Sunday, April 29, 2012

Aging skin bruising

It is not uncommon for a friend or relative to corner me with a worried look on his face and ask me about bruising on the arms or legs.  It is one of the more common concerns of patients in the office too.  People are worried that it is a harbinger of leukemia or some other blood disorder.  "Look at my skin.  These spots just appear for no reason.  What are they?"

What I'm seeing is the natural effect of aging and sun damaged skin.  The medical term is "Senile Purpura"...a term I actually hate and pronounce "sanili purpura"  just to make it sound better for patients.   It is simply easy bruising that shows through thin dermis.  Many people are taking aspirin or blood thinners that make the capillaries fragile.  Couple that with the lack of subcutaneous fat and elasticity that occurs with aging and you have purplish bruises that look positively frightful.  These bruises usually appear on the forearms or backs of the hands and shins.

There is no treatment for senile purpura.  It is not a marker for any serious disorder.  There have been some studies that show over-the-counter arnica montana ointment can help clear the reddish appearance faster.

It is never too late to protect the skin from damaging effects of the sun.  Giving arnica montana gel or capsules a try might help too.  Let me know if it does.

Sunday, April 22, 2012

The Dangerous Choking Game

There is a game that pre-teens are playing that has killed 82 kids since 1995, according the the Centers for Disease Control (CDC).    It is called the "choking game" and these youngsters have no idea how dangerous it is.  There are probably thousands of choking deaths all across the country that have not been reported to the CDC and countless parents who think their child committed suicide, when he might have just unknowingly been playing a game.

The choking game is not new at all.  I know about the choking game because I played it with my girlfriends as a kid too.  I hadn't thought about it for decades and we had no clue that it was dangerous and just thought we were having fun.  At a slumber party (now called a "sleep-over") one girl would hyperventilate for a few minutes and then hold her breath while another squeezed her from behind across her chest in a tight bear hug.  Within a few seconds she would black out completely and fall to the floor. 

I can't tell you now why we liked playing this game or what the motivation was.  I remember the sensation of waking up from a "faint" was unique and weird and maybe it was our safe way to get "high"...long before alcohol came on the scene.  Of course now as an adult,  and with knowledge of physiology, it is obvious that this game is dangerous and deadly.

The choking game deprives the brain of oxygen and a person becomes unconscious within a few seconds.  As the body slides to the floor and becomes flat, breathing resumes and the person starts to wake up.  The deaths in the choking game occurred when kids used ropes or ties to choke themselves, thinking they would wake up.   I shudder to think of how many parents might believe their child committed suicide, when they might have just been normal kids playing a deadly game.

 Parents need to be aware that this is happening and know that it could be your child too.  One study published in Pediatrics reported over 6% of middle-school kids in Portland, Oregon have tried the choking game.  This occurs at  ages between 9-15.

We cannot expect our children to know what they don't know.  Every pre-teen should be told about the dangers of breath holding and how it is really just starving brain cells of oxygen.   If you have a pre-teen or know someone who does, please send them a link to EverythingHealth or tell them about this crazy and dangerous game that should never be played.  It can be called the choking game, pass-out, black-out or fainting game.  This should be a wake-up call for parents and kids.

Tuesday, April 17, 2012

Hidden Health Care Pricing and Costs

More and more employed people who have health insurance are facing large deductibles so they are actually paying "out of pocket" for tests, Xrays and doctor visits.   Health care policy-makers talk about involving the consumer in the cost of care as a way to force competition and hold down prices.  But finding out how much something costs can be a herculean effort and take hours of time phoning around.   Despite a law in California that dates back to 2006 that requires hospitals to post common test prices, it is nearly impossible for a patient to find out ahead what something costs.

I gave my patient an order for a hip Xray to evaluate pain that would not go away.  Because she has a $5000 deductible with Anthem Blue Cross insurance, she knew that she would be paying for it.  She spent hours calling local hospitals to compare prices and became more frustrated and confused as time went on.  She was told they couldn't look it up without a code.  She was asked what hospital campus she would use for the Xray.  (implying there are different prices at the same hospital if you used a different X-ray machine)  She was placed on hold and cut off when transferred.  She was quoted a price of $745 at one hospital and $886 at another and this did not include the radiologist fee for reading the Xray.

I have advised her to call her insurance company, but I have doubts they will tell her their contracted price (which becomes her cost) in advance.

This is the reality of health care in the United States.  Even patients who have insurance struggle with decisions about cost and benefit of tests and spend hours trying to get information to make health decisions.  It is time for patients and employers who buy health insurance to stand up and demand transparency of costs.

Monday, April 16, 2012

Red Meat Linked to Death

Advanced warning: meat lovers are not going to like this. 

A well done study published in the Archives of Internal Medicine as shown that red meat consumption is linked with an increased risk of total death, cardiovascular death and cancer death.  Yup...death!  That goes further than what we knew before about red meat connection to heart attacks and strokes.  This is the big one.

This study looked at two large studies that contained 28 years of follow-up data:  The Health Professionals Follow-up Study and the Nurses' Health Study.   The researchers excluded subjects that had a history of CVD or cancer at baseline or left more than 9 study questions blank.  They ended up with 37,698 men and 83,644 women.   

They found some interesting things.  Both men and women with higher intake of red meat were less likely to be physically active and were more likely to be smokers, drink alcohol and have a higher body mass index (fat!).   Additionally, those with higher intake of meat had lower intakes of whole grains, fruits and vegetables.  Over time,  (from 1986 to 2006) the daily intake of red meat dropped.  (perhaps this was the result of public service education about the cardiovascular dangers of red meat that occurred during that time period)

This was a strong study.  Because all of the participants were professionals, their education was similar.  The study size was huge as were the years of follow-up.  But the researchers could not differentiate between "lean" meat and higher fat content meat.  They did find that bacon and hot dogs had higher risk than other types.  They found that processed meats that contain sodium and nitrates increased cardiovascular disease, cancer and death.

If one serving of total red meat was substituted with l serving of fish, poultry, nuts, legumes, low-fat dairy products or whole grains daily, there was a lower risk of total mortality.  The authors estimated that 9.3% of deaths in men and 7.6% of deaths in women could have been prevented if the participants consumed fewer than  1/2 serving per day of total red meat.

Salmon -yum
Here is the bottom line.  Eating meat is bad for the planet and bad for your body. If you can't become a vegetarian do yourself a favor and reduce your red meat intake to a few ounces a day.  Have meatless days where you substitute fish or plant based meals.  Replacement of meat with alternative healthy dietary components will lower your mortality risk.

Saturday, April 14, 2012

Lepromatous leprosy

The answer to yesterday's diagnostic challenge is #2.  Leprosy.

 Most of you were correct.  The patient's face had multiple nodular lesions that coalesced into plaques.  After 9 months of multidrug treatment the skin infiltration and weakness in the left eyelid had diminished.

Leprosy is caused by the bacterium, Mycobacterium leprae.  It is not very contagious and has a long incubation period before symptoms begin.  The lepromatous type causes large bumps and lumps and is the most severe. 

Effective medications exist to treat leprosy, which is also known as Hansen's disease.  Usually different antibiotics are used together.   It is important to diagnose the disease early so treatment can limit damage and disfigurement.

Thursday, April 12, 2012

What is the Diagnosis?

Today's diagnostic challenge is from The New England Journal of Medicine and it is pretty straight forward.  Click on the image for a better view and make your diagnosis.  Check back tomorrow for the answer.

1.  Granulomatosis with polyangitis
2.  Lepromatous leprosy
3.  Neurofibromatosis type 1
4.  Sarcoidosis
5.  Tertiary syphilis

Don't be shy.  Post your guess in the comments section.

Friday, April 6, 2012

Doc Groups Identify Unnecessary Tests

When nine prestigious Medical Specialty Groups get together and identify tests that are unnecessary and wasteful, it is time to take notice.  In a rare effort, each specialty identified 5 tests and procedures that do not add value and that may be unnecessary or overused.  In all, 45 tests and procedures were listed as part of the ABIM "Choosing Wisely" campaign, a multiyear initiative that aims to reduce the waste in medicine and increase dialog between patients and physicians. 

What are some of the 45 tests and procedures we should not do?

From The Academy of Allergy, Asthma and Immunology:
  • IgG and a battery of IgE  and other unproven allergy skin tests.
  • Antibiotics for uncomplicated sinusitis (only .5-2% are bacterial infections)
  • Inhalant or food testing or extensive diagnostic tests for chronic itching/hives.
From the American Academy of Family Physicians:
  • Xrays or MRI scans for low back pain within the first 6 weeks. (unless exam points to red flags).
  • Dexa bone scans in women younger than 65 or men younger than 70 with no risk factors.
  • Routine EKGs in patients without symptoms.
  • Pap smears on women younger than 21 or women who have had a hysterectomy for non-cancer disease.
From The American College of Cardiology:
  • Annual cardiac stress tests as part of routine follow-up in patients without symptoms.
  • Stent placement in the non-infarct artery of patients who are stable, even if they have a ST-segment elevation myocardial infarction (STEMI) in another artery.
From The American College of Physicians:
  • Pre-op screening chest X-rays.
  • CT or MRI scans for a simple fainting spell if patient has no neurological findings on exam.
From The American College of Radiology:
  • Imaging for uncomplicated headache.
  • Routine admission Chest Xray.
  • Follow up imaging for small (under 1cm) ovarian cysts  (common and usually benign). 
From The American College of Gastroenterology:
  • Colorectal cancer screening before 10 years after normal colonoscopy.
From The American Society of Clinical Oncology:
  • PET, CT and bone scans for early prostate cancer at low risk of metastasis.
  • PET, CT and bone scans for asymptomatic patients that have been treated for breast cancer for curative intent.
These are just a few of the noted "wasteful" tests that do not provide value to patients.  Any and all of these are valuable  IF a patient has symptoms that require diagnostic testing but using them as "screening" or routine tests has no value and can actually cause harm.  Not to mention $billions of wasted health care dollars.

Some doctors do these because of habit, prior training, not keeping up with current literature,  fear of litigation or patient pressure to "do everything".  When esteemed specialty societies come out with lists like this, we should all take notice.

   Of course it is up to the individual patient and the individual physician to determine risk factors and risk/benefit of any test.  But these lists should at least stimulate the question "why" and valid reasons are necessary.

Wednesday, April 4, 2012

Doctors Coat Helps Focused Attention

A recent study in the Journal of Experimental Social Psychology found that wearing the white coat of a doctor caused the person to focus and pay more attention.  Wearing the white coat of a painter or other occupation didn't have the same effect.  The scientists call this enclothed cognition: the effects of clothing on cognitive processes.

The experiment was done with 58 undergraduates who wore either a white lab coat or street clothes.  Those who wore the lab coat made half as many errors on incongruity trials than those who wore regular clothes.  In a 2nd experiment, they randomly assigned 74 students to either wear a doctor's coat, wear a painter's coat or see a doctor's coat.  They were given tests for sustained attention and those who wore the doctors coat found more differences and had more heightened attention than the other two groups.  Further experiments also showed that the students who wore the doctor's coat had improvement in attention.

It appears that certain articles of clothing affect how a person behaves and what "role" they take on.  Other experiments show that if you carry a heavy clipboard, you will feel more important.  Dr. Adam Galinsky, a professor at the Kellogg School of Management at Northwestern University says that women who dress in a masculine fashion during a job interview are more likely to be hired and a teaching assistant who wears formal clothes is perceived as more intelligent than one who dresses more casually.

I love this experiment.  There is an old saying that "clothes make the person".  If you dress in old, ill-fitting, shabby clothing it is hard to feel successful and confident.  This study points to the idea that it goes further than just wanting to "look nice".  Perhaps clothing really does change the psychologic state of the wearer in a way that affects behavior and skill.

Now if I can just get my teenager to stop wearing those saggy, butt drooping pants!

(hat tip to Sarah for the article tip)

Tuesday, April 3, 2012

The Supreme Court and Health Care Act

The Nation is anxiously awaiting the ruling of the Supreme Court on the Health Reform Act (Accountable Care Act..aka: Obamacare) which will be announced in June.  The 6 days of hearings were unprecedented in their partisan tone and we got a good idea of how the justices will vote.  But no-one can truly predict how it will turn out until the last minute.  Each one has already rendered a private decision and the next two months will be for counterarguments and more deliberation before the final decision.

The justices can overturn the entire law, which would nullify many important health provisions that have already taken effect.  For example, 2.5 million young adults under the age of 26 could lose insurance coverage through their parents' plans.  Patient safety improvements that are already in effect would be reversed.  Preventive care goes away and  value based purchasing has just begun under ACA and could be reversed if the act is struck down. 

The justices could strike down the individual mandate part of the law.  After all, we are a free country and no-one should be forced to buy health insurance, right?  Never mind that everyone is forced into Social Security and Medicare through payroll taxes and car insurance is mandated if you drive.  Millions of people pay into Medicare and never use the service if they die before age 65 or are Christian Scientists or just hate doctors.  No-one gets a rebate.  Never mind that Emergency rooms and physicians are REQUIRED by law to treat uninsured people in the emergency room.  No-one seems to mind about that mandate! 

If they strike the mandate, they also nullify the provision for community rating and guaranteed insurance.  There is no ACA without the mandate...something the GOP knows.  Mitt Romney and Newt Gingrich were fervent supporters of the mandate before they ran for President. If the mandate is eliminated,  it's back to the status quo.

The Republicans would like to make Medicare into a voucher program.  That shifts the buck back to people who can least afford it and guarantees higher administrative costs.  It essentially dismantles Medicare.

The Accountable Care Act is simply a start.  It doesn't go far enough to reduce spiraling costs.  It does address inequalities of care and helps reign in abuses.  It is a start at shifting from "do more, despite the outcome", to focusing on value.

I support it and hope the Supreme Court does too.

Sunday, April 1, 2012

Toxic Sugar

I watched "60 Minutes" tonight and it reinforced my evolving understanding that refined sugar is toxic for the human body.  Dr Lustig, a pediatric endocrinologist at UCSF, was interviewed along with other researchers and the evidence strongly confirms just how bad sugar is for us.  We know about its contribution to obesity and diabetes, but now research shows sugar raises LDL cholesterol, the culprit in heart attacks and stroke.  To add to the "sugar is toxic" message, research also shows that certain cancers have sucrose receptors and sugar makes cancer grow.

You may be saying, "Hey, refined sugar has been around for centuries and it was never a problem before. What's the big deal now?"

 The big deal is just how much sugar and high fructose corn syrup are hidden in our foods and the vast quantities that are now consumed.

 According to Whole Health Source, in 1822, the average American ate the amount of sugar found in one 12 ounce soda every 5 days.  Now we eat that much every 7 hours. We know that candy, soda and junk food are loaded with sugar.  But did you know that crackers, yogurt, ketchup, Popsicles, low fat salad dressing, white bread and buns, and spaghetti sauce are also loaded with sugar?  In fact you have to really read the label to find a food product that does not contain sugar or high fructose corn syrup.

Here is a mind boggling fact.  Four grams of sugar equals one teaspoon.  A can of regular soda (12 oz) contains 40 grams of sugar.  That is 10 teaspoons of sugar in one soda!  The next time you are at the market, notice the rows and rows of soft drinks offered.  Most of the containers are 64 oz size!  The average male between  ages 12-29 drinks 1/2 gallon a day.

What does all of this mean?  Well for me...I'm starting a sugar free diet.  Yes, that means I am eliminating all (yes all) refined sugar from my diet.  I will eat fruits that are naturally sweetened but I'll be checking labels and if it has sugar...I'm not eating it.

I encourage all of you reading this to join me.  This will mean consciously drinking more water and having it with me where ever I go. For a sugar craving I will use Stevia natural sweetener and  fruit.  Increasing foods high in B vitamins and whole grains will also help reduce sugar craving.

I always thought I ate healthily but sugar has got to go.  Join me? 

When to Use Urgent Care

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