Monday, December 31, 2012

Remembering 2012 - Top Ten Health



 As 2012 draws to an end,  EverythingHealth will reflect on our top 10 health and medicine events to remember.  


1.  The world did not end on December 21 as predicted by the Mayan Calendar,  but a new Age of    Enlightenment may just be beginning!!!   "Be the change"

2.   The Supreme Court upheld the Affordable Care Act ( ObamaCare) and President Obama was re-elected to carry out the most significant health care legislation since the creation of Medicare.

3.   As of this writing the United States "fiscal cliff" has not been averted and an automatic 26.5% cut in Medicare pay for physicians is part of that cliff.  Not good for seniors!

4.   Deaths from fungal meningitis and joint infections continue to be announced as the result of contaminated injectible products from the New England Compounding Center.  More stringent regulations and authority to the FDA will likely result.

5.   Nine Medical Societies published a compendium of 45 clinical tests and procedures that are not rooted in evidence-based medicine, greatly drive up costs and bring no value to patients.

6.   The US Preventive Services Task Force recommended against PSA prostate cancer testing in healthy men, regardless of age.

7.   A soda a day was found to raise cardiovascular heart disease risk by 20%

8.   Researchers found breast tumors fell into four major subtypes. The knowledge could translate into changes in the way doctors treat breast cancer for different patients.

9.   Scientists discovered that "insignificant" portions of DNA are really the metabolic switches that regulate how and when genes function and when they manufacture certain proteins.  Future discoveries may allow us to control or even cure diseases by focusing on these portions of the human genome.

10.  New dialog about gun violence and gun safety is beginning, sadly because of the deadly shootings that are ravaging our society.  Various medical societies are joining with The American Academy of Pediatricians and urging physicians to be strong leaders in gun reform.

Happy New Year to all my faithful readers across the globe and new readers to EverythingHealth.  May 2013 be magical for all of you!

Hillary Clinton and Subdural Hematoma

 Addendum to the post below:  New reports show she may have a venous blood clot in a vein that goes to the brain, rather than a bleed under the skull known as a subdural hematoma.  The treatment is quite different as venous thrombi (clots) are treated with blood thinners.  The information below is still quite accurate but may not apply to Madame Secretary Clinton.....

 

 

Secretary of State,  Hillary Clinton has been hospitalized with a subdural hematoma after fainting, hitting her head and suffering a concussion less than a month ago.  Here is a repeat of a blog I did a few years ago about "a bump on the head".


Even a minor blow to the head can lead to serious trouble. A close relative of mine is an active, sharp guy in his 80's. He was hospitalized a few weeks ago with an infection and like many older folks, he wasn't aware of how weak he was and he tried to get out of the hospital bed and go to the bathroom and "whoops", he slipped and fell. Hospitals all have procedures in place to prevent falls and they monitor the number of patient falls and try very hard to get to zero. But, try as they do ...falls happen. OK, he got a bump on the forehead and a bruised shoulder but, fortunately no broken bones.

Fast forward 4 weeks. One weekend Allen was slurring his words and not walking well. You would think they would rush to the hospital to get things checked out, but they decided to wait and see if he was better the next day. This is a HUGE mistake. In a prior post I wrote about stroke and the need to seek immediate attention for any change in speech or one sided weakness. I am always surprised at how many patients do not seek medical help and instead wait to see if things will improve on their own. Ten out of ten times, symptoms like this do not improve.

Allen and his wife finally went to their doctor and he was immediately admitted to the hospital. A computed tomography (CT) scan revealed a large hematoma on his brain. The fall that occurred several weeks earlier had caused bleeding around the brain. Blood vessels can be damaged when the skull receives a blow, especially when the head hits a hard surface like the pavement. A hematoma is caused by a bleeding vessel and a subdural hematoma occurs when blood collects in the small space between the brain and the skull. The blood clot presses against the brain and the resulting pressure can severely damage the brain unless a neurosurgeon removes the blood. Fortunately, blood and blood clots are easy to detect with a CT scan.

After the subdural hematoma was diagnosed, Allen was rushed to surgery and the blood clot was removed. He has a large "s" shaped scar where the skull was removed (and replaced) and he is now home and doing great. His speech is back to normal and he continues to improve each day. Without surgery, Allen would not have made it. It is always nice when a story has a happy ending.

There are several take home messages here:
1. Any sudden change in speech or weakness or trouble walking needs immediate attention at the Emergency Department of the closest hospital.

2. Any fall that causes facial bruising or loss of consciousness needs evaluation.

3. Any time the head smacks against a hard surface, there is a chance of brain trauma because the brain can strike the inside of the skull.

4. Symptoms can show up weeks after trauma so don't ignore changes in personality or behavior, especially in older folks.

Sunday, December 30, 2012

Lactose Intolerance in the Genes

National Public Radio (NPR) reported on a fascinating theory of Mark Thomas, an evolutionary geneticist at University College London.  He points out that we human beings all started out being unable to digest milk's dominant sugar, lactose, after childhood.  In fact, most adult mammals do not drink milk.  But 20,000 years ago,  people of Northern and Central European descent and certain African and Middle Eastern populations began developing lactose tolerance.  He theorizes that there was a strong natural selective pressure to allow those lactose tolerant genes to survive.  Drinking milk was an advantage to our species.

According to Thomas, milk was a "superfood" to early man.  It contains protein, calcium, fat and carbohydrates.  The ability to digest milk without developing diarrhea would give it's drinker an evolutionary edge.  The people who had the lactase mutation genes would survive the harsh winters, famines and even other illnesses that caused early death.  Those genes would survive and be passed on to further generations and create more lactose tolerant milk drinkers.  Other scientists have speculated that fresh milk provided a more pure fluid alternative as water was often contaminated or difficult to find in arid climates.   Milk  may have also given people a fertility advantage.  We know that women need a certain amount of body fat to produce children so the lactose tolerant women may have produced more offspring.

I was surprised to learn that only about 35% of the adult population worldwide can drink milk without a problem.  East Asians and Indigenous North Americans may be 80-100% lactose intolerant yet the Brits in the UK run a rate of  only 5-15%.  

Lactose intolerance is not an allergy, but is caused by lack of the  enzyme, lactase.  There are a number of genes that contribute to lactase and the ability to break down the milk lactose into glucose and galactose. 

 People with lactose intolerance frequently get symptoms of nausea, cramping, bloating, diarrhea and gas about 30 minutes to 2 hours after drinking milk.  But the symptoms can vary and some individuals can drink small quantities of milk or other dairy products without a problem.   The intolerance can also change during pregnancy. Lactose intolerance may be the culprit in many instances of "Irritable Bowel Syndrome".

If you don't have the lactase gene (and are lactose intolerant), you can still use lactaid free milk in baking and eating.  Three lactose free milks tested by ConsumerLab - Lactaid Fat Free Milk, Land O' Lakes Dairy Ease Fat Free Milk and Organic Valley Lactose Free Organic Fat Free Milk all tested as having no lactose.

For ice-cream lovers, Breyers makes a lactose free ice-cream as does Turtle Mountain and Lactaid.


Sunday, December 23, 2012

Happy Healthy Holidays


I Wish That I Could Wrap Up Christmas

I wish that I could wrap up all the love and Holiday cheer
That comes along with Christmas and with New Year's every year,
Pack it in a pretty box and put it on my shelf
And pull it down again each year and give it to myself.
I wish that I could tie up all my favorite carols with twine,
Wind around some ribbon, too, and for twelve months call them mine
Until the next Yuletide came when the sounds again could be unfurled
And untie every single one then give them to the world.

Monday, December 17, 2012

Medical Fraud - Lock 'em Up

When most Doctors and care-givers are trying to deliver "value" and keep costs down, it really chaps my hide to read about Medicare Fraud.  Here is the latest:

Dr. Michael Reinstein, psychiatrist in Chicago,  submitted at least 50,000 claims to Medicare and Medicaid, falsely stating that he provided "pharmacologic management" for patients at more than 30 area nursing homes and long-term facilities.  If that weren't enough, he also accepted kickbacks from Novartis, IVAX and Teva Pharmaceutical companies to medicate elderly patients with serious anti-psychotic medication.

The kickbacks go back as far as the 1990's and Dr. Reinstein had more than 1000 patients at a time on a rarely used medication called Clozaril.  Clozaril is typically used only as a last resort in treatment-resistant psychotic patients and is of particular risk to the elderly.  It is extremely rare to have a nursing home patient on Clozaril.   Reinstein was the largest prescriber of Clozaril to Medicaid recipients in the United States and at one nursing home 75% of the residents were on Clozaril.  It should only be used for severely schizophrenic patients that have failed other treatment,  yet in 2000 and 2001 Dr. Reinstein prescribed more Clozaril than the next 9 top prescribing physicians in the United States combined.

Even after the Novartis patent for Clozaril expired in 1998, Dr. Reinstein, who was still receiving payments, kept hundreds of patients on the brand name drug and refused to switch to the generic form.  He only switched to the generic clozapine when Novartis stopped making the drug and he struck a new kickback deal with IVAX Corp, maker of a generic clozapine.  He then became the largest prescriber in the country for the generic form.

Dr. Reinsten's kickbacks included cash, trips for himself and his entourage, support of his pharmacy owner wife, support of his assistant, research support, boat cruises and tickets to sporting events.  He also received annual speaker fees for promoting the drug to others.

There are so many things wrong with this case that go beyond fraud and greed.  This is a dangerous drug and by 2009 allegedly 3 of his patients died of clozapine intoxication. One 50 year old man had 5 times the toxic level of clozapine in his blood when he died.

But there are no criminal charges here, simply civil penalties. It is unknown if the pharmaceutical companies involved will face charges relating to anti-kick-back laws.  In my opinion, fines are not enough.  I think jail time is warranted.

If you want to read the full False Claims Act complaint from the Illinois Eastern Division Court go here.

Addendum:  I'm not an investigative reporter but if I had time I'd look into the illegal kick-backs from Astra Zenica Corp also.  It seems Reinstein was also the top prescriber of Seroquel and was paid over $490,000 in 2000-2001 for that honor.  Thanks to the internet it wasn't hard to find confidential communication between him and Astra Zenica.   Astra Zenica admits that Reinstein and his partner are not respected by their peers and that they do bad research on patients, but then said is a "win-win" to fund them.  The internal document says, if they don't give him the money, Reinstein will switch patients off Seroquel to a competitor.  They are an "important source of business" for Astra Zenica.

For more on Reinstein:
See Pro-publica here


 I feel so sorry for the patients.

Sunday, December 16, 2012

Health and Weapons


There have been eight mass shootings in the United States this year and at least 61 since 1982.  The Connecticut community of Newtown is grieving for it's 20 slain children and 6 adults.  The towns of Columbine, Tucson, Aurora, Oak Creek, Minneapolis and Clackamas, to name a few, are still  grieving for their lost children and adults to gun violence.  Now is the time to stop this craziness.

As president Obama said, "Surely we can do better than this."  This cannot be a political, Blue vs. Red, North vs. South, Right vs. Left issue.  It is every one's issue now.  As a nation we are not doing enough to keep our children safe.

The rifle used by Adam Lanza, the mass murderer in Connecticut and by James Holmes, who killed 12 people in a movie theater in Colorado in July and by Jacob Roberts who killed two people in a shopping mall last week,  was an AR-15 semi-automatic weapon. This means it can rapidly fire multiple high-velocity rounds.  These rifles, along with glock semiautomatic pistols (also found at the scene) are efficient killing machines and are completely legal to buy in gun shops and online.  The pistol costs less than $500 and you can buy both online and "add to your cart", oh so easily.  Sadly, the guns used by Lanza were legally owned by his gun enthusiast mother.  
The NRA attorney, Stephen Halbrook, argues that the number of people unlawfully killed with these semi-automatic weapons is "really quite small."  When you add in the violence in our poor neighborhoods with millions of these weapons in circulation, is is not a convincing argument.

The National Rifle Association (NRA) has 1.7 million Facebook fans. After the shooting in Connecticut, the NRA facebook page has gone dark and there has been no public statement.





Gun makers, sellers, ammunition companies, and gun accessories are big business and the NRA may care more about protecting the money flow than by protecting citizen rights to bear arms.   Our failure as a Nation to regulate (and outlaw) dangerous firearms is literally killing us.  Surely no-one needs a semi-automatic weapon for hunting or for self-defense.  There is no justification that would make any sense to a rational person.

Beware of the NRA coming forth after their moment of silence to defend these weapons by saying (as they did after the Denver movie theater massacre),   "The future of your Second Amendment rights will be at stake. And nothing less than the future of our country and our freedom will be at stake.”

This has nothing to do with freedom and everything to do with protecting law-abiding citizens. We have regulations that keep us safer in cars, safer with our food supply, safer with medical care and pharmaceuticals and even regulations for schools and pre-school.  Now we need regulations that keep us safer from gun violence.

We cannot prevent unbalanced people from existing but we can make it harder for them to massacre and then take their own life (as often happens).

 Now is the time for banning semi-automatic weapons and large rounds of ammunition.  Join EverythingHealth and make your voice heard.




Monday, December 10, 2012

RxTimer Cap

EverythingHealth get's PR pitches on a daily basis...companies and PR agencies wanting me to cover their latest product, book, speaker or start-up.  You can't buy your way into my endorsement but I have found something that I tried and I want to share it with you.  It is a new smart cap that fits on a regular prescription pill bottle and it is called RxTimer Cap:

I know how hard it is for patients to keep track of their medications and it is the number one cause of preventable medical harm.  Medications are prescribed "once a day", "twice daily", "every 8 hours", "AM and PM with meals or any number of confusing regimens.  Many patients are taking 10 or more prescription medications A DAY!  Of course it is confusing.  I take just one prescription pill a day and even I forget if I already took it or not.  That's where Timer Caps come in.

They come in various sizes and just become the new cap on any pharmacy pill bottle.  Each cap has a built-in LCD timer that works like a stopwatch and tells the patient how long it has been since they last took their medication.  Wonder if you took that noon pill?  Just look at the cap.

The battery in the cap is programed to last up to one year.  Although they recommend a new cap for each prescription, I have been using mine for 3 months and just putting it on the new month bottle.

I really like the RxTimer Cap and think it is a great innovation to help patients adhere to medications.
Check it out.  It might make a good Holiday present (along with some good Chocolate or Wine) for that friend or relative who takes lots of pills.

Saturday, December 8, 2012

Keratoderma

Acquired Keratoderma
The answer to yesterdays image challenge is #2 - Keratoderma.  This scaly condition affects hands and feet and can be congenital (passed on by genes)  or acquired.  There is a yellowish thickening and scaling of the skin and deep fissures can occur.   There are a number of different types of inherited conditions that have keratoderma and they are difficult to treat.  

Hereditary Keratoderma
Acquired keratodermas can be caused by eczema, lichen planus, psoriasis, Reiter's syndrome, drugs, internal malignancy and AIDS.   Besides treating the underlying disorder, the keratoderma is treated with topical solutions (salicylic acid 5%, lactic acid 10%, urea 10-40%) and topical retinoids.  Ulraviolet A (PUVA) may be needed in severe cases.

Wednesday, December 5, 2012

Be the Doctor and Make the Diagnosis

The EverythingHealth ever popular image challenge from New England Journal of Medicine is good this week because the photo is so interesting (and challenging).  Be greatful your feet do not look like this.  Please make the diagnosis in the comment section and check back tomorrow for the answer.  Is the condition?

1.    Nephrogenic systemic sclerosis
2.    Keratoderma
3.    Poikiloderma
4.   Punctate psoriasis
5.   Verrucae

You be the diagnostician and have bragging rights at your next cocktail party.


Sunday, December 2, 2012

Primary Care - Trying to Do Right

Winter is officially here and  we are in the cold and flu season.  This is the time that patients get sick with viral illnesses and primary care doctors get even more frustrated as they try to do the right thing for patients.  What is the right thing?

 First of all we want to relieve suffering.  But we also want to do that without causing harm.  We  want to practice the best evidence-based medicine.  And evidence shows us that antibiotics and extra testing does not help the time course of a virus.  In fact, overuse of antibiotics drives drug resistance, increases the overall cost of health care and causes unintended side effects. 

I've seen comments on the internet that doctors are part of the "Business of Medicine" and they order tests and use "big pharma" drugs so they can "make money".  Well, folks, Primary Care Doctors make no money ordering tests or prescribing drugs.

 Zero!  In fact, it actually costs us money to do both.  Blood and imaging tests (X-rays) require documentation, follow-up,  time informing patients and can even lead to more testing if something is "borderline".  We don't get a dime for this time consuming work that occurs after the patient is long gone from the exam room.

But even with the extra time it takes to order and follow-up on tests and order prescriptions, it takes even more time to explain to a patient WHY  these things are not needed for a viral illness.

Believe me, I get it.  I know how miserable a virus makes you.  I know how nights are worse and how hard it is to sleep with a sore throat or congestion.  I also understand the false hope that taking a pill will make it all better in a day or two.  I know we all want instant cures.   Here is how a typical scenario goes...usually on a weekend phone call:

Patient: "Doctor, I really need to be on an antibiotic.  I get sinus infections every year and I'm congested now and last night my throat was burning and I couldn't swallow and I couldn't sleep all night long  and I just know this will turn into a sinus infection because I get them every year and I need something called in RIGHT AWAY because I have to go to New York on business on Thursday and I just CAN'T BE SICK".

This phone call will take about 20 minutes because I will get more details and then explain, as kindly as I can,  that this illness will probably last 7-10 days no matter what we do.  I will offer  my suggestions for comfort care, rest, pain relief and natural healing methods and the opportunity to re-evaluate if things get worse.

At the end of this phone call, the patient is usually frustrated and may be even angry with me because they really don't believe what I have said and they really do feel miserable.

This scenario plays out multiple times, day in and day out during the winter season.  Sometimes I just give in and prescribe the antibiotic.  I can only try to do the right thing so long.