Saturday, December 31, 2011

Seven Tips for Healthy 2012 Planning

As we welcome a new year it is an opportunity to re-evaluate, consider the coming year and make intentions for improving our health and sense of well being.  EverythingHealth sifts through the latest medical literature and evidence to offer these proven recommendations for staying on top of your game.
  • If you are 50 or older and haven't had a colonoscopy, schedule one in 2012.  It's time! 
  • Go online and check your Body Mass Index (BMI).  If you are too high, plan and execute on that diet.  (contact me for a diet coach referral if needed)
  • Get rid of sugar and soft drinks.  Stevia is a natural sweetener that is safe and yummy.  The average American eats 160 lbs of sugar a year. Break the sugar habit in 2012
  • Stop smoking. For motivation go here.
  • Relax your mind.  Start yoga, meditative dance, meditation.  These practices have been shown to lower blood pressure and general stress.
  • Send one thank you note a week.  That is 52 notes in 2012.  You can send it to your child, co-worker, grocer, doctor, spouse or even an acquaintance.  The act of thanking and reaching out to others is healing for both sides.
  • Become an activist.  Find one cause that you feel passionate about and get fully involved. Here are some to consider,  but there are hundreds of other great organizations and it has to be your own interest.
                                                            (micro loans to people around the world)
          Women for Women International.    (adopt a sister in a war torn nation.  Many of these women  have suffered atrocities, have no money and support many children.  If you help the women, you raise the standard for the whole community)
         U.S Humane Society  (They do wonderful work to protect animals, expose inhumane and unhealthy farming and promote legislation to make humans and animals safer)
         Foster Children -  (You don't need to adopt,  but you can get involved in a number of organizations that help these kids transition out of foster care into adulthood.  When they reach 18 the system is "done" with them.  Can you imagine your own 18 year old making it alone?  Check in your own community for programs and mentorships.)
Happy New Year to all of my readers!!!!

Friday, December 30, 2011

Top EverythingHealth Books of 2011

We at EverythingHealth love end of the year lists and we love reading.  Here is our pick for the best read Health (and everything)  books in 2011.  (not in order...all are terrific)
  • The Immortal Life of Henrietta Lacks, by Rebecca Skloot
  • Cutting For Stone,  by Abraham Verghese
  • Outliers,  by Malcolm Gladwell
  • The Help,  by Katheryn Stockett
  • The Checklist Manifesto,  by Atul Gawande
  • Middlesex,  by Jeffrey Eugenides
  • The Known World,  by Edward P. Jones
  • Complications,  by Atul Gawande
  • The Curious Incident of the Dog in the Night-Time,  by Mark Haddon
  • A Short History of Nearly Everything,   by Bill Bryson
If you have other favorites, let us all know.

Answer to Medical Challenge

The answer to the CT scan image medical challenge is #3, Intercostal Muscle Rupture.

The image shows subcutaneous emphysema and an intercostal muscle defect between the ribs.  the patient recovered after repair of the intercostal hernia.  Subcutaneous emphysema is air under the surface of the skin. 

It is not unusual for these muscles between the ribcage to be strained or even get small tears with sports, extreme coughing or trauma.  It is very unusual for the tear to be this extreme and affect the pleura around the lung and the lung itself.

Thanks for your diagnoses.

Wednesday, December 28, 2011

Medical Challenge

For my non medical readers, this is an abnormal CT scan.  The CT scan takes a transverse image sliced through, so you are looking at the patient sliced in half transversely.  This is the chest area. I will orient you:

The whitish circle and v-shaped part is the vertebral column.  So you know that is the back.   Bone shows up whiter than organs.  The small whitish lines in a circle are the ribcage (more bone) sliced through.  Air shows up dark so the big dark areas are the lungs.  Notice there is darkness streaking on one side and not the other.  As my 16 year old would say: "That is messed up".  What ruptured to allow air to penetrate the muscle area? (click on the image for a better view)

1.  The diaphragm
2.  The esophagus
3.  An intercostal muscle
4.  The interventricular septum
5.  The pericardium

Medical professionals and others:  Make your diagnosis.  The answer will be posted tomorrow.

High Ratings for Personal Physicians

It's time for some good news!   A study that looked at online patient ratings  about their physicians from 2004 through 2010 showed that the average physician rating was 9.3 out of 10.  That is amazingly high and shows that patients (at least the ones who posted on Dr.Score) are very content with the care they receive from their doctor.  Even though some patients will post a nasty comment about the doctor, the overall patient satisfaction is high.  Seventy percent of doctors earned a perfect 10.

The survey asked patients to rate physicians on attitude, the thoroughness of the visit,  how well the doctor communicated and how long they sat in the waiting room.  It is not a surprise that the longer patients waited, the lower was the rating.  Forty two % of doctors were primary care physicians and the remainder were specialists outside of primary care.

Patient satisfaction is finally getting attention in medicine.  More than 60% of health care organizations are using patient satisfaction scores to determine physician incentive payments and large medical groups measure satisfaction and give the doctor feedback on a regular basis.  Medicare will also link patient satisfaction with hospital payments and hospitals who do not rate high will lose revenue. 

We read a lot about the problems in health care in the United States but those issues are usually concerned with cost and access.  In fact a November Gallup poll found that 82% of adults say the quality of health care they receive is "good" or "excellent".  A 2010 study by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems found that 94% of nearly 42,000 patients rated their physicians a seven or higher on a 10-point scale.  (that group needs a new name)

Another study I read shows that 90% of physicians feel stressed nearly every day.  It is good news that that stress is not being felt by the patients and that we are delivering the patient-centered care that we pledged when we took our oath.

Monday, December 26, 2011

Holiday Dinner from the Boss

Marney is bossy.  Click to read her instructions for the Thanksgiving Potluck and be glad you aren't invited.

EverythingHealth tip:  Stay out of the stores today.  Rest, play games with the kids, Take a long walk in nature with the entire family and the dog and then drink the rest of the Christmas wine.

Saturday, December 24, 2011

Happy Holidays EverythingHealth

I get a lot of pleasure out of being a health blogger and it is only possible because of you, the reader.  Thank you for visiting EverythingHealth and allowing me to keep my mind sharp by researching articles and healthy living for you to read and enjoy.

Merry Christmas, Happy Hanukkah, Happy Holidays, and may we all have a wonderful 2012, no matter where we live on Earth. 

Wednesday, December 21, 2011

Kwashiorkor in Northern California Means Fraud

Kwashiorkor in Niger
Is it plausible that one small hospital in rural Northern California treated 1,030 cases of Kwashiorkor within a two year period?

Before you answer that, let me explain what Kwashiorkor is.  It is a severe form of protein malnutrition...starving to death actually.  It is the type of starvation you see in African children.  It is so severe that the patient needs special nutritional support including special re-feeding with vitamins and it occurs mainly in children ages 1-4.   Adults can starve to death, but they do not develop classic Kwashiorkor.

Medicare pays hospitals a flat rate based on diagnosis codes for patients.  Patients with more severe coded illnesses get paid at a much higher rate.  Shasta Regional Medical Center, located in Redding, Shasta County, California is under the microscope for billing Medicare (our tax dollars at work) for 1,030 cases of Kwashiorkor to the tune of $11,463 for each diagnosis.  This medical center is a 246 bed facility in a town of about 90,000 people.  The entire county is less than 200,000 population.  The median home price in 2010 was $245,000 and the average household income is $62,222.  Hardly the demographics for Kwashiorkor.

Patient described as kwashiorkor
Prime Healthcare Services owns 14 California hospitals, including the one in Redding.  After they took over the hospital in 2008, the diagnosis of Kwashiorkor exploded.  One of the patients that they billed Medicare for was interviewed and she said she was never malnourished and was never told she had Kwashiorkor.  She had diabetes and kidney failure and, according to her daughter, was actually overweight. There was no notation in her chart about edema swelling or nutritional consult.  She received no vitamins. 

A former medical coder at another Prime Healthcare Hospital told California Watch that she was pressured to write up patients for kwashiorkor if they had low albumin levels and were diagnosed for ordinary malnutrition.  Low albumin is very common in hospitalized patients and it can accompany a number of medical illnesses.  Coding these as kwashiorkor is fraud, plain and simple.

Most hospitals across the Country are doing their best to take care of patients and function with the byzantine regulations of Medicare and hundreds of insurance companies.  The majority of hospitals lose money on Medicare patients.   Flagrant abuse in billing, such as is suspected at Shasta Regional Medical Center, gets no sympathy from me.  I hope the CEO ends up in stripes and that all of the Prime Healthcare Hospitals are closely investigated.

Monday, December 19, 2011

Strange Compulsion

Pica is a medical term that refers to people who eat substances that are not nutritious like clay, dirt, paper or starch.  Lithophagia is the eating of rocks or pebbles.  The Xray above is from a 48 year old homeless man who came to the emergency department with abdominal pain, constipation and intermittent blood in his stool for 2 weeks.  The abdominal Xray showed small radio-opaque pebbles and gravel that the patient admitted eating over the last 9 months.  He believed that "God might turn it to bread in his belly."  He was given the diagnosis of nonspecific delusional disorder.

The patient underwent a purge with polyethelene glycol electrolyte solution.  (It is the same solution that is used for bowel prep before a colonoscopy).  Some of the pebbles had to be manually removed under general anesthesia.  His symptoms improved and follow-up Xray showed compete removal of the stones.  Unfortunately the patient was lost to follow-up after discharge from the hospital.

Geophagia is the eating of clay or dirt and it is not uncommon in the setting of famine and poverty.  There have only been 2 cases of lithophagia reported in the medical literature.

(Case from University of Wisconsin School of Medicine and Public Health, ConsultantLive)

Wednesday, December 14, 2011


Severe osteoarthritis of the hands
One of my patients came to see me today with severe right knee pain.  This is not a new problem, and in fact, we have been dealing with flare ups of  her osteoarthritis for years.  It mainly affects her knees and hands and today her right knee was swollen and felt like the "bone was rubbing together" with each step. She could hardly walk because of the pain.

Osteoarthritis is also known as degenerative arthritis and it is one of the most common maladies of aging joints, affecting millions of people.  The cartilage in joints wears down and inflammation causes the bones to build up spurs and small micro tears.  It affects women more than men and  the cause is unknown.  There are likely genetic factors as it tends to run in families.  Arthritis can occur in any joint but the most common are the fingers, wrists, hips, neck and spine and knees.  Stiffness (especially in the morning) and pain are the main symptoms that limit mobility.

You can see the bony changes that have occurred over time in my patient's hands. (click on the photo for a better view)  Note the swelling at the wrists and the way the thumbs angle inward.  She cannot stretch those thumbs out and there is wasting of the intrinsic muscles in her hands.  Surprisingly, she was not experiencing any pain in her hands or wrists today, although in the past it has been a problem.  Today it was the knee.

Because arthritis is chronic and affects millions of people, there are many purported "cures" and treatments.  Many of them are a big waste of money.  Here is what has worked for many patients:
  • Stay active and keep weight down.  Work on flexibility and range of motion.  For severe arthritis pain, aquatic exercise helps without causing more pain.
  • Yoga
  • Heat on the painful area alternating with ice as anti-inflammatory.
  • There is no proof for the "anti-inflammatory" diet, but eliminating sugar, glycemic white flour and processed foods increases energy levels and helps with weight control.  If you aren't exercising you probably need very few calories and they should be mainly fruits, vegies, grains and protein.
  • Trial of gluten free diet
  • Pain relievers like Nsaids, tylenol and aspirin can help
  • The evidence is still not clear for glucosamine or other supplements.
  • Cortisone injections
  • Hot tubs/hot baths
  • Joint replacement
A cortisone shot will hopefully help this patient and quite down the flare up in the knee.  Osteoarthritis is truly a pain and it requires a lot of attention.

Tuesday, December 13, 2011

Affordable Health Care Act Provides Senior Benefits

While the courts and politicians wrangle about the Affordable Care Act (ACA, "Obamacare"), some of the benefits have kicked in for Medicare beneficiaries.  The Act empowered the Center for Medicare and Medicaid Services (CMS) to eliminate co-payments for a number of preventative services and to cover services that were not included before.  Patients on Medicare now receive:
  • Bone mass measurements
  • Cervical Cancer Screening
  • Cholesterol and other cardiovascular screening
  • Colorectal cancer screening
  • Diabetes screening
  • HIV tests
  • Annual influenza, pneumococcal and Hep B vaccines
  • Mammograms
  • Medical Nutrition therapy
  • Prostate Cancer screening.
Previously Medicare did not cover screening tests or required co-pays.

It's not just seniors who have benefited from ACA.  It also allows young adults to stay on their parents' health plan until age 26 years.  These young adults do not need to live with their parents or be listed as a dependent on the tax return to be eligible.  This alone allows 1.2 million more Americans to be covered by insurance.

Unfortunately people with conditions such as diabetes who cannot find affordable health insurance will have to wait until 2014, when it will be unlawful for insurance companies to discriminate against preexisting conditions.  For now there is a temporary program to act as a bridge for patients until 2014.  There is a preexisting Condition Insurance Plan (PCIP) that can provide insurance for someone who has been uninsured for at least 6 months, has a preexisting condition or has been denied health coverage because of a condition.  For an estimated premium range for a given state, go to

Americans should be embracing health care reform and demanding their legislators come together to understand the complicated law and change it if needed and strengthen it to make it better.  We understand that it does nothing to address runaway costs, although there are many provisions to educate and reinforce healthier diets and lifestyle.  The plan is complicated and includes provisions that few legislators have taken the time to understand.  In the meantime, health plans across the U.S. are posting record profits and raising rates up to 60% a year.  There is nothing that has occurred in the ACA that can be blamed for this. 

As I have said before.  Why do Health Insurance Companies raise rates?  Because they can... and Wall Street rewards them handsomely for doing so.  They are only doing what we have asked them to do. 

Saturday, December 10, 2011

Women Don't Need As Many Pap Tests

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin' because new guidelines issued by the US Preventative Services Task Force and the American Cancer Society say women should undergo screening NO MORE OFTEN than every 3 years starting at age 21.  To further strengthen this recommendation, even the American Society for Clinical Pathology (those folks that read the pap smears) agrees with the recommendation.  They also recommending stopping routine pap smears after age 65 for women who have had 3 negative Pap test results in the past 10 years.  These women are just not at high risk.

So why the change?

The pap smear is a screening test for cervical cancer.  Evidence shows that more frequent screening than every 3 years doesn't find more cancer and we now know that cervical cancer is the result of infection with Human papillomaviruses (HPVs).  Women that have not been exposed to HPV are not at risk of cervical cancer.  Furthermore, out of 150 related viruses, of which 40 are sexually transmitted, only certain ones are high-risk, oncogenic (or carcinogenic) HPVs.    Persistent infections with these high-risk HPV types can cause cell abnormalities that are picked up on pap tests.  But the majority of infections with even high-risk HPV types go away on their own and do not cause cancer.  Two types of HPV (types 16 and 18) cause 70% of all cervical cancers and they are very slow growing.

When a pap test detects cervical cell changes, an HPV DNA test is usually done.  If the HPV test is negative, a women is safe from cervical cancer for many years.    Even if a pap test shows equivocal changes, if the HPV test is negative, it is recommended she be re-tested in 3 years.

Despite these recommendations, annual testing remains a common practice in most gynecology offices.  Even in women who have been tested for HPV and found negative, less than 15% of physicians recommended that patients wait 3 years before repeat testing.  Women are still being told to come back annually.


Some doctors may not know about the guidelines, even though they are also supported by the American College of Obstetricians and Gynecologists.  Doctors as well as patients are in the habit of "the annual pap test".  Doctors are also concerned that if they don't recommend pap smears, women will not come in for an annual exam and other preventive screening.   But doing unnecessary testing is not a way to have women come in.

For most women this will be a welcome change.  Stretching out those gynecologic screening exams will save time, money, false positive tests and unneeded follow-up.   Keep in mind this only refers to non-symptom screening.  Women who have any gynecologic symptoms (unusual bleeding, discharge, pain, pressure) or any other  concern or questions should see their physician.

Friday, December 9, 2011


Let's see how much you know about fingernails?  The arrow points to what part of the fingernail?
1.  Lunula
2.  Eponychium
3.  Cuticle
4.  Nail groove
5.  Proximal nailfold

If you answered #1, you would be correct.  The lunula is most noticeable on the thumb.

Did you know that nails on your dominant hand grow faster than nails on the nondominant hand?  As you age, nails are usually thicker and they grow more slowly.  A six month old will grow a new fingernail in 3 months.  A 70 year old will take twice as long.

Toenails take 12-18 months to regrow.

Photo and info credit to Medscape

Thursday, December 8, 2011

Unhealthy Food at Childrens Hospitals

A study published in the journal Academic Pediatrics reveals that 93% of California children's hospitals offered unhealthy food to outpatients, visitors and staff in the cafeteria and snack bars.  Said another way, only 7% offered healthy food.  What did these foods consist of to be called "unhealthy"?  Try fried food, sweetened beverages, burgers and lots of sugary sweets.

The study found that 81% of the cafeterias placed high-calorie, high-sugar items like ice cream right by the cash register, a well known marketing plan to tantalize and increase selection.  Forty four percent didn't even offer low calorie salad dressing and fewer than 1/3 had no nutrition information.

Health care workers, like the rest of America, suffer from increasing obesity.  One study showed over 54% of nurses are overweight and both stress and shift work can contribute to unhealthy eating and weight gain.  If the cafeteria offers high calorie food, it is no surprise that obesity will prevail.  The study didn't mention it, but I wonder how many of these hospitals use contracted food vendors.  Sugar, fat and empty carbohydrates are, unfortunately, cheaper than fresh, nutritious food.  We have seen the results of this in cafeteria school programs across the United States.

This study should wake up hospital administrators and they should choose only vendors that care about and supply healthy food.  If you work at a hospital...check out your own cafeteria and speak up if changes need to be made.

Tuesday, December 6, 2011

Don Berwick Says Medicare is Wasteful

I was thrilled when Dr. Don Berwick took over as head of the Center for Medicare and Medicaid Services (CMS).  It was a politically charged appointment and the GOP wasn't standing for his type of medicine.  He would have never been confirmed and now he is saying goodbye to Washington.  Dr. Berwick admits Government is more complex than he realized and said "Government decisions result from the interactions of many internal stakeholders-different agencies and parts of government that, in many cases, have their own world views."  Ya think?

He also said the GOP criticism of him and his policies was "purely political, a world of sound bites" and that they "completely distorted his meaning."

Berwick reflected on his 17 months in office and said these are the ways we waste money in healthcare:
1.  Over treatment of patients
2.  Failure to coordinate care
3.  Complex administrative restrictions on the health care system
4.  Burdensome rules; and
5.  Fraud

I would say 9/10 physicians queried would agree 100% with this assessment.  As Berwick says, "Much is done that does not help patients at all, and many physicians know it."  The problem is that patients don't know what is helpful and what is wasteful.  They depend upon our judgment and ethical decision making to know. 

Items 3 and 4 regarding the complexity and burdensome rules placed on caregivers is also true.  The complexity of treating patients is enough without jumping through government and insurance hoops that add no benefit to anyone.  Despite the restrictions, Fraud is rampant and more rules and regulations will not stop it.  Simplify the system and it will be easier to detect fraud.

We truly do need health care reform, not just health insurance reform.  Obama is headed in the right direction by insisting we have 100% coverage for all opt out of the system.  Can we at least agree on that and work together to improve health care for everyone?

Ciao, Dr. Berwick.  Thanks for trying.

Sunday, November 27, 2011

Scientists and Tattoos

Prof Datta's  Love Tattoo
A surprising number of scientists have tattoos hidden under their lab coats and these tattoos are examples of their cool geekiness.   Prof Sandeep Robert Datta has a tattoo of a twisting ladder of DNA.  The DNA message spells out the initials of his wife, Eliza Emond Edelsberg.  True love manifested through amino acids that are the building blocks of protein!!!  
Science journalist, Carl Zimmer, posted a blog at Discover Magazine and asked scientists if a tattoo like this was a trend.  Without trying, he became the curator of tattoos and a scholar of science ink.  He found out that many scientist sport tattoos of carbon atoms, DNA, ancient fish, embryos...just about anything that interests them and is meaningful.  He has published a book called Science Ink.

Body ink has been around for thousands of years.  Two hikers climbing the Austrian Alps discovered the freeze-dried body of a 5,300-year-old hunter whose skin was preserved in the ice.  He had tattoos made from fireplace ash rubbed into incisions on his skin.  Ancient Greeks used tattoos as a method of secret identification and communication between spies.  In ancient Asia, tattoos were used to signify rankings in life and tattooing has been among the Polynesian culture for over a thousand years.

Most people who get tattoos find designs that are meaningful or mark a certain passage in life.  I often hear of mothers and daughters getting tattoos together and I find that really charming.  I guess it is no surprise that scientists would use tattoos to signify their work and what is important to them also.

Thursday, November 24, 2011

Thanksgiving Idea

Happy Thanksgiving to EverythingHealth readers.

Thanks to KM for this way to appreciate Thanksgiving.  I did it and it only took about 7 minutes.  Here's the concept:

Get a piece of paper or a word doc on your computer.  Write one thing you are grateful for for each year of your age.  If you are older, you have lots of reasons to give thanks.  Don't over think it or try to put it in order of "importance".  No-one has to see it,  but the act of giving thanks for your life is an exercise that will improve your entire being.

Have a great day and Thanksgiving weekend.

Saturday, November 19, 2011

Smoking is still a Huge Problem in the U.S.

I live on the West Coast and where is rare to see a smoker.  Because it is not socially accepted,  smokers are not out in the open.  They lurk behind buildings to take a smoke break at work and I don't even own an ashtray for friends because none of my friends smoke.  But San Francisco isn't the rest of America.   In 2010 there were 45.5 million Americans who smoke, with men smoking more than women.  Tobacco remains the single largest preventable cause of death and disease in the United States.  Each year approximately 433,000 people die of smoking-related illness.

Here are some more stats on American adult smokers.  The highest prevalence is American Indians/Alaska Natives (31.4%) followed by whites (21%).  Smoking incidence decreases with increasing education and improved economics.  By region, the Midwest has the most smokers in Oklahoma, Arkansas, Mississippi, Louisiana, Kentucky, Ohio and West Virginia (22-27%).  That is huge.

California and Utah have the lowest percentage of adult smokers at 9-12%.

During 2005-2010 the overall proportion of U.S. adult smokers declined, but not nearly as much as it should have.  Also, the decline (about 3million people) was not uniform across the population.  The study of smokers was conducted by the Centers for Disease Control and Prevention and likely underestimates the number of current smokers.  The fact that more than 1/5 Americans still smoke is a huge problem for our health care system.  Here is a list of diseases that are associated with smoking:

  • Lung cancer
  • Cancer of the mouth
  • Cancer of the throat
  • Cancer of the larynx
  • Cancer of the oesophagus
  • Stomach cancer
  • Kidney cancer
  • Cancer of the bladder
  • Cancer of the pancreas
  • Liver cancer
  • Cancer of the penis
  • Cancer of the anus
  • Cervical cancer
  • Prostate cancer
  • Heart attack
  • Coronary heart disease
  • Cardiovascular disease
  • Congestive heart failure
  • Stroke
  • Atherosclerosis
  • Abdominal aortic aneurysm
  • Peripheral artery disease
  • Ischaemic heart disease
  • Angina
  • Leukaemia
  • Emphysema
  • Chronic bronchitis
  • Pneumonia
  • Asthma
  • Diabetes
  • Stomach ulcers
  • Cataracts
  • Gum disease
  • High blood pressure
  • Crohn's disease
  • Premature aging of the skin
  • Loss of smell and taste
  • Osteoporosis (women)
  • Gangrene
  • Impotence
  • Reduced fertility

I think most people know the risks of smoking.  Nicotine smoke, like inhaled cocaine, moves into the bloodstream and up to the smoker's brain within 7-10 seconds.  It is not a "bad habit", it is an addiction.  But with more than 4000 toxic chemicals in nicotine, it is far worse on the body than other addictions.

Stopping smoking is one of the most healthful things a person can do for themselves.

Wednesday, November 16, 2011

Amazing Spider Animation

This is one of the most accurate and beautiful pieces of animation I've ever seen. And I love the title: "Loom" (Warning: if you are arachnophobic you may wish to avoid but if you want to see nature at her best, the detail is amazing.)

Hat tip to Micro Voyage and the creators at Polynoid

Monday, November 14, 2011

Yoga for Back Pain

Low back pain is one of the most common conditions to affect humans.  More than 80% of Americans experience low back pain at some time in their lives and "chronic" pain is on the rise as people live longer and get heavier.  Numerous studies have shown that doctors and patients underutilized exercise as a treatment for chronic back and neck pain even though it has been shown to be effective.  A new study was published in the Annals of Internal Medicine that showed yoga to be an effective treatment for chronic low back pain.

The study authors took two groups of patients and compared yoga to usual care for chronic or recurrent low back pain. All patients received a back pain education booklet, but the study group also received a gradually progressing yoga program delivered by 12 teachers over 3 months.  The teachers were from 2 yoga associations - The British Wheel of Yoga and Iyengar Yoga and the sessions they taught were the same.  They focused on foundational elements of yoga that were adapted for low back pain.  The poses targeted stiff, weak and uneducated areas of the whole body with the intention of improving mobility, strength and posture, while reducing pain.

The yoga group participants continued to have better back function at 3, 6 and 12 months than the patients in the usual care group. The benefits of yoga did diminish after 12 months when only 60% of the participants continued with home yoga.  But 60% is a pretty high rate for continuing a practice!

Despite the fact that the most benefit was observed during the group Yoga and within 3 months afterward, even at 12 months the benefits persisted, especially in those patients who continued the practice.  Yoga was safe and effective for treatment of low back pain.

Here is my favorite low back yoga position:

I recommend a book called Yoga as Medicine by Timothy McCall, MD

Friday, November 11, 2011

Answer to Medical Challenge-Yellow Nail Syndrome

Yesterday's Medical Challenge answer was clear to some readers and a mystery to others.  The answer was:
#4  Yellow Nail Syndrome.  Although nails can become discolored from nail polish, the medical Yellow Nail Syndrome is a sign of a serious disorder and not well understood.  It is believed to be associated with  restrictive lung disease or  (rarely) problems with lymphatic drainage channels. (good memory, Grady Doc!)

nail fungus-onchomycosis
Because these nails stop growing and become thicker, they are susceptible to fungal infections too.  Those who guessed Onchomycosis were not far off.   Onchomycosis is very common and the fungus infection causes lifting of the nail from the nail bed.

Psoriatic nail
Psoriasis of the nail can also cause changes that can be confused with Yellow Nail Syndrome.   Ninety-five% of these patients have cutaneous psoriasis also.

Thanks for your diagnosis in this challenging case!

Wednesday, November 9, 2011

Medical Challenge

This weeks medical challenge from the New England Journal of Medicine is a hard one.  Patients come all the time with nail problems and most are easy to diagnose.  Full disclosure to my readers...I missed this one.   A couple of hints...all of the nails are obviously affected.  Click on the image to enlarge and make your diagnosis in the comments section.   I will post the answer tomorrow so be sure to check back and see how you did.

1. Melanoma
2. Onychomycosis (fungus)
3. Psoriasis
4. Yellow-nail syndrome
5.  Zinc deficiency

Good luck!

Sunday, November 6, 2011

Ode to Andy Rooney

Andy Rooney, the broadcaster with a wry look at life, has died at age 92.  He worked up to the end after delivering his 1,097th commentary on life.  Andy Rooney had a knack of picking a topic that no-one had thought about, comment on it and listeners would say "Oh yea, that is so true".  He touched a nerve in modern American society.  Here are my Andy Rooneyisms:
  • Why do we have foods like "Go-Gurt"?  Is it so hard to eat yogurt that we need to make it faster?  Does squeezing it into your mouth from a tube save time?  Have you ever been late to something because you were "eating yogurt"?
  •  When did we end up with 700 TV channels?  How did that happen? And why, when I'm watching the news, do I have to see a streaming commentary about different news across the bottom of the screen?  Aren't the 700 channels enough?  Do we need to be seeing several things at one time on each channel?
  •  What happened to elevator operator jobs?  There was a time when someone actually pushed the button for you on the elevator and that was a real, full-time job.  I don't think they were exported to foreign countries.  Somehow someone just figured out we could push the button ourselves and save the labor cost.
  •  Do you know the difference between a good haircut and a bad haircut?  About a week.
  • Why do commercials for mascara, both on TV and in print, use models with false eyelashes?  Isn't the mascara good enough for our real eyelashes?  Anyone can have lush eyelashes if they are false.
  • Why don't people use turn signals anymore?  I think it is still the law and it helps when you are following someone to know what they are going to do.  How hard is it to flip up the little lever?
  • Who invented "call waiting?"  It should be called "caller preference".  When I'm talking to someone and they say "just a minute" to answer another call, it is a bit of an insult. Isn't that why we have voice-mail?  The caller can just leave a message and you can call them back as soon as we hang up.  I really hate call waiting.
  •  Attention dog owners!  The purpose of the plastic bag that picks up your dog's pooh is to dispose of it in the trash.  Leaving the baggy on the side of the road is ridiculous.  Pooh is biodegradable and your plastic is not.  Come-on people!
Andy Rooney was one of a kind.  He loved what he did and it showed.  That is a legacy we can all emulate.

Thursday, November 3, 2011

Follow Up on 1991 Gulf War Veterans

Remember the 1991 Gulf War between the United States and Iraq (aka: "Operation Desert Storm")?  A new study has been published in the American Journal of Epidemiology that assessed the health status of 5,469 deployed Gulf War veterans compared to 3,353 non deployed veterans.  At 10 year follow up, the deployed veterans were more likely to report persistent poor health.  The measures were functional impairment, limitation of activities, repeated clinic visits, recurrent hospitalization, perception of health as fair or poor, chronic fatigue syndrome illness and post-traumatic stress disorder.

From 1995 to 2005, the health of these veterans worsened in comparison to the veterans who did not deploy to the Persian Gulf.  A study done in the United Kingdom that compared Gulf War veterans to UN peacekeepers who served in Bosnia and other non-deployed Gulf War soldiers found the same thing.  The deployed veterans had significantly worse health in all realms. 

This was a longitudinal study and the veterans self reported their health status.  Over time the deployed veterans reported new conditions that persisted or worsened with time. 

The authors note that the health problems cannot be proven to be due to the effects of the military service in the Gulf War.  But previous studies also found a higher prevalence of PTSD and other mental disorders among deployed Gulf War soldiers.  This study also showed high rates of PSTD (14.4% compared to non-deployed, 4%). 

There are numerous animal experiments that show exposure to repeated stress disrupts the blood-brain barrier and increases neurotoxicity induced by chemicals in many cerebral areas.  Gulf War soldiers were exposed to organosphosphate chemical warfare agents.  Even low level exposure to nerve agents can have a negative effect on brain structure years later.   In another study of Gulf War veterans, they found the soldiers with fatigue, mood or cognitive complaints demonstrated impaired immune function.

There is no doubt that our war veterans return home with significant health risks, even if they are not visibly wounded in battle.  These young men and women deserve not only our respect and praise, but the best mental and physical health care that we can provide.

Thursday, October 27, 2011

Carpal Tunnel Syndrome

Immediately Post-op Carpal Tunnel release
Carpal Tunnel Syndrome (CTS) is common and is the result of the median nerve becoming squeezed or "entrapped" as it passes through the wrist down into the palm of the hand.  Because this is a sensory nerve, the compression causes tingling, burning and itching numbness in the palm of the hand and fingers. A different nerve goes to the little finger and the lateral half of the 4th finger so the sensation there would feel normal.  There is often a sensation of swelling even though there is rarely any true edema that can be seen in CTS.

The symptoms of Carpal Tunnel Syndrome  usually start at night when people sleep with flexed wrists.  As it progresses, the tingling and numbness can be felt on and off during the day.  It can cause decreased grip strength and weakness in the hands.

CTS can be worsened by medical conditions like rheumatoid arthritis, diabetes, pregnancy or wrist trauma.  Women are three times more likely to develop CTS than men,  and it is rare in children.  Most of the time no cause is found.  The space that the median nerve traverses is very tiny and it doesn't take much to compress the nerve.  Even small amounts of tissue swelling such as occurs in pregnancy can cause severe symptoms.

The treatment for Carpal Tunnel Syndrome starts with simple remedies like aspirin or NSAIDs.  Some people are helped by wearing wrist splints at night to avoid flexion.  Stretching and strengthening exercises can help, but if the nerve is inflamed exercises are not going to help.

For severe CTS, a corticosteroid injection into the wrist to reduce swelling can provide prolonged symptom relief (4-12 months).  If injections fail or if there are signs of hand weakness, carpal tunnel surgery that releases the trapped nerve can be the answer. This surgery, done under local anesthesia, is quick and usually provides permanent cure.

Thanks to my patient, SP, for providing this photo immediately post-op after undergoing endoscopic surgery.  Two tiny incisions are made in the wrist and the palm,  and a camera attached to a tube visualizes the carpal ligament that can then be cut by the hand surgeon.  The patient can resume normal activities within days.

Tuesday, October 25, 2011

Teens and Soda and Junk Science

The headlines of a number of newspapers say "Soda Boosts Violence Among Teenagers."  A new study out of Harvard's Public Health Division analyzed data from 1878 14 to 18 year olds and found those who drank over 5 cans of non-diet soda a week consumed more alcohol and smoked more cigarettes.  Additionally those teens were more likely to carry a knife and exhibit violence toward family and peers.

According to the Washington Post,  "About 23 percent of those who drank one or no cans of soda a week carried a gun or knife, and 15 percent had perpetrated violence toward a partner. In comparison, among those who consumed 14 or more cans a week, 43 percent carried a gun or knife and 27 percent had been violent toward a partner, the researchers found. Similarly, violence towards peers rose from 35 percent to 58 percent while violence towards siblings rose from 25.4 percent to 43 percent."

The study was published online in something called "Injury Prevention". Despite the fact that I've never heard of this "journal", somehow the study got National coverage in the news.  To the author's credit, they admitted that the study did not prove causality and there may be other factors that weren't accounted for.  The students self reported their soft drink consumption and their "violent" tendencies. 

As the mother of a teen, I can tell you that teen boys think they are "badder" than they are and I would guess some of the self-reporting would be questionable.  Just sayin'....

This story, with it's sensational headlines, should make us all take pause with the hundreds of pseudo-science reports that come out daily as "breakthroughs" or "news".   With 24 hour news shows, the Internet and the need for content that will grab the reader, a big dose of skepticism should be our first thought.

Sunday, October 23, 2011

Robots Bring Care to Remote Places

Both in the United States and around the globe there is a mismatch between needed medical care and the doctors who can provide it.  Most physicians are located in urban areas where there are hospitals, teaching schools, lab and Xray and specialists to deal with most every medical condition.  Rural areas in the United States lack these resources and patients either do without,  or must travel far to be seen.  In developing countries there may be no services at all for hundreds of miles.  That is where telehealth can play a huge role in bringing medicine to the  people.

The "In-touch" robot is one technology that can work all over the world.  Through a simple lap-top computer a doctor and reach out across the globe and "see and be seen" by the patient and have a conversation with the patient.  The robot is mobile and can be remotely navigated from room to room (or hospital bed to hospital bed) and "visit" the patient.  A dermatologist can see the skin and recommend treatment.  The robot can perform electronic stethoscope, otoscope and ultrasound and transmit that data back to the physician.

We are using this technology to provide care to rural community hospitals in Northern California that cannot get certain specialists in the community.  We are also able to provide remote night medical coverage so patients can stay in their own community and not be transferred to larger hospitals for care.  Many conditions can be managed well in the rural hospital with physician expertise to evaluate the patient and prescribe treatment.  Patients and their families love it and it saves in cost, transportation and inconvenience.

The robot is also providing needed expert consultation for a hospital in Haiti and a rural hospital in Kolwezi, Democratic Republic of Congo.   Specialists are donating their time to be "on call" and provide support to the patients and care-givers there.  Imagine the benefit of having consultation for a high-risk pregnancy or neurology or pediatrics or any number of medical conditions.

I wrote about this technology  way back in 2007 and now the robot is being used far and wide.

Thursday, October 20, 2011

Kid's Allergies and Asthma

There never seems to be enough time for parents to ask all of the questions they want of their kid's pediatrician.  And parents whose children have allergies or asthma have lots of questions and new concerns that pop up all of the time.  The American Academy of Pediatrics has published an updated guide called "Allergies and Asthma - What Every Parent Needs to Know."   This paperback should go a long way toward answering those questions and letting parents know how to deal with health problems.

This book is easy to navigate and is written in language that will be understood by the reader, yet it is not a "dummy guide" but a real source of information.   It starts with basic physiology and  explains what happens with the immune system when an allergen is encountered.  Those allergens can cause skin allergies, hay fever, food allergies, killer allergies (anaphylaxis) and asthma.  The authors advise how to identify, prevent and treat these conditions.

Childhood asthma is one of the most common chronic conditions in the United States, yet it is poorly understood by parents.  The numbers of young people and children with asthma is rising and no one can say exactly why.  "Allergies and Asthma" helps parents understand the disease and it dispels outdated beliefs like "Asthma is an emotional disorder; it's all in the mind" or "People with asthma should use medication only when they have attacks."

The book is well written, has a glossary of commonly used terms and definitions and contains an extensive lists of foods that may have allergic potential for some children.  The foods that contain egg protein is quite surprising, like processed meat products and breakfast cereals.  And milk protein can be found in sausages and packaged soups.  (This is another reason to eat simple foods without additives as much as possible)

I recommend "Allergies and Asthma" for anyone who is interested in learning more about allergic reactions or wants to know if allergies could be causing a problem with their child.  It is a great resource written by the experts.

"Allergies and Asthma - What Every Parent Needs to Know." (Michael J. Welch, MD, FAAAAI, FAAP, CPI, Editor in Chief.)

Tuesday, October 18, 2011

Ovarian Cancer Screening of No Value

If you want to create an outcry of indignation,  just inform people that certain screening tests are of no value and do not increase time on this earth.  People love the idea that if they do all the right things and get all the medical tests at the right time, they can prevent disease (, tests don't prevent anything) or catch cancer early and cure it.

The furor over the lack of benefit for men of the screening Prostate Specific Antigen test (PSA) is still being heard.  It seems everyone knows someone who was "saved" by getting a PSA and don't try to tell me there is evidence to suggest otherwise, dammit!

There is a new report in the Journal of the American Medical Association (JAMA) that confirms previous studies and shows there is no benefit for women to obtaining screening ultrasounds and Ca125 for ovarian cancer.  This is bad news because every year over 21,000 women are diagnosed with ovarian cancer.   Most of them are diagnosed in advanced stages and the 5 year survival rate is only 30%.  Of course we want a safe, effective screening test that can detect abnormalities early.

Ca125 (blood test) and transvaginal ultrasounds should work...but they don't.  The 13 year old study confirmed a prior report that the predictive value of these tests was low and additionally it confirmed there was no difference in mortality in women who underwent screening compared with those who did not.  Additionally they found a high number of false positive tests and 15% of women with false positives suffered serious complications of surgery.

The discouraging findings may be because ovarian tumors are aggressive and annual screening is ineffective.  The serious complications associated with false positive tests also makes it a bad screening test for the population.

Someday we will find good tests to detect these cancers.  Right now patients and doctors should just say "No".


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...