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 later...it 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 Kiva.org.  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.

Kiva.org is really fun to surf.  Check it out and get healthy too.

Thursday, November 11, 2010

Great Healthy Holiday Food Ideas

I have permission to share these tips from MD Anderson Cancer Center with the readers of EverythingHealth.  With the holidays coming up,  these choices make sense.  Enjoy!
biscottiMaking healthy food choices can be tough during the holidays, especially at gatherings where festive snacks abound But who says holiday snacks have to be high in fat and sugar?

“Many holiday foods can easily be replaced with more nutritious alternatives — without sacrificing festive smells and flavors,” says Sally Scroggs, health education manager at MD Anderson’s Cancer Prevention Center.

That’s good news because a cookie or two, a slice of cake, and a few trips to the chip and dip bowl can easily add up to more than a meal’s worth of calories.

“Most of these holiday treats are filled with empty calories and don’t provide the nutrients your body needs to reduce your risk of diseases like cancer,” Scroggs says. “Plus, they may not keep you full, so you end up eating more, taking in more calories and gaining weight. This could, over time, increase your risk for some cancers.”

Whether you’re hosting or attending a holiday gathering, try these healthy party snack swaps.

1. Instead of salted mixed nuts or candied pecans, serve spiced toasted almonds.almonds

The salt in mixed nuts and the butter and sugar in candied nuts add unnecessary calories to nuts’ nutritional perks.

By replacing salt, oil and butter with cayenne pepper and thyme, you trim added fat. This recipe for spiced toasted almonds also delivers cancer-fighting vitamin E, as well as magnesium and fiber.

“Nuts are naturally high in fat, so don’t eat more than one portion of nuts,” Scroggs says. “That’s one-fourth cup, or about as many nuts as you can fit into the palm of your hand.”

2. Instead of chocolate peppermint bark, serve strawberries with dark chocolate.

The white and milk chocolate used in most peppermint bark have slightly more saturated fat than dark chocolate.strawberries in chocolate

For a healthier treat, serve strawberries with melted dark chocolate or dip the strawberries in dark chocolate and chill them ahead of time. Either combo can satisfy chocolate cravings for a fraction of the sugar and fat. Added bonus: dark chocolate’s antioxidants and the ellagic acid, vitamin C and fiber in the strawberries help reduce your risk of cancer.

3. Instead of gingerbread cake, serve ginger spice biscotti.

Gingerbread cake is loaded with butter and sugar. Go easy on the butter and sugar by trying this recipe for ginger spice biscotti.  It delivers festive ginger flavor at a fraction of the calories.

Even healthier: Give guests an antioxidant boost by serving the biscotti with green tea.

4. Instead of melted cheese dip, serve chunky cranberry dip.

Melted cheese dip packs on the fat and calories. Get more seasonal flavor and less fat in this lower-calorie chunky cranberry dip recipe. Added bonus: The fiber in the cranberries helps fight cancer.

Even healthier: Serve the dip with whole grain crackers instead of chips. Whole grain provides vitamins, minerals and plant compounds, which curb cancer risks. And, the fiber helps you stay full.

5. Instead of fruitcake, serve angel food cake topped with fresh berries.strawberries in chocolate

Fruitcake is loaded with calories from fat. But angel food cake is generally fat-free. Topping it with fresh berries provides fruitcake’s one nutritional perk — the fruit — without the butter. Plus, the fiber, vitamin C and ellagic acid in the compote’s berries may help prevent cancer.

“Be realistic. You should certainly try to make healthy food choices so you don’t gain weight during the holidays,” Scroggs says. “But don’t beat yourself up over a moment of weakness or deprive yourself of occasional holiday treats.”

Focused on Health - November 2010
by Laura Nathan-Garner

Monday, November 8, 2010

Doctors as Employees

The days of doctors running their own offices and starting practice are coming to an end.  As this graph from today's Wall Street Journal shows, since 2005 more doctors are becoming employees of hospitals rather than owning their own medical practice.

The reasons are not that hard to understand.  Medicine has become a complex and difficult business.  Dealing with dozens of different insurance companies, Medicare,  Medicaid and the hassles of being an employer are not what doctors are trained to do.  The days of the simple medical practice with a receptionist and a well trained (smart and loyal) nurse at the doctor's side are long gone. 

Why don't doctors in the U.S. have electronic medical records, as does much of Europe and other developed countries?  They cannot afford to capitalize the technology or  support the IT infrastructure.  A hospital organization can!

In my medical community only one of the recent Internal Medicine residents stayed in private practice.  And he joined his dad!  The rest leave to work for Kaiser Permanente or be employed as hospitalists.  The young doctors know they cannot survive with the insurance reimbursements for primary care.  They are not established enough to set up concierge (retainer) practices so a steady paycheck with benefits, insurance coverage, cell-phone, electronic medical record, time off for continuing medical education looks like a very nice deal.  In fact it looks like a nice deal for doctors that have been running their own practices and they are leaving for employment in record numbers too.

Why do hospitals across the country want to employ physicians?  Everyone knows that the doctor is the entry portal for patients.  Even hospitals lose money on primary care services.  But our insane reimbursement structures pay for procedures, imaging, tests, scans, days in beds,  and lots of stuff that generates billings.  Primary Care becomes the lost leader.

Until we get a grip and place value on prevention and primary services for patients that pays for "thinking" rather than "doing", we will never get our financial house in order.  There is nothing wrong with employment as long as it is designed to produce real benefits and improve quality for patients.  Aligning different specialties of physicians with hospitals to drive efficient quality care could lower costs and improve service.  Time will tell if that is a direction that we are going.  Right now it is the same system with a different owner on the shingle.

Thursday, November 4, 2010

Answer to Diagnostic Challenge

The answer is #4 - Median rhomboid glossitis.  This condition shows a round or rhomboid shaped patch of smooth tongue that lacks both papillae and taste buds.  It is usually located in the midline.  It is thought to arise from an embryologic defect but it doesn't usually cause problems nor does it require treatment.

Wednesday, November 3, 2010

This Weeks Diagnostic Challenge

This Weeks Diagnostic challenge from the New England Journal of Medicine is a good one.  What is the diagnosis for this unusual looking tongue?  Answer will be posted tomorrow so make your best guess. (click on the image to enlarge and get a better view)

1.  Atrophic candidiasis
2.  Erythroplakia
3.  lingual thyroid
4.  Median rhomboid glossitis
5.  Tertiary syphillis

Tuesday, November 2, 2010

Smarter Medical Care

The internet is a wonderful place to get medical information when and how you want it.  You may not be interested in the topic of "Coumadin" until you or a family member is prescribed the drug.  What does it mean when your father tells you his doctor wants to do a "laparoscopy" or that your mother has a "venous thrombosis"?  It is important to get your medical information from a reputable source that is not filled with advertisements and gimmicks.  That is why I recommend Smarter Medical Care.

Smarter Medical Care was started by a San Francisco Hematologist named Dr. Robert Rodvien in memory of his wife, Rayna, who died of ovarian cancer.  It contains over 65 podcasts dedicated to patient information that is easy to digest and free of commercial bias.  It is an easy site to navigate and it addresses medical topics directly and compassionately.

Smarter Medical Care is a good site to bookmark and come back to when questions need answering.  So far Dr. Rodvien is supporting it himself and is about $80K  in the red.  Hopefully it will find a home that can monetize it and keep it going.

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...