies.

Since the publication of the first report card in 2000, the Nation made progress on several women's health indicators including lower death rates from coronary heart disease, stroke, breast and lung cancer.  Smoking declined and more women received colorectal screening.  That is good news.

The Patient Protection and Affordable Care Act (ObamaCare) will have significant positive implications for women's health.  Unfortunately most of it won't begin until 2014 when expansions in health care coverage and improvements in preventive care go into effect.  Family planning services will be covered under Medicaid and smoking cessation treatment will be covered.

The ACA will also protect women from health discrimination and will not allow insurers to charge a woman more because of her gender.  (Being a woman is not a pre-existing condition!).  It will also ensure health services including maternity and newborn care, mental health care and preventive services.

We have a long way to go to bring this report card from unsatisfactory to an "A".  At least it tells us where we are now and points the way to what is needed for women to be healthy.  We cannot deny that improvements in health care policy at a federal and state level are critical to keep moving forward.

Addendum:   In re-reading this post after a good nights sleep it is important to point out that I'd rather be a woman in the USA than about 75% of the world.  To understand and help women in the most oppressed parts of the world go to Women for Women International.

Monday, December 6, 2010

Just follow the Money for Cardiac Stents

History repeats itself again with the new expose' in the New York Times about the Baltimore Cardiologist who inserted (at the least) 585 stents in patients who did not need them.  On one single day he inserted 30 stents!  I didn't know there was that much time even available in the cardiac cath lab but with Medicare reporting payments of $3.8 million for a two year period to Dr. Mark Midei,  I guess it isn't a surprise that he might have worked "overtime".

The Times article is pretty scathing and implicates his hospital, St. Josephs,  who treated him like a king and gave him a $1.2 million dollar salary just to be on the medical staff and bring those $10,000 cases to their institution.  St. Josephs settled with the OIG by paying a $22 million dollar fine for charges that it paid a kickback to Dr. Midei.

Abbott labs, the maker of the expensive stent, was thrilled with his excessive surgeries and showered additional millions in consulting fees and perks for the good doctor since he was one of their best customers.  The fact that he inserted 1200 stents annually, a number that would raise professional eyebrows, didn't phase the stent maker.

I mention history repeating because there have been a number of similar high profile cases across the country over the past 5 years.  In 2005 a group of cardiac surgeons in Redding, California and the hospital owned by Tenet Healthcare paid nearly $1/2 billion to settle charges of unnecessary surgery.  The cardiologists did not lose their licenses.  Can you believe that?

Other cases include another Maryland cardiologist and a Louisiana cardiologist who did jail time for similar offenses.

About 1 million angioplasties are done in the United States each year and half are for non-emergencies. Studies reported in the New England Journal of Medicine in 2006 and 2007 showed that stents were unnecessary in many cases and that patients who received medication instead of stent had a slightly longer life expectancy.  NEJM also estimated that 100,000 heart attack patients in the U.S. do not need stents even though they are placed.   A 3rd article in NEJM in 2009 showed stents have been overused and cause potentially dangerous care.

So how do these cardiologists and hospitals continue to get away with it?  The decision to place a stent is often made "on the spot" during the angioplasty based on the doctors impression of how much blockage is seen.  The patient is told he had a 90% blockage and "isn't it lucky we found it in time and saved you from a heart attack?"  Patients see the cardiologist as a savior.   (I know Cardiologists who have received vacations, cruises, tickets to the Super Bowl from grateful patients)

Invasive Cardiologists who bring in the business are treated like kings at the hospital.   The "rainmaker" top physician is often the director of the cardiology catheterization lab.  Other specialist doctors are often part of the same group and the cardiology departments are small.  The hospital likes being the epicenter of cardiac referrals and has no incentive for enforcing peer review of the cases.  Dr. Midei ran the peer review at St. Josephs, guaranteeing no-one would be looking at his work.

Almost all of the surgery abuses at all of the hospitals over the past 5 years were discovered via a whistleblower.  I do not know of one that was discovered because of peer review.

St. Josephs Hospital was accredited by The Joint Commission last month and is in full compliance with all applicable standards.

Go figure!

Sunday, December 5, 2010

Tinnitus-Ringing in the Ears

Tinnitus is derived from the Latin word tinnire meaning "to ring".  It is an extremely common complaint and 50 million adults reported tinnitus in the past year.  Up to 3 million people have symptoms that are severely debilitating. You would think that we know a lot about tinnitus and how to cure it but you would be wrong.  Here is what we learned from a study reported in The American Journal of Medicine.

Tinnitus increases with age until age 60-69 and then it decreases. We don't know if the symptoms improve as part of the natural history or if having tinnitus goes along with other conditions that cause mortality.  Black people and Hispanic people suffer less tinnitus than Whites.

There are significant associations between tinnitus, smoking and hypertension.  Loud noise exposure is also a risk factor for developing tinnitus.  The noise could be leisure (loud music or sports), occupational or firearm exposure.

Anxiety and major depressive disorders were associated with increased tinnitus.  People with generalized anxiety disorder have more than 6 times the odds of developing tinnitus.  Tinnitus can result in sleep deprivation, decreased work productivity and psychological distress so that might worsen symptoms of anxiety and depression.  On the other hand, depression and anxiety might exacerbate tinnitus.

Tinnitus is often subjective and there are no objective signs that can be seen.  People can perceive it in one or both ears and it can be intermittent or continuous.  The medical workup looks for structural causes that can be treated.    Over 260 medications can cause tinnitus as a side effect, but usually the cause is never found.

There are a number of treatments for tinnitus ranging from electrical stimulation to sound therapy and tinnitus maskers.  There is even an American Tinnitus Association where you can learn more about the disorder and get some tinnitus tips.

Beware of the  number of quack sites on the internet that will sell you something to cure tinnitus.  Save your money.

Thursday, December 2, 2010

Answer to Yesterday's Medical Quiz

The answer to the strange  lesions seen on the patient in yesterday's image challenge is #5 - bleomycin reaction.  The patient was treated with intralesional bleomycin for a lesion on her tongue.  Within a week she developed painless, non-itchy hyperpigmentation on her trunk. 

Bleomycin is a medication that is used for certain types of cancer.  Twenty percent of patients treated with bleomycin have such a reaction.

Wednesday, December 1, 2010

What is the Diagnosis

Here is your medical challenge for today compliments of EverythingHealth and the New England Journal of Medicine.  This 39 year old woman presented with these marks on her back.  You be the doctor.  What is the diagnosis?   Click on the image for a better view and the answer will be posted tomorrow.  (hint: 3/4 of the physicians got it wrong.  I got it right)

Save yourself from remembering to check back by signing up on the right side for an EverythingHealth email alert

1.  Arsenic Poisoning
2.  Cushing's Syndrome
3.  Pellagra
4.  Self-flagellation
5. Treatment with Bleomycin

Tuesday, November 30, 2010

Health Care is Not Recession Proof

I've heard people say that health care is recession proof.  Even when the economy is suffering, people still get sick and need service.  The current recession is entering the 3rd year and it has finally caught up to the health industry.  The latest Bureau of Labor Statistics reports that there were 16 mass hospital layoffs in October, up from 10 in September.  Mass layoffs involve 50 or more employees and in the first 10 months of 2010,  128 mass layoffs occurred.  The Bureau projects 12,349 initial claims for unemployment benefits, which surpasses the number in 2009.

What causes mass layoffs?  The recession and unemployment has reduced demand for elective procedures and reduced reimbursement from government programs (Medicaid and Medicare).  Charity care has also increased and hospitals are adjusting to a lower bottom line by eliminating their most costly item...employees.

Physicians, too, have noticed a decrease in patients in the office.  Doctors who previously had a long wait for appointments are now more available.  That is a good outcome.  But bad debt is soaring.  Insurance companies have shifted more first dollar coverage to employees in the form of high deductibles and co-pays.  Neither the patient nor the doctor knows how much the patient's responsibility will be at the time of the visit.  When the bill is finally adjudicated...sometimes months is increasingly more difficult to collect from the patient.  (As an example, I just got an insurance check from an office visit in June.)

Despite these gloomy facts, health care remained among the few sectors adding jobs.  The health sector grew by 0.2%.

Vitamin D Controversy

I have written before about the value of evidence based medicine and the need for doctors to alter their practice as new evidence comes in.  But I am totally thrown off by the new IOM report about Vitamin D and Calcium.  The report is 999 pages long.  Let me repeat that, dear readers...999 pages. (Available for purchase for $53.96)

The Committee was asked to review current data and make a recommendation about appropriate dietary intake of Vitamin D and Calcium. I will give you the cliff notes.  They report that most Americans and Canadians are getting just about enough Vitamin D and Calcium in their diets and sticking with the recommended 700 mg to 1,300 mg a day of Calcium is just fine.  For most people, 600 IUs of Vitamin D is enough for bone health but those age 71 and older may need 800 IUs.  These levels are easily reached through a healthy diet without the need for nutritional supplements, according to the researchers.

Talk about confusion!  Over the past 5 years I have read numerous studies in reputable journals that correlate higher Vitamin D levels with decreased heart disease, depression, bone disease, fractures, hypertension and several autoimmune diseases.  One study linked low levels of Vitamin D with Parkinson's disease and another from Harvard Medical School linked low levels with asthma in children.  These studies were in peer reviewed journals and doctors were encouraged to test for and treat low Vitamin D. 

I trust the Institute for Medicine (IOM).  They are not biased. But I am keeping a healthy degree of suspicion that this is not the end of the story.  I have never recommended the supra-high doses and there has been no evidence that low levels need to be "quickly" raised with 50,000 IU doses.  I have usually recommended 1000 to 2000 IU/day for patients that have low levels and I aim for a target of at least 40 on a blood test. 

At this time, I will continue these recommendations and await the fire-storm to smolder out. 

Go here and here and here to read my prior (well researched) posts on Vitamin D.

Good Health Simplified

You can't do anything about your genes but here is the formula for good health...simplified:

0           Cigarettes
          Servings Fruits and Vegetables a Day
10         Minutes of Silence or Relaxation a Day
30         Body Mass Index below 30
150       Minutes of Exercise a week    

You knew this already...but are you really doing it?

Sunday, November 28, 2010

Rabies 101

Rabies is a virus that causes neurologic encephalitis and is almost 100% fatal.  Since 2000, 31 cases of human rabies have been reported in the United States.  Seven of them were acquired from exposure abroad (Phillippines, Ghana, El Salvador, Haiti, Mexico and India).  Rabies is mainly contracted from an animal bite or saliva from an infected animal.  The most common animals are dogs, bats, coyotes, raccoons and skunks.  The average incubation period between exposure and illness is 2-7 weeks but symptoms can first occur after 3 months.

If  Doctors don't suspect rabies, it can be difficult to diagnose at first and once symptoms occur it is 100% fatal.  Symptoms may include anxiety, loss of feeling in an area of the body and loss of muscle function.  Fever is low grade and the patient is restless.  As the infection develops,  drooling, difficulty swallowing and convulsions occur.  Hydrophobia (aversion to water) is common.  Death occurs as quickly as one week.

The only treatment for rabies is postexposure prophylaxis (PEP) administered if there is expected exposure and before symptoms begin.  Family members who are in close contact with or exposed to saliva from a suspected infected person also undergo PEP.  This consists of one dose of Rabies immune globulin, followed by four more injections over a two week period.

It is important for travelers to be aware of rabies.  Although rare in the United States, 55,000 people die of rabies around the world every year.   Rabies is found on every continent except Antartica. For travelers going to endemic areas where PEP is not available and there is limited access to medical care, pre-exposure vaccination is available.   This consists of three injections and if all three cannot be received the traveler should not start them.  If all three doses are not given, the traveler will not be considered vaccinated and any exposure will require PEP.

Most developing countries do not have PEP and any bite or exposure may require immediate travel to an area where it is available.

The old form of rabies vaccine was manufactured from viruses grown in animal brains and some of these vaccines are still in use in developing countries.  Travelers who are offered a large injection daily for 14-21 days into the abdomen should refuse these vaccines and travel to another country where immune globulin is available.

The best prevention is understanding that rabies is out there and stray animals should be avoided.  Any bite or scratch that occurs in a rabies endemic area should be grounds for seeking post exposure rabies immunoprophylaxis.

Monday, November 22, 2010

Health Care Reform Cannot be Stopped

Now that the Republicans have taken over the House, they are calling for repeal of The Patient Protection and Affordable Care Act (ACA).  They are calling it a "bad product" and a "monstrosity" and the airways are full of pundits telling the American people that they intend to "take back our country."  But what would repeal of the bill really do?

Overturning ACA would cause 32  million Americans to forgo insurance.  It would deregulate the insurance industry and cause those children that are on their parents plans (until age 26) to be dropped  like a hot stone.  The part that went into effect today about mandating that insurance companies spend 80-85% of your  premium money on the insured would be reversed.  Children would not be covered if they had preexisting conditions (active now) and the practice of denying coverage for adults with preexisting conditions would continue if the law is repealed.  Increased funding for primary care physicians and nurses would go away.  Preventive care is part of the bill.  That would be repealed along with insurance companies dropping people from coverage once they get sick or hit their lifetime limit.

Take away Health Care Reform and the deficits and health care costs will rise at higher rates.  Continuing to pay for  quantity and not quality got us into this mess.  Continuing the current system is the most expensive and irresponsible choice any politician could make.

 What are the Republicans planning on replacing ACA with?  They want to get rid of insurance exchanges (which preserves the current insurance system in America) and replace it with purchasing of insurance across state lines.  When people can't afford insurance in their own state, I don't see how buying it  from another state (that can't be regulated) adds anything.  They want expanded use of health care savings accounts.  Again, that works fine for high income people, but is that solving a problem?  Estimates from the Congressional Budget Office (CBO) report that similar principles would insure only an additional 3 million Americans.

The Democrats made a big mistake by delaying many provisions of ACA until 2014.  They also blew it by not getting the message out to Americans.  Many liberals are angry that Health Care Reform didn't go far enough.  It actually has many principles that were mouthed by Republicans a few years ago but are strongly opposed now that it came from Obama.

It is not a perfect law but unless I see an alternative that does as much for all Americans, I support "Obamacare"

Sunday, November 21, 2010

Total Knee Replacement in Younger Adults

The surgery that replaces the knee joint rose by 66% in American age 65-84 from 1997 to 2007.  And in Americans age 45-64, the rate tripled in that time.  The technology has improved and more surgeons are willing to perform this operation in younger people and the public has a greater familiarity with the procedure and its results.

We don't know if more patients age 45-64 are getting osteoarthritis or if the rise in sports injuries is driving it.   With the baby boomers now reaching Medicare age, it is anticipated that the knee replacement rate will continue to soar.

Total knee replacement is a big surgery.  Some have referred to it as "precision carpentry".  The recovery period is 4-6 weeks and the full recovery takes about a year.  For older, retired people who are more sedentary, this disability time is not such a big deal.  But for working adults, it consumes a lot of time.  The surgery is usually not done until the patient has tried all of the other treatments but still has severe pain with normal activities.

Non operative treatment options include weight loss, anti-inflammatory meds, joint supplements, cortisone injections, hyaluronic acid injections and activity modification.

One study of 84 patients younger than 55 years old who underwent knee replacement found that 82 of them improved their activity after knee replacement and 18 years later, 94% of the knees were still working well.

There is a forum site where people exchange tips and stories about total knee replacement.  The person who started the site was 27 when she had a TKR!

Friday, November 19, 2010

Gastroenteritis and Hypertension

There is provocative new research from the British Medical Journal this week. They have made a strong connection between EColi infection and subsequent development of hypertension.  I'll try to break it down here into the "cliff notes" but to read the entire study go here to BMJ.

We know that most hypertension diagnoses have no etiology (cause).  We also know that in the U.S. escherichia coli 0157:H7 (EColi) infections cause 50,000-120,000 gastroenteric illnesses annually. (commonly known as food poisoning).  We also know that there are receptors on the kidney for toxins and exposure can cause both renal and vascular injury causing severe and subtle nephron (kidney cell) loss.

This study followed 1977 adults from Walkerton, Ontario, Canada after the town suffered from a municipal water system contamination with EColi and other bacteria.  Acute gastroenteritis was reported by 1067 participants. The researchers followed all the participants of Walkerton annually and excluded people who had hypertension, kidney disease, or cardiovascular disease at the time of the outbreak.

They found that four years after the contamination outbreak, there was a  28% increased risk for hypertension among adults with GI illness. Hypertension was defined as over 140/90.   They also found the exposed patients were 3.4 times more likely to develop renal impairment and 2.1 times more likely to have a cardiovascular event (stroke or MI).

In conclusion, this rare oppportunity study showed that acute gastroenteritis from drinking water contaminated with E Coli 0157:H7 was associated with an increased risk for hypertension, renal impairment and self reported cardiovascular disease.  Because hypertension and renal impairment are silent, annual blood pressure monitoring and periodic monitoring of renal function is needed for people who have acute gastroenteritis.

What this study does not tell us:  We don't know if other bacteria have the same effect or if it was a combination of bacteria that caused it.  We don't know if the participants that did not get sick from the drinking water may have been exposed and didn't know it. 

Thursday, November 18, 2010

Answers to Derm Quiz

Scroll down to see the photos and here are the answers. If you cant see the images in the previous post, click on "EverythingHealth" and you'll see the entire blog.

#1 - Actinic Keratosis - these dry crusty bumps are on sun damaged skin and can be either flat or raised in appearance.  They occur after long periods of sun exposure and damage.  They are not life threatening and can be treated with freezing (cryosurgery), excision or chemical peels.

#2- Basal Cell Carcinoma- this is the most common type of skin cancer and can usually be cured by removing it.  They also occur in sun damaged skin.

#3- Solar Lentigo- This is a large freckle caused by the skin damage from UV radiation (sun).  They are also called sun spots or liver spots or age spots as they occur in people over age 55 after years of sun damage.

#4 Squamous Cell Cancer-This is the 2nd most common skin cancer and it also occurs with sun damage. Men are twice as likely to have SQ cancer.  Most are curable and they do not metastasize but they can spread and cause large areas of damage to the skin.  Any non-healing sore on a sun exposed part of the body (ears, lips, nose, face) could be a squamous cell cancer.

Nobody got them all right. 
Doctors love skin pics.  Here is a site with lots of skin pics.

Tuesday, November 16, 2010

Dermatology Quiz

Let's see how many of these common skin lesions you can identify.  The answer will be posted tomorrow.
Match the diagnosis with the images:
  • Basal Cell Carcinoma
  • Solar Lentigo
  • Squamous Cell Carcinoma 
  • Actinic Keratosis   


Medical Updates for Older Adults

New clinical trials and published research is giving us information on how to improve health in elderly patients.  Here are some brief points from The Cleveland Journal of Medicine that were surprising to me:
  • Each year 30% of people age 65 or older fall and sustain serious injuries so preventing falls and fractures is important.  Vitamin D prevents both falls and fractures, but mega doses of Vitamin D (50,000 mg) might cause more falls.  A better dose is 1000mg a day in people who consume a low-calcium diet. 
  • Exercise boosts the effect of influenza vaccine.
  • The benefits of dialysis in older patients is uncertain as it does not improve  function in people over age 80.  We don't even know if it improves survival.  Older patients who receive dialysis for kidney failure had a decline in function (eating, bed mobility, ambulation, toileting, hygiene and dressing) after starting treatment.
  • Colinesterase inhibitors (Aricept, Razadyne and Exelon) are commonly used to treat Alzheimer disease but they all can have serious side effects.  Syncope (fainting),hip fractures, slow heart rate and the need for permanent pacemaker insertion were more frequent in people taking these drugs.  The benefits of these drugs on cognition is modest.
  • A new drug called Pradaxa (Dabigatran) will likely prove to be safer than Coumadin (warfarin).  2.2 million adults have atrial fibrillation and the median age is 75.  The blood thinner warfarin is critical for prevention of strokes but it caries a high risk of bleeding and drug levels have to be monitored frequently.  Dabigatran will probably replace warfarin but it will probably also be a lot more expensive.
As I often say, medicine and science are constantly changing and evolving.   As new evidence comes forth, physicians and patients need to re-evaluate they way we do things.  I'm glad we are no longer bleeding people. 

Sunday, November 14, 2010

Micro Loans and Your Health

Research has shown that giving to others can lead to a healthier, happier and longer life.  Generous behavior reduces depression and risk of suicide in adolescents.  Volunteerism on the part of older adults significantly reduces mortality.  Giving to others enables people to forgive themselves for mistakes; a key element in well-being.

One way to have a lot of fun on the internet and get a health boost while doing so is to log onto a cool site called  For as little as $25.00,  ordinary people like you and me can be part of the world-wide micro-loan community.  Kiva's mission is to connect people, through lending, for the sake of alleviating poverty.

I have made 14 Kiva loans and I got to pick the recipients.  By viewing the photos and reading the bios, I wait until a person "speaks" to me.   I like loaning to women because I know that when women are able to earn money, they spend it on their children's education and it benefits the entire village.  This morning I loaned $25.00 to contribute to funding a woman in Nicaragua expand her retail store.  She is 60 years old, single and has 4 children.   Other loans have been to a baker in El Salvador and a woman who does charcoal sales in Togo.  She is illiterate but supports her family and sends her children to school.  In many developing countries school  costs money and these people live on so little that they cannot afford uniforms or pencils.  Sending a child to school is a huge deal.  She has paid back 22% of the loan and is right on time with repayments.

My loans to Kenya, Tajikistan, Palestine,  Uganda and Nigeria (Afolabi Ibiwoye seen in this photo) have been paid back 100% and I can re-loan that money.  Yippee!  I am feeling healthier and better already. is really fun to surf.  Check it out and get healthy too.

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...