Tuesday, June 26, 2012

Incense and Bath Salt Intoxicants

I've been hearing about kids ingesting bath salts and incense to get high for the past year.  I had never heard of this before.  These synthetic legal intoxicating drugs (SLIDs) have come on the scene and have increased in popularity.  Who would want to snort bath salts or smoke incense?   What the heck are these things?

Although they are sold as bath salts and incense to avoid FDA regulation, they are really powerful psychoactive drugs that can have intoxicating effects.  They are sold over the counter at quick-marts and on the Internet.  Herbal incense products affect the cannabinoid receptors in the brain just like marijuana (THC).  Although they differ in chemical structure from natural occurring cannabinoids, they affect the same receptors and can be stronger than THC with potential for overdose and severe toxic effects.  Some of the effects reported by emergency departments and poison control centers were agitation, anxiety, dysphoria, elevated blood pressure, hallucinations, nausea, paranoia, seizures and tachycardia.  Natural THC rarely affects users in this way.

Bath salts are also labeled "not for human consumption" in an effort to bypass laws governing mind-altering substances.  Two of the more common ingredients are 3,4-methylene-dioxypyrovalerone (MDPV) and 4-methyl-cathinone (mephedrone).  The effect is on the dopamine and norepinepherine reuptake inhibitor that acts as a powerful stimulant.

The US government made it illegal to possess or sell any substance containing MDPV or Mephedrone for one year to allow the DEA time to collect data.  These are difficult to regulate, however,  because new stimulants and formulations take their place and are freely sold.  There are numerous sites on the Internet where you can buy these substances and they are so blatant they show up in "google ads".

Most patients that become intoxicated with SLID drugs exhibit anxiety, agitation and psychosis.  Seizures and chest pain have been reported along with a number of deaths.  The clinical effects persist for more than 24 hours which is far longer than other drugs in this class.  Emergency Room physicians need to be on high alert that patients who present with psychiatric symptoms or seizures with elevated blood pressure and tachycardia may have SLID intoxication.

These are very dangerous substances with benign names.  "Bath Salts" and "Incense" (also known as "Spice" or "K2") are truly not for human consumption.

What if Health Law is Overturned?

The Supreme Court is likely to rule on the 2010 Accountable Care Act (ACA-Health Insurance Reform-Obamacare) this week and it will be the most important decision this court has undertaken. The court could strike down the entire act or rule that the individual mandate is unconstitutional.  Washington and policy makers are buzzing with possible scenarios depending upon what the court does.  Here are a few of those:

First let's look at Medicare.  The ACA changed the formulas that Medicare uses to pay providers and it will be increasing reimbursement for primary care.  It baked in financial incentives for doctors and hospitals that achieve quality benchmarks.  The Centers for Medicare and Medicaid pays out 100 million medical bills each month according to the new pay scale.  What will happen if the law is overturned?  Will it go back to 2009 pay?  Will pay be frozen until the House Ways and Means and Senate Finance Committees can meet and decide?  No-one knows.

The Health care law also dedicated billions of dollars to expand community health centers and the health care workforce including the Indian Health Service.  If it disappears the legal authority for those programs and funding would also disappear.

Lets look at the Centers for Disease Control and Prevention (CDC).  The law's Public Health and Prevention Fund would lose $10 billion dollars for community health ventures like lead-poisoning prevention and immunization programs.  There are no contingency plans for this funding.

More than 22 million people who would have gotten cheaper health insurance or coverage from Medicare will be out of luck if the law is overturned.   "More than 5.2 million Medicare beneficiaries have saved a total of $3.7 billion on their prescription drugs since the health care reform law went into effect", according to CMS Acting Administrator Marilyn Tavenner.   If the law is overturned, the "donut-hole" will remain open.

Without the federal law, insurers can still deny coverage to people because of their medical conditions and they can exclude pre-existing conditions from coverage.  Take that, Americans, if you have diabetes or arthritis or prior cured cancer.   If you are a young adult covered on your parents policy you might lose that coverage.  In California that has become State law but most States do not cover it.

I have never understood how partisan politics should enter into Health Care. Studies show that most Republicans want the law nullified and have even turned it into a religious issue which absolutely baffles me.  Anti Obamacare spending has outspent supporters 3:1.  But even for people in the health industry the law is confusing and way too complex with provisions that kick in slowly over time.  That has confused everyone.

One thing that is guaranteed.  The Supreme Court ruling will make half of American happy and half of America unhappy.  Attorneys will be employed for the next decade with appeals and further confusion. The Insurance Industry and Pharmaceutical Industry will do just fine in any case because health care will continue to be a growth industry. 

Thursday, June 21, 2012

Herpes Zoster

Yes, you smart readers.  The answer to yesterdays challenge is Herpes Zoster, AKA: shingles.  Grady Doc was most precise with Herpes Zoster Ophthalmicus.  (involving the eye and optic nerve).  Note that the lesions do not cross the midline as they remain in the nerve distribution.

Treatment with antiviral medication is effective if started within the first 48 hours of symptoms.

Tuesday, June 19, 2012

Diagnostic Challenge

Here is this weeks diagnostic challenge where readers of EverythingHealth can test their diagnostic skill.  This man had a mild headache, fatigue and tingling sensation, followed by this weepy rash.  His right eye also became blurry.  What is the diagnosis?  In this case I am not giving you any multiple choice answers.  Just make the diagnosis.

The Answer will be posted tomorrow.  Good luck

Image from consultant360

Manipulating Gift Giving

Haguette Clark in 1930
A court appointed official that oversees copper heiress Huguette Clark's estate wants the money back.  It seems this elderly, eccentric multimillionaire showered her private nurse with $28 million in real estate, jewelry, checks and other gifts.  The nurse, Hadassah Peri made a salary of $131,000/year in addition to the "gifts".  Her immediate family received another $3 million.  Other nurses and doctors that cared for her received more than $4 million and she even paid one doctor's malpractice insurance.

Mrs. Clark was frail and reclusive and died at age 104.  Her lawyer and accountant have both come under scrutiny for their management of her affairs and their own large gifts bestowed by this woman.  They were both suspended by a judge from further overseeing her estate.

Huguette Clark was the daughter of a wealthy Montana senator who mined copper, built railroads and founded Las Vegas.  She spent the last 20 years of her life in two Manhattan hospitals, finally dying at Beth Israel Medical Center.    Prior to going to the hospital in 1991, she weighed 75 lbs and lived in a disheveled apartment illuminated by a single candle.  She refused to go home and reportedly paid the hospital $400,000 a year to care for her.

The public administrator on the case said the heiress suffered from various physical and mental infirmities and was not of sound mind to be changing her will and distributing money.

Was she exploited by those who were in her inner circle or was she just  generous?  Nurse Peri's attorney said "This was a very generous woman who made gifts to people she rarely or never saw so it's absurd to think that she would not give gifts to the individuals who worked with her."

Sunday, June 17, 2012

Overused Tests

The American College of Physicians (ACP) is committed to promote high-value, cost-conscious medical care.  They make the point that some treatments are expensive but offer great value, while others may be considered inexpensive and offer little value.  Price (cost) does not equal value. (for more on this read my post on price and quality)

One area where overuse is common is in testing or screening tests.  ACP published a consensus that named 37 commonly overused diagnostic procedures and treatments.   You may be surprised about what they are and here are a few:
  • Annual lipid screening for patients not receiving lipid-lowing drugs or diet therapy
  • Screening low risk people for Hepatitis B  (If you don't have unsafe sex or use IV drugs you are not at risk)
  • Screening for colorectal cancer in adults older than 75 or with a life expectancy of less than 10 years (Yes, lots of doctors do colonoscopies on demented folks in a nursing home or 85 year olds)
  • Ordering chest Xrays for hospital patients who are being discharged home and making a good recovery. (These radiographs give no information at all)
  • Ordering annual electrocardiograms or other cardiac screening for asymptomatic low risk patients.
  • Doing pap tests on patients younger than 21 years or in women who have had a hysterectomy for benign disease.
  • Ordering antibiotics for moderate sinusitis unless symptoms last for more than 7 days. (Stuffy, runny nose is not a symptom to be treated)
The United States has run amok with tests and treatments that drive up costs and offer no value to patients.  I saw an ad on TV tonight for a new drug (that I could not pronounce) for rheumatoid arthritis.  These "disease modulator" drugs have extremely high complication rates and can cost over $2500/month.  The ad encouraged the patient to ask for the medication and promised to pay the co-pay for the patient or to refund the copay if it didn't work.  I did some quick math in my head.  If the copay is $40/month the Company is certainly crafting a good deal for itself.  Insurance companies, Medical and Medicare Part D would pay tens of thousands of dollars for each patient.

And what is with prime-time ads for a disease that only affects about 1 million people?  We are one of the only countries that allows these direct-to-consumer pharmaceutical ads on TV and in magazines.  Other countries have found that this type of advertising brings no value to patients or to society.

  (People with RA:  No need to write me.  I am not against treatment for this terrible disease and it may be that these overpriced medications actually do bring great value.  I just want to make sure the right drugs are going to the right patients)

If we are to dig ourselves out of this medical affordability hole we need a change in the culture of medicine.  We are over tested and over-treated  but don't have the health outcomes to show for it.

Friday, June 15, 2012

Calcium Supplements and Heart Attack

Many patients who have been advised to supplement with Calcium (especially women for bone protection) were thrown for a loop by the study in the British Medical Journal that linked calcium supplements to heart attack.  Here is what the researchers found:

They studied 24,000 German and European patients ages 35-64.  Using questionnaires, they quizzed them about their vitamin and mineral supplements.  They also tracked their health for 11 years, looking at heart attacks, strokes and death.  (These studies can be easily done in countries with Socialized Medicine because everyone has health coverage and electronic records!!!)

They found that the intake of calcium supplements did not affect the risk of stroke, either protection or causation.  But the people who took calcium supplements daily were 86% more likely to have a heart attack than those who didn't use any supplements.  Dietary calcium caused no problem, it was just the supplements.

What should we make of this study?  Dietary calcium is a good thing and calcium from food actually lowered the risk of heart attack.  So eating foods with calcium is just fine.  But we have relied too much on supplements that are increasingly being found to be worthless in preventing disease and even harmful when taken in large doses. 

The average person should not take calcium supplements.  They can increase the risk of kidney stones, cause gastrointestinal problems and even heart attacks.    It is now becoming clear that recommending vitamin supplements can be harmful and they do not replace good, balanced diets.

Foods with calcium:

low fat dairy, yogurt, cheese, collards, spinach, potatoes, soybeans, turnips

Friday, June 8, 2012

Risk of Suicide with Antidepressants Over Estimated

When the US Food and Drug Administration issues a black box warning, it is usually to alert physicians of a serious side effect of a drug.  That warning is highlighted in all of the package material of the pharmaceutical and is a big deal.  For years, the SSRI antidepressants have carried a black box warning that the drug might cause suicide in children and adults.  This warning was there despite the fact that no actual suicides occurred during the drug trials but patients did experience suicidal thoughts and behavior.  I remember hearing about lawsuits against psychiatrists when medication was prescribed and it was thought to have contributed to suicide attempts.

A new meta-analysis study has been published in the Archives General Psychiatry that analyzed 9185 patients who took Fluoxetine (Prozac) and Venlafaxine (Effexor).  These included 7517 adults, 960 geriatric patients and 708 youths.  Contrary to the black box warning, they found that these medications decreased suicidal thoughts and behavior in adults compared to placebo.  No differences were found for youths.  In all age groups, severity of depression improved with medication and was significantly related to suicidal thoughts.  There were no suicides that were attributed to the medication.

This study is important because some clinicians may not prescribe and some patients may be afraid to take antidepressants that could significantly help their quality of life.  Major depressive disorders are life threatening and SSRI medication has been an amazing modern breakthrough to help people get back on track.

If you google this topic you get lots of scary anecdotal information about antidepressants causing suicide and violence along with the usual conspiracy stories and pharmaceutical bashing.  When you consider that 70% of people who commit suicide did not see a psychiatrist within the last year, you realize how serious depression is.

Antidepressants do not cure life problems, but they bring significant relief and save significant lives in millions of humans.

Tuesday, June 5, 2012

How to Cut Risk of Heart Disease

Which of the following measures will cut a patient's risk of heart disease by 50%?

1.  Losing weight
2.  Stop Smoking
3.  LDL-C below 100 mg/dl
4.  Blood Pressure below 120/80 mmhg

If you said "Stop Smoking" you would be correct.  Does that surprise you?  We hear about blood pressure control, cholesterol control and getting weight under control but cigarettes are the biggest risk factor for having a heart attack or stroke and quitting smoking is the single most important step to reducing risk.  A 50 year old male smoker who is overweight, hypertensive, and has high cholesterol has about a 25% change of having a heart attack in the next 10 years.  If he stops smoking he can reduce that 10 year risk to 11%.

It is hard to believe anyone still smokes but according to the Center for Disease Control and Prevention (CDC) there were 43.5 million adults in the United States who smoked in 2010.  Smoking related diseases cost us all about 96 billion in health care costs annually.

The Tobacco Industry spends $10.5 billion annually in marketing its products nationwide.  The entire GNP of Liberia is only $.44 Billion.

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...