Katrina Racial Violence

I read an article in the New York Times about the post hurricane violence in New Orleans after Katrina and the stories that are finally emerging about vigilante white people, including police, who threatened and murdered innocent blacks.  These accounts, so many years later are difficult to believe and several police officers have finally been indicted in various cases.

It takes me back to the post flooding of New Orleans and my work there as a medical volunteer.  I wasn't writing a blog then, but I wrote about it later.  One of the things I have never mentioned or written about was the story one survivor told me when I was taking care of him at the refugee center in Baton Rouge. 

The patient was a young black man in his 30s who was displaced and was with his uncle at the Center that served as temporary housing for about 5000 victims.  He left his home as the waters started rising and was walking shoulder deep through the murky water.  People were left to fend for themselves and, except for helicopters flying overhead and CNN recording the events below them on the ground, there was no organized rescue effort at that time.  This man was trying to get to higher ground and was helping others around him.  As the sun started to set a rowboat came along side of him with men carrying guns.

He told me they said, "Get out of here or just die. We want you dead."  I couldn't believe my ears.  "Are you sure they said that?" "Maybe you were in shock and didn't really hear them right", I naively replied.  "Why didn't they help you? Did they just leave you there?"  I asked...not really hearing what he was saying.  

I was incredulous that no help was offered and that they threatened him while he was helpless.  Frankly I just didn't believe the story, despite the details he provided and the sad, matter of fact way he spoke of it.  I brushed by his story and now I wish I would have listened with a more open ear and encouraged him to talk even more.

When people survive atrocities, just being heard and validated can help with healing.  My lack of understanding of the overt racism that exists in the South prevented me from hearing the truth and I failed that gentleman after the disaster.  The stories that are emerging now need to be heard.

Humane Farming to Prevent Salmonella Infected Eggs

More than a thousand Americans are ill from egg contaminated Salmonella and it has forced a recall of 1/2 billion eggs and increased scrutiny of the safety of eggs.  The Centers for Disease Control and Prevention have tracked the contaminated eggs to two Iowa facilities, one with over 1 million chickens.  It turns out that less than 200 big companies supply 95% of the eggs in the United States. Wholesalers and distributors routinely repackage the eggs for sale under other names, like Albertsons or Wholesome Farms.

According to National Public Radio, the Iowa egg producer is part of the DeCoster family business who has run large hog and chicken operations.  They have faced a number of complaints and charges including employment discrimination, environmental violations, federal immigration charges and animal cruelty charges against their chickens.  They paid millions in fines to settle the charges.

There have been nine studies published in the last five years that show higher rates of Salmonella in chickens who are kept in forced confinement compared to a cage-free environment.  A caged hen is given only 67 square inches of cage space to live her life. That is less space than a single sheet of paper.  The hen cannot nest, perch, spread her wings or walk.  Even cage free animals aren't outside pecking on the ground, but they can at least walk and lay their eggs in nests, which is a natural behavior and reduces levels of stress and frustration.

A study published in the American Journal of Epidemiology reported that by switching to cage-free systems, the egg industry may be able to cut the risk of Salmonella for the American public by half. 

California passed a law requiring that all whole eggs sold statewide be cage-free by 2015.  Michigan has also passed laws to phase out the use of cages to confine hens.  With 95% of egg-laying hens confined to cages, this is a small start and more legislation is needed to protect food safety.

You can do your part by buying only cage free eggs at the market.

Weight Loss Requires a Major Change in Lifestyle

I know it is not politically correct to look at what other people buy at the grocery store, but as a physician I just can't help noticing.  Some baskets contain huge containers of soda pop, Doritos, frozen pizza and other packaged goods.  I'm not surprised because at the end of every isle is a display case that offers the giant soda for 89 cents or the Doritos on special for $1.29.  With this type of marketing it takes a strong person to resist the "bargain".

Yesterday the woman in front of me (overweight, middle age) had a strange assortment of goods that she probably thought would help her lose weight.  She had several "weight watcher" type meals, diet drinks, power bars, and lots of "light" items..."light butter", "light crackers", "light yogurt", "light ice-cream". 

Folks, this will not work.  Eating this way will not help her lose weight.  She needs to make dramatic changes to drop the pounds. 

Recent research shows that sweet tasting, low calorie beverages may trigger cravings for more sweets.  A study of rats showed that the animals who were fed saccharin yogurt ate more calories and got fatter than those who ate yogurt flavored with glucose.   It doesn't take long for our taste buds to stop craving sweet drinks and enjoy water.  The first step is to cut out the diet drinks.

The "light" items are a joke.  Cutting a few fat calories a day will not lead to weight loss.  She needs to avoid those center isles that have cereal, crackers, frozen food, canned food, pasta and rice and shop the periphery.  Fruit is the best snack and if you want to have a bowl of ice-cream (once you are at ideal body weight) there is no problem.  But to get to ideal body weight she will need to cut out the processed carbs, sugar and packaged foods.

And lets talk about "power bars".   Is 230 calories really a bargain?  With 45g of carbohydrates and 20g of sugar this is only useful if it is eaten by itself as a meal or if you are an endurance athlete that needs a burst of carbs to finish riding in the tour de france.

Unfortunately people believe they are doing the right thing by shopping this way. Then they get frustrated with themselves when they don't lose weight.  Weight loss requires a major change in lifestyle and it starts by avoiding the middle isles, and ignoring the display cases at the grocery stores.  Madison Avenue advertising is not our friend.

Answer to Medical Challenge

The answer to yesterday's image and patient case was #3-Ludwig's angina.  Ludwig's angina is an infectious process involving the submental (chin), Sublingual (under tongue) and submandibular (under the jaw) spaces. The bacterial cause is usually strept.  It can rapidly progress and is considered a medical emergency because it can affect the breathing and airway.

The term angina means "strangling".  Whilhelm Fredrich von Ludwig first described the condition in 1836.

Aren't we all smarter now?

Medical Challenge

This weeks Medical Challenge from the New England Journal of Medicine is a tough one.  This patient had been treated with penicillin for a toothache the day before.  You be the doctor.  What is the diagnosis?

1. Acute parotitis
2. Angioneurotic edema
3. Ludwig's angina
4. Penicillin allergy
5. Peritonsillar abscess

The answer will be posted tomorrow.

Communication Gaps Between Doctors and Patients

In a surprising report from the Archives of Internal Medicine, we learn that most hospitalized patients (82%) could not accurately name the physician responsible for their care and almost half of the patients did not even know their diagnosis or why they were admitted.  If that isn't enough, when the researchers queried the physicians, 67% thought the patients knew their name and 77% of doctors thought the patients "understood their diagnoses at least somewhat well".  I would call that a pretty significant communication gap!

Ninety percent of the patients said they received a new medication and didn't know the side effects.  Although 98% of physicians thought they discussed their patient's fears and anxieties with them, only 54% of patients thought they did.

The researchers from Yale University School of Medicine and Waterbury Hospital concluded: “Significant differences exist between patients’ and physicians’ impressions about patient knowledge and inpatient care received.” Moreover, responses didn’t significantly differ by sex, age, race, language or payment source, for the patients, or level and type of training, for the doctors.

A great deal of evidence exists that shows patients who understand their condition, are educated about medication and have good rapport with their physician have better outcomes.  It is just common sense.  I know that medical schools teach interpersonal relationships and the fact that so many physicians think they are doing it right makes me wonder how they can be perceived so differently by the patients.

Some possible explanations are:

• Patients are stressed while hospitalized and do not remember what is said.
• Many patients are heavily medicated and that affects ability to learn and remember.
• Doctors are too rushed and deliver information too quickly to be understood.
• Hospitalized patients have too many consultants and no one is identified as the "responsible physician".
• The trend to get patients out of the hospital quickly short changes communication time.
• Nurses, consultants and hospitalists don't communicate well together and the patient gets a different message from each visit.

There may be many other potential reasons.  Everyone in medicine should take a pause to look at this study very carefully because it shows so much room for improvement.

Osteoporosis Testing with DXA

One of the good things that has come out of the Affordable Care Act (the name for Health Care Reform) is that the payments to providers who do DXA screening for osteoporosis will increase immediately from Medicare and Medicaid.  Unfortunately these increased payments expire at the end of 2011.  To show how crazy the Medicare payment policies are, in 2006 the DXA service was reimbursed at $143.00.  Now the fee for the same  CPT code 77080 is $45.00 and it will increase to $98.00.  So the increased payment now is still only 70% of the payment in 2006 and there is no guarantee it won't be ratcheted down again.

The cost of a new DXA dual energy Xray absorptiometry machine is about $35,000 and the life span is about 8-10 years.  Training for employees, space and variable costs to run the program are added to this.  A patient's access to this test depends upon where they live.  In large metropolitan areas, most hospitals offer DXA testing.  But it doesn't take advanced math to see that this would not be a good investment by a small clinic or doctor's office and patients in smaller communities will have difficulty finding this test.

Identifying and treating bone loss early results in savings later from hip fractures and hospitalizations.  Until we start looking at the entire cost of care for certain high-risk conditions, we will never be making the right decisions on where to invest money.  Vitamin D screening and DXA screening are important for high risk patients so we can identify them and start early treatment.  The costs spent on these tests is minuscule compared to the cost of hospitalization, surgery and nursing homes after the fact.

Top 10 U.S. Pharmaceutical Sales

The top money makers for the U. S Pharmaceutical Industry might surprise you.  These are not necessarily the most prescribed medications (although some of them are) but they are the top products in terms of sales in 2009.  The revenues were in $ Billions:

1. Lipitor  -      used for high cholesterol                 $7.5
2. Nexium  -    a proton pump inhibitor for reflux     6.3
3. Plavix   -      a blood thinner                                 5.6
4. Advair Diskus-   used for asthma and COPD            4.7
5. Seroquel -    used for bipolar disorders                  4.2
6. Abilify   -     used for bipolar disorders                  4.0
7. Singulair-     for asthma and allergies                    3.7
8. Actos     -     for diabetes                                      3.4
9. Embrel  -      injectible for rheumatoid arthritis     3.3
10. Epogen  -     injectible for low red cells                 3.2

All of these medications are used on a chronic basis.  One month of Advair inhaler can cost $150 - $200.  Lipitor can cost between $2.00-4.00 a day, even though there is no proven advantage over a generic that costs 25¢ a day.  Embrel is for severe rheumatoid arthritis but at a cost of $1500/month, how many seniors could afford it without Medicare Part D coverage?

Amgen has a monopoly with Epogen, used for patients on dialysis and other anemias.  The margin is believed to exceed 85%.  The Pharmaceutical lobby is second to none.

Hey, folks, I'm not against pharmaceutical medications.  I take them, I prescribe them and I believe we have enhanced life because of new discoveries.  But with Health Care Reform, it is time to look at all costs and there should be no sacred cows.

Don't Wait After Miscarriage to Get Pregnant Again

About 15-20% of women who know they are pregnant will have a miscarriage.  The loss of a pregnancy before 20 weeks is considered a miscarriage. Many women suffer grief and shock after a miscarriage and fear there is something wrong with them or that they did something to cause it.  But the reasons for miscarriage are usually not known.  Women are often told to wait "a few months"  to get pregnant again to let their bodies recover.

A new study published in the British Medical Journal looked at over 30,000 women who had a miscarriage in their first recorded pregnancy and subsequently became pregnant again.  They found that women who conceived again within six months were less likely to have another miscarriage or problem pregnancy.  They were even less likely to have a cesarean section, preterm delivery or infant of low birth weight.  These women were more likely to have an induced labor.

The researchers wrote, "Women wanting to become pregnant soon after a miscarriage should not be discouraged."  These women had the best reproductive outcomes.

One of the best sites I have found that gives a great deal of information about miscarriages is women's health.

Are Teens Overmedicated?

It is summer camp season for kids and well run camps require a medical history and record of prescription medications that the child is taking.  One prestigious camp for teens (ages 11 to 19 - average camper is 16) in Southern California had 153 residential teenagers last week.  These kids come from California and other states across the U.S.  Fifty percent come from out of state and a number of campers each week are international.  OK, so far so good.  Healthy teens getting together for a week of learning and fun.   Here is the shocker!

I was amazed to learn that almost 25% of these kids are on prescription medication.  Can it be that we are over medicating teens?

I am not counting birth control pills in this count. (All sexually active teens should be on the pill or another reliable form of birth control).  I'm also leaving out medication for asthma, allergies, or acne. The medications that 23% of the teens took were:

• Adderal
• Acyclovir
• Ambien
• Fluoxetine
• Lamictal
• Lexapro
• Naprosyn
• Prozac
• Strattera
• Vyvanse
• Zoloft

I don't know the medical history of these kids but at first glance that seems excessive.  I know that certain disorders are serious and can respond to medication.  For serious psychiatric conditions it can be life-saving.  But those conditions are not the norm. Many of these drugs are used for ADHD or anxiety disorders.  The sheer number of meds in those categories is alarming.  Parents and physicians need to question if we are trying to make our children fit a certain mold.  Are we less accepting of diverse personalities and behavior? 

I fear the pendulum for using pharmaceutical medications to treat teen angst or teen hyperactivity may have swung way too far.

Being a teenager is one big mood disorder.  It doesn't need to be medicated away.