Saturday, February 27, 2010
Research from Denmark shows that life expectancy is increasing steadily and there is a good possibility that by controlling life factors, most everyone can live to be 100. Of course, living in a high income, first world country is the first factor. The Danish experts report that since the 20th century, people in developed countries are living about three decades longer than in the past.
Check out the list (click on it for a better read) to see what factors you can control.
Tip: Don't eat the nuts if you have an allergy. That would definitely lower your chances! And having a baby "later in life" does not mean with IVF or infertility drugs. And a "little" wine doesn't mean a bottle a day.
Posted by Toni Brayer, MD at 3:26 PM
Friday, February 26, 2010
The answer to yesterdays Medical Challenge is...drumroll....
#4 - Intraabdominal Cancer.
The nodule is called a "Sister Mary Joseph's" nodule and is a lymphatic metastasis to the umbilical region. This 12 year old girl had decreased appetite, vomiting and weight loss. A CT scan showed a large pelvic mass originating from the ovary, hepatic metastasis, ascites and a mass through the umbilicus.
Sister Mary Joseph Dempsey (born Julia Dempsey; 1856-1939) was the surgical assistant of Dr. William J. Mayo of Mayo Clinic. She drew Dr. Mayo's attention to the nodule and he published the first article about it in 1928.
Posted by Toni Brayer, MD at 6:20 PM
Thursday, February 25, 2010
How good of a diagnostician are you? This challenge from the New England Journal of Medicine is tough. (I missed it the first time).
Q: This 12 year old presented with decreased appetite and vomiting. What is the most likely diagnosis?
4. Intraabdominal cancer
5. Urachal duct cyst.
Click on the image for a better view and make your guess. The answer will be posted tomorrow.
Wednesday, February 24, 2010
In 1922 the intact tomb of King Tut was discovered in Egypt. Technology shows us that the boy died around 1324 BC and was probably around 19. Anthropologists from Egypt, Germany, Italy and other countries studied DNA and performed tests on 16 royal mummies and found that four, including King Tut, had contracted a severe form of malaria called Plasmodium falciparum. Tut also had a broken leg and they believe malaria killed him.
It is amazing that scientists are able to take a mummy and find out so much about his life after studying the DNA for two years. Here is what we now know about King Tut:
- He had a cleft palate, a left clubfoot and other bone ailments
- He suffered from Kohler disease, which can cause foot bones to collapse from lack of blood
- He probably needed canes to walk
- Two of the other mummies were Tut's father, Akhenaten and his grandmother, Tiye, based on shared blood groups.
- His parents were brother and sister
- There was no foul play in his death
Posted by Toni Brayer, MD at 6:57 AM
Tuesday, February 23, 2010
EverythingHealth feels justified in awarding this weeks Hall of Corporate Shame Award to California Anthem Blue Cross. California Insurance Commissioner Steve Poizner said Anthem Blue Cross "violated state law more than 700 times over a three-year period by failing to pay medical claims on time and repeatedly failed to respond to state regulators as they investigated complaints over the last year". They uncovered 133,000 violations of state law over payments for medical care.
In addition, Anthem Blue Cross raised rates on their private paying customers a shocking 39%, stating the recession and people losing coverage made it happen. They said the shifting demographics took a big bite out of their profits.
Hmmm...somehow Anthem's parent company, Wellpoint outpaced inflation 10 to one and posted $2.7 billion profit in the last quarter of 2009 alone!
Anthem is the largest for-profit insurer in California. The rate hikes would affect many of the 800,000 individual policy holders in California who are held hostage for insurance coverage by Blue Cross. Finding other affordable coverage is impossible if a patient filed any claim at all...even for a minor condition like migraine headache or conjunctivitis.
The Obama administration has postponed the rate hike by two months. Insurers are free to set their rates at any level they like as long as they spend 70% on claims.
Congratulations, Anthem Blue Cross. Your egregious and greedy behavior goes far beyond the open market.
Monday, February 22, 2010
Why do some kids get allergies and some don't? A new study published in Allergy 2010 may give us some answers. The women who ate more green and yellow vegetables, citrus and high beta carotene while they were pregnant had fewer babies with eczema. They also found that foods high in vitamin E lessened the risk of having a wheezy baby.
The researchers from Fukuoka University in Japan studied 763 pregnant women and evaluated their fruit and vegetable intake during pregnancy. The women averaged 30 years of age and were 17 weeks pregnant at enrollment. (average gestational time is 40 weeks). After controlling for exposure to smoke, number of older siblings and breastfeeding history, they found that women who ate more vegies, citrus fruits or beta carotene were less apt to have an infant with eczema. (54 vs 32 infants).
Like other studies from the U.S. and U.K., these researchers showed higher intake of Vitamin E reduced the likelihood of having a wheezy infant.
These are pretty easy steps for pregnant women to take and may make a difference in the health of the baby.
Posted by Toni Brayer, MD at 5:14 PM
Sunday, February 21, 2010
I am one who loves medical history and Genius On The Edge - the bizarre double life of Dr. William Stewart Halsted, was a captivating read. For those who don't know, Dr. Halsted is known as the "Father of Surgery" and practiced medicine after the civil war. Written by author physician, Dr. Gerald Imber, the medical facts are sound and the story is fascinating for any reader.
We learn that in 1850 there was no anesthesia, no knowledge of germs, no IVs or blood transfusions and no more than 200 surgeries a year were performed because the outcomes were usually disastrous. The patient who needed emergency surgery died of overwhelming infection, gangrene or shock from blood loss.
Dr. William Halsted, like all physicians of that time, was born into wealth and privilege. He began his training in 1875, ten years after Louis Pasteur showed sour milk was caused by a bacteria and when Robert Koch was able to cultivate the anthrax bacillus. At a time when surgeons were not washing their hands and were operating in dirty clothes, the concept of antisepsis was a critical advance that Dr. Halsted seized for his own training. Medical Schools were for-profit trade schools and no laboratory or clinical work was required but like many wealthy young physicians, he traveled to Europe to study the newest techniques.
In early 1884 Sigmund Freud began experiments with an exciting new drug called cocaine. William Halsted saw its possibilities as an anesthetic and began injecting it into himself and patients. It was a successful anesthetic but he became powerfully addicted. He turned to morphine (the other widely available drug of the time) and ended up with a dual addiction that he hid and struggled with until he died in 1922.
In telling the amazing story of Dr. William Halsted, the author takes the reader through the beginning of modern medicine. It is the story of Johns Hopkins University and Medical Center and the story of the great names of medicine...Dr. Osler, Dr. Cushing, Dr. Welch and Dr. Kelly. We see how the specialties of gynecology, pathology, medicine and neurosurgery were born. These early physicians were men of great curiosity and innovation but they were also aristocrats that lived a life of privilege.
Dr William Halsted took a 5 month vacation every year and when he was working he actually avoided surgery unless it was an "interesting case" that he could learn from. He much preferred the lab where he could work privately on experiments and technique. Despite being arrogant, aloof and detached, patients flocked to his hospital because he performed successful surgery for hernia, mastectomy, thyroid and aneurysms at a time when they were not being attempted. His infection rates were close to zero before antibiotics due to his meticulous habits and rules in the OR. The surgeons that trained under him also adopted these habits and went on to spread the "Halsted Surgery Method" across the country.
I couldn't put Genius On the Edge down. Here was a man who transformed medicine but was so personally flawed with addiction and a bizarre marriage. (I believe he may have been homosexual). He was so meticulous, he sent his linen shirts to Europe to be laundered and always wore a top hat. He often forgot the patients on the wards that were waiting weeks for surgery. He actually didn't like patients very much, nor did the other professors, with the exception of Dr. William Osler, who spent most of his time with patients and teaching residents.
So much of medical training as we know it today, stemmed from the "modern" medical school that was developed at Johns Hopkins. The controversy between faculty being on salary versus having to "earn" their income from patient care and research carries over even until today. I was also interested that the salary of $10,000/year paid to the professors is equivalent to about $300K today. In addition they saw private patients and seemed to have a great deal of leisure time to smoke cigarettes, join special men's clubs and travel to Europe.
Genius on the Edge is a portrait of a brilliant, drug addicted surgeon who transformed medicine and ushered in the 20th century. The descriptions of hospitals, training, surgical technique and bizarre beliefs makes this a fascinating true story.
Posted by Toni Brayer, MD at 10:20 PM
Thursday, February 11, 2010
Stuttering has always been a fascinating phenomenon to me. Stuttering is a speech disorder where the person repeats or prolongs a sound and doesn't have a normal flow of speech. I have known severe "stutterers" who have undergone speech therapy without much help. There have been famous singers (Mel Tillis is one) who stuttered severely when they spoke, but not when they sang.
Now for the first time, a study led by researchers from the National Institute on Deafness and other Communication Disorders, and published in the New England Journal of Medicine, has identified three genes that they believe are involved in stuttering. Three million Americans stutter and until now the cause has been a mystery.
The researchers found the same gene mutation in unrelated families in the United States, Britain and Pakistan.
When I read about these discoveries that link disorders to genes it makes me feel a little sad. Like autism and bed wetting, doctors in the past would blame mothers and child rearing for these problems. Mothers were told autism occurred because they were distant and cold with their infants. Bed wetting was a lazy child. Stuttering was a child who was nervous or didn't have proper speech development at an early age. Clearly these theories are nuts and our ability to identify genes as the cause will finally let mothers off the hook.
Wednesday, February 10, 2010
While the U.S. argues about health care reform and Blue Cross Anthem raises rates a shocking 39%, somehow our "socialist" brothers across the Atlantic are able to implement better hospital gowns.
The British government of Bristol, England commissioned designers to develop a better hospital gown. The U.S. born designer Ben deLisi, who has designed for Kate Winslet and other stars came up with a luxury cotton wrap around gown that limits exposure.
Health Minister Ann Keen said the designer gowns would be introduced into NHS hospitals in England by early 2011.
The hideous, ill fitting old gowns will be replaced by the new gowns
Posted by Toni Brayer, MD at 7:10 AM
Tuesday, February 9, 2010
The internet is full of colon cleansing methods that tout the benefits of colon detox. I saw one website that showed long "worms" that live for years in the colon that "need" to be removed with special expensive potions. One of the most common questions for GI doctors is about colon cleansing and if it is beneficial. I don't know any physicians who believe the colon needs "detoxification" or special cleansing, but until now I didn't have a scientific way to answer that question from patients.
A study from the Am J. Gastroenterology now gives us the answer. The study authors looked at all relevant articles published between 1966 and 2008. They blinded the articles and measured outcomes and adverse events.
No research articles addressed the effect of colon cleansing on general health or on specific conditions such as hypertension, asthma, irritable bowel syndrome, arthritis, sinus congestion or alcoholism, despite the fact that these conditions are mentioned in ads. They did find adverse events such as electrolyte imbalances, septicemia, colitis, rectal perforation and death. One article reported an outbreak of amebiasis (amoeba infection) attributed to colonic irrigation therapy with at least 36 patients infected. Ten required colectomy and six patients died.
There was no good quality published evidence of any health benefit from colonic cleansing and many reports of adverse events. This practice has a large following with many colonic substances including coffee enemas and other herbs administered in the enema fluid.
The colon is designed to absorb nutrients and remove waste. The best way to keep your colon and GI tract healthy is to eat fruit, vegetables and fiber, stay hydrated and active. Special potions or enemas not needed.
Monday, February 8, 2010
Two nurses in Texas reported a physician to the Texas Medical Board for unethical and unsafe behavior toward patients. They directed the Medical Board to six cases where Dr. Rolando Arafiles should be investigated for improper prescribing and surgical procedures. In one case he performed a failed skin graft without surgical privileges. He also sutured a rubber tip to a patient's crushed finger for protection. This was so unconventional that it was flagged as inappropriate by the Texas Dept of State Health Services. The nurses believed the hospital administration (and presumably the medical staff too) were not properly monitoring him so they made their anonymous report to the Medical Board.
It seems Dr. Arafiles has friends in high places. His friend is the Winkler County sheriff and he used his power to find out who the nurses were and Dr. Arafiles has filed suit against them for "misuse of official information," a third-degree felony in Texas. The 2nd nurse was dismissed from the case. Both nurses have worked a combined 47 years at Winkler County Memorial Hospital and had excellent reputations.
The same cannot be said of Dr. Arafiles who was also selling herbal supplements to patients. He had been sanctioned in the past for improprieties in writing prescriptions and performing surgery. He had a restriction on his license from when he ran a weight-loss clinic.
This case stinks to high heavens. We have finally reached a time when patient safety is paramount and turning a blind eye to bad medical practice is not tolerated. The body that accredits hospitals wants the Medical Staff to perform ongoing physician assessment to make sure doctors are well trained and behaving properly.
Physicians have due process laws that protect them. Sometimes they are even over-protected and it is almost impossible to get a doctor thrown off the medical staff. It would appear Texas goes even further and punishes the nurses who report in good faith. This is pretty outrageous and will set back patient protection if it goes through.
To see Dr. Rolando Ariafiles in his full glory, go here.
Posted by Toni Brayer, MD at 7:40 AM
Saturday, February 6, 2010
Friday, February 5, 2010
Dr. Conrad Murray, the Huston, Texas cardiologist celebrity doctor to Michael Jackson will be charged with involuntary manslaughter today in the Los Angeles courtroom when he voluntarily surrenders.
He has been virtually underground since June 2009, after he gave the singer a powerful anesthetic (Propofol) and other sedatives that were blamed for his death.
Propofol is a strong anesthetic that is usually given in a hospital, by medical doctors that are trained in its administration and with rescue equipment close by. Also known as Diprivan, it is an injectable that is used in intensive care units for patients that are intubated (on respirators) or for patients that are undergoing surgical procedures where sedation is required. In healthy patients, Propofol causes a decrease in blood pressure, depending upon the dose and the speed of infusion.
Propofol is never given as an injection and the patient left alone. It is a drug that requires constant monitoring of the vital signs and respiration of the patient unless that patient is on a ventilator.
Although we do not know every aspect of the details of Michael Jackson's death from the lethal injection of Propofol, we do know that at 1:30 AM, Dr. Murray gave Jackson 10 mg of Valium, followed by injecting 2mg of the anti-anxiety drug, Ativan. An hour later he gave him 2mg of the sedative, Versed followed by another 2mg of Ativan. At 5AM he administered another 2mg of Ativan and at about 7:30 AM Murray gave Jackson another 2mg of Versed while monitoring him with a device that measured the oxygen saturation of the blood.
At about 10:40 AM, Murray administered between 25-50 mg of Propofol and Michael went into cardiac arrest. Dr. Murray attempted to do CPR while he was in his bed. Doing CPR without a hard surface under the back is ineffective. There are also reports that he waited more than an hour to summon emergency officials because there was no "land line" in the bedroom. He reportedly made three other calls.
The DEA has been unable to find a record of Dr. Murray purchasing, ordering or obtaining any Propofol under his medical license or DEA number. He does not have a DEA number in California for prescribing or administering controlled substances or narcotic medication.
Dr. Murray had a booming concierge practice, jetting off to see patients in New York and Washington and making house calls to high-profile clients in Las Vegas and Houston. He was reportedly paid $150,000/month to join Michael Jackson on tour and be his personal physician.
Is involuntary manslaughter the right charge? Some medical bloggers believe he should not have any charges brought at all. I believe the charge (or even worse) is warranted and he should lose his medical license permanently.
If you want to see how vibrant Michael Jackson was at the time of his death, rent the video "This is It". It is great entertainment and his death was certainly premature.
Wednesday, February 3, 2010
I went to my physical therapist yesterday for knee treatment and we talked about the fact that Blue Cross is cutting their reimbursement to the point that the cost of providing care will not even be covered. All I could do was lament with him and listen. One insurer even told him (the owner of the business) to just "make the sessions shorter and don't give as much care." As if that is how it works..."You get little money..so just do a little".
Clearly the insurance intermediaries, who never actually see a patient or deliver any care, haven't got a clue how this whole health thing works. They are happy with mediocre doctors that cut time and care. Those doctors (and physical therapists) run mills, but the insurance companies are happy with them. Quality and quantity of time are not rewarded, and in fact are punished in the health care environment we have.
He asked me if Primary care had any problems like that. I felt like screaming "Aren't you reading my blog?". Or more to the point...why doesn't the entire population know that access to a primary care physician will become as rare as swimming with dolphins. It will depend upon how much money you have to buy concierge/retainer medicine. Where you live will play a role. If your community has a large multispecialty clinic like Kaiser or Sutter Palo Alto Medical Group, you may have access.
Doctors in training are flooding away from general Internal Medicine, Pediatrics and Family Medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lerher report discussed the reasons. We've been talking, talking, talking about it for years but things have only gotten worse, not better.
The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation. Primary care is valued by the government, the payers, the population and even by the physicians.
We have it all backward. It is time to revamp the system from the bottom up. Frankly I don't care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new " next generation" imaging scanner until we can rationalize how we pay for care.
We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers (you know who you are, Ed) said "you can't clear the swamp until you get the pigs out of the way".
We have a lot of pigs to move aside so more people can get to the water.
Posted by Toni Brayer, MD at 7:42 AM
Tuesday, February 2, 2010
Monday, February 1, 2010
One patient informed me today that her Anthem Blue Cross insurance premium went up by $89.00 this month. She is responsible for a large up front deductible and she is (thankfully) healthy and ends up paying out of pocket for her health care because she seldom meets the deductible.
A 2nd patient sent me this from the Wall Street Journal:
UnitedHealth Group Inc.'s fourth-quarter earnings rose 30%, helped by prior-year litigation-related charges, higher enrollment than the company expected and subsiding costs related to the H1N1 flu outbreak.
The company reported a profit of $944 million, or 81 cents a share, in the fourth quarter, compared with $726 million, or 60 cents, a year earlier. Results for the prior year included $350 million in litigation settlement-related costs.
With the failing economy I guess we should be happy that there is an industry that is booming. Unfortunately it is booming at the expense of the customer paying outrageous premiums.
It turns out that the CEO of United Health Care makes $102,000/hour.
Posted by Toni Brayer, MD at 8:47 PM
The thought of ovarian cancer strikes fear for many women. Although it is not the most common cancer for women (Breast, Lung, Colon and Skin Cancer are more common), it is one of the most deadly because we have no early screening tests for ovarian cancer and it is usually advanced when detected. Women have been told that paying attention to "symptoms" and informing their physicians may be the best way to detect early ovarian cancer.
A new study published in the Journal of National Cancer Institute unfortunately shows that symptoms are a poor way of detecting early ovarian cancer. The study included over 800 women with ovarian cancer matched against a control group. The women were questioned about symptoms a year before diagnosis. The symptoms were abdominal pain, bloating or urinary urgency...symptoms that women are told to be vigilant about.
The study found that women with cancer were 10 times more likely to experience those symptoms. But there was no difference between detection of "early" vs. "advanced" ovarian cancer so the symptoms failed as a way to detect the cancer when it could be cured.
The good news is that the prevalence of ovarian cancer is low in the general population.
This study highlights the urgent need to develop better molecular markers and improved imaging modalities for ovarian cancer screening. To truly affect the cure of ovarian cancer, we need better diagnostic tools for asymptomatic women.
Posted by Toni Brayer, MD at 5:30 PM