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Showing posts from 2013

The Microbiome

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I am fascinated by the new research and information on the gut microbiome.  These microorganisms (germs, bacteria, microbes) live harmoniously in every part of our body and especially in our gastrointestinal system.  It wasn't even really discovered until the late 1990s and we now know that these microbial communities affect our health in ways we never dreamed.  The human microbiome may play a role in obesity, immune response, diabetes, irritable bowel syndrome, and maybe even anxiety, depression and autism.

Anything that is this new has many possibilities the science is just starting, but there is clearly something very important here.   The Human Microbiome Project  is a NIH initiative with the goal of identifying and characterizing the microorganisms which are found in association with both healthy and diseased humans.  They intend to test how changes in the human microbiome are associated with human health or disease.

A new study published in Nature this week showed that adap…

Answer to Medical Challenge

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OK, the answer to yesterday's Image Challenge was #3, Squamous cell carcinoma.

Ninety percent of all mouth cancers are squamous cell cancer.  Factors that increase your risk of mouth cancer are:
tobacco use of any type (including smoking, chewing, cigars and pipes)heavy alcohol useHuman Papillomavirus (HPV)  (think of Michael Douglas) Usually surgery is needed to treat squamous cell carcinoma in the oropharynx, along with radiation therapy to eradicate all of the cells.

Image Challenge

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Back by popular demand is this weeks medical challenge where you get to make the diagnosis. (click on the image for a close up view)

The patient opens his mouth, says "ahhh" and this is what you see.  Is it:

1. Aphthous stomatitis
2.  Pyogenic granuloma
3.  Squamous-cell carcinoma
4.  Syphillis
5.  Traumatic fibroma

Make your diagnosis in the comments section and check back tomorrow for the answer.

Things Doctors Do (That Normal People don't)

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I have been too swamped to blog recently on EverythingHealth, spending lots of time with my physician colleagues (as well as patients).  I realized that doctors are really not normal when it comes to a few things.  Here is a list of things doctors do that normal people don't.  You may have more to add!
Eat standing up, while walking or while charting on patientsTake expired medication (we know that expiration date is phony)Work hard-core, even when sickDon't get regular check-upsCannot watch doctor TV shows (House is especially intolerable)Freely discuss body functions at dinner.  Nothing is off limitsSilently diagnose medical conditions on strangers.  No lump or rash goes unnoticed.Combine vacations with workWhen we shake hands, think "Oh, that's a nice vein"When our child is hemorrhaging, we can fix anything with steri-stripsSeldom use antibiotics on ourselves or familyListen to lectures and medical information while commutingTake suitcases full of journals to …

How the Genes and Drugs work

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Infographic by12 Keys Rehab

Oral Melanoma

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The answer to yesterday's image challenge was #4- Melanoma.  Many of you diagnosed correctly.

Oral malignant melanomas are uncommon and like other melanomas of the skin they arise from melanocyte cells.  Unlike cutaneous (skin) melanoma which are linked to sun exposure, the risk factors for oral melanoma is unknown.  We think they arise de novo (from no cause).

Oral melanomas are more common in Japanese race and occur in men more than women (2:1)  It is rare in people under 20 and more common in men over 40 years.

Good oral exams by the dentist are always important to identify mouth lesions.  Most are benign and many other less serious conditions can cause pigmentation.

You Be the Doctor

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This 42 year old man came to the doctor with these changes in his gums.  What is the diagnosis?

1.  Chewing tobacco
2.  Implantation of amalgam
3.  Lead Poisoning
4.  Melanoma
5.  Peutz-Jegher's syndrome

Make your diagnosis in the comment's section and check back Friday for the answer.  Can you be the doctor that gets it right?

Ignore these 15 Obamacare Myths

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I've pulled my head up from frantic medical work just in time to give faithful readers 15 Myths that are being spread about Obamacare.  I have been first to admit that the government has done a lousy job of explaining the plan and it is no wonder the Tea Party has had a field day with mis-information.  But now that sign-ups for the Exchanges are open to the uninsured and under-insured population, these are the lies you should avoid:
Congress is "Exempt" from the Affordable Care Act  Premium prices will increase due to Health Care LawThe Affordable Care Act includes death panelsShutting down Government over Obamacare funding will stop the Health Care LawThe ACA is "socialized medicine" and a "government takeover"People will be able to commit subsidy fraud on the ExchangesObamacare "Narrow Networks" will constrain health choicesThe Affordable Care Act is bad for womenThe Affordable Care Act covers abortionsThe Affordable Care Act is a job kill…

New Hep C Screening for Baby Boomers

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If baby boomers weren't special enough,  now the U.S. Preventive Services Task Force has singled them out as a special group to be screened for Hepatitis C virus (HCV).  Individuals born between 1945 and 1965 are recommended to undergo this one-time blood test screening because they are at high risk for the virus.

What is it about this age group that gets special notice?  According to the Centers for Disease Control, baby boomers account for three out of four people with HCV.   Many of them contracted hepatitis C from blood transfusions or needle procedures before we had a screening test for the virus.  Others may have caught it from high risk behaviors like injecting drugs, HIV or piercing or tattoos in unclean environments.  It is less common to contract it through sexual relations but it can happen.

We have had a test that could screen for Hepatitis C antigen for many years but only recently are we able to treat chronic Hepatitis C with anti-viral medications.  There is an incr…

Some Doctors Set Their Own Pay

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The Centers for Medicare and Medicaid (CMS) sets the rates all physicians get paid and insurance companies base their rates on the same formula.  So who creates the formula?  Well, it's the doctors, silly!  Or at least some of the doctors.  Here's how it works:

A 31 member committee formed by the American Medical Association is made of of representatives from the various specialty societies.   This Relative Value Update (RVU) Committee meets in private and decides how much value each unit of medical work represents.  That unit of work is then assigned a dollar amount and that creates the pay scale.   The catch is that primary care (Internal Medicine, Family Medicine, Pediatrics) is very poorly represented on the committee.  The surgical specialties; anesthesia, radiology and even tiny surgical specialties (like urology or ENT) are equally represented and as a group they get to decide how to value a doctors time and expertise.   This is why primary care has been "underval…

Answer to Challenge

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The answer to yesterdays Medical Challenge is...drumroll....

#4:  Harlequin color change

Harlequin color change is a dramatic but benign phenomenon in which the color on 1/2  (downward) of an infant turns deep red, while the upper half is pale.  Usually this color change is abrupt and lasts between 30 seconds and 20 minutes, then it resolves.  Up to 19% of infants undergo this color change which occurs between the 2nd and 5th day of life.  It is attributed to a temporary imbalance in autonomic regulation and it is more common among low-birth-weight infants.

The fact that the baby did not have IV lines or oxygen or evidence of being in an ICU pointed to a less serious cause and was the "hint".

The other conditions would indicate a life-threatening condition.
Collodion baby is a genetic condition that causes the skin surface to crack and completely peel.  It also includes the mucous membranes, eyes and mouth.  It has the same genetic abnormalities as Bullous ichthyosiform ery…

Medical Challenge

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I couldn't resist this challenge from the New England Journal of Medicine.  Make your best guess in the comment section and answer will be posted tomorrow.  One hint:  The newborn baby doesn't have any IV's or tubes inserted. (click on the image for a close up). 

Any neonatal specialists out there?

1. Bullous ichthyosiform erythroderma
2. Collodion baby
3. Cutis Marmorata
4. Harlequin color change
5. Staphylococcal pyoderma

Delay Cord Cutting in Newborns

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A new study has shown that delaying cutting the cord in a newborn baby is associated with better health for the baby because more blood (hemoglobin) passes from the mother to the baby as the cord is still attached.  Prior studies have also shown this advantage but there was a concern of hemorrhage in the mother if the cord cutting was delayed.  Doctors often rush to cut the umbilical cord as soon as the baby is delivered.  This study, published in The Cochrane Database of Systematic Reviews, shows there is no increased danger of hemorrhage  to the mom and the benefit is for the neonate.

The researchers found that babies who had later cord cutting (after one minute) had higher hemoglobin levels 24-48 hours post-partum and they were less likely to have iron deficiency at 6 months, compared to the early cutting babies.

This is especially important in developing countries where anemia is common.  The World Health Organization (WHO) has long recommended waiting 2-3 minutes to cut the umbi…

Poem - Do Not Resuscitate

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Do Not Resuscitate
I can say your father is dying. I can say wishing will not make it so, belief doesn't change a thing.
I can say love does not conquer all, miracles are pretty stories told in church, the movies you saw as a child are lies, blind hope is not a recipe for success, underdogs usually lose, death is not the worst thing, it is just the last thing. But for you that is not true.
I can say we have to pretend that we can bring him wheezing back to you like an old accordion, chest pleating in and out, singing his customary songs, oxygen bumping its hurdy-gurdy way again through his ancient heart.
But how can I tell you how someone will shout down the hallway, kneel frantic on the bed, lean his fists against that old breastbone, sharp, frail, one onethousand, two onethousand, and count it out.
I can say we should not do this. He will never be the same. I can say if it were my father.
I can say do not confuse resuscitation with resurrection, although neither works particula…

Morning After Pill Now Available Without Prescription

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The U.S. Justice Department has dropped its appeal to block a ruling by a New York Federal Judge to allow easy access, over-the -counter purchase of the "Morning After" pill for birth control. The emergency contraceptive, named for women who either got caught without a contraceptive, or the condom broke, is called  Plan B One-Step.  (I guess that is when plan A fails.)  Plan B is a one dose pill of 1.5mg levonorgestrel that reduces the possibility of pregnancy.  It is to be taken within 24 hours of unprotected sex and the drug’s principal effect is to prevent ovulation, but it may also make the lining of the uterus less hospitable to a fertilized egg.

The controversy about Plan B began when HHS Secretary, Kathleen Sebelius, invoked her authority over the FDA, who had approved the drug for purchase from a pharmacy without a prescription.  Ms. Sebelius, in an unprecedented move, stated that prescription dispensing requirements should not be removed for women of all ages.  She…

Answer to Image Challenge

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The answer to the image challenge this week is #1 - Atherosclerosis.  Most of you got the right answer because you obviously know that the diagonal crease seen in the earlobe is known as "Frank's sign".  The sign was originally described as a marker for coronary artery disease, with a moderate sensitivity ( approximately 48%) and specificity ( approximately 88%).  Frank's sign has been associated with other cardiovascular risk factors like atherosclerosis.

Good job, readers!  How many of you have looked in the mirror at your own earlobe?

Komen Suffers For Its Blunder

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How do you wreck a beloved brand?  Just look at Susan G. Komen Foundation For the Cure (Breast Cancer) and remember what a well-known brand they had.  From pink ribbons to breast cancer walks and gala events, corporate and individual sponsors were happy to give to such a worthy cause.  The "Race for the Cure" was catchy and easy to promote.

 Fast forward to January 2012 when Komen foolishly bowed to social conservatives and announced they would "defund" Planned Parenthood because of the highly political abortion issue during the last Presidential race.  The Breast Cancer Foundation decided not to pay for screening mammograms for poor women through Planned Parenthood.

The backlash was rapid, strong and widespread on Facebook, Twitter and other social media.  The Komen board of directors reversed their decision within a few days.  Two top executives at Komen Foundation resigned and apologies were rendered.  But that wasn't enough to keep the brand that women lov…

Medical Challenge

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This weeks Challenge from the New England Journal of Medicine is a good one.  Check out the photo (click on it to see closer) and make your best guess as to the diagnosis.  The answer will be posted tomorrow so put your answer in the comment section and check back to see if you are a good diagnostician!

What condition would cause this ear abnormality?

1.  Atherosclerosis
2.  Fabry's disease
3.  Gout
4.  Hashimoto thyroiditis
5.  Ulcerative colitis

Ovarian Cancer Screening

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Here is a real case study from American Family Physician with the correct "answers" that may surprise women (and men).  It is a common case in my practice too as more and more women are health conscious and want to do everything possible to detect early cancer.

CASE STUDY

A 35 year old woman presents for a routine well-woman exam.  She is worried about ovarian cancer because one of her friends was recently diagnosed.  She has no family history of breast, ovarian or colon cancer.  What do you do?

Answer:  Based on U.S. Preventive Services Task Force recommendation on screening for ovarian cancer, you advise against screening tests because they do not have good sensitivity for cancer and there are too many false-positive results.  The screening tests like Ca125 and transvaginal ultrasound have not been shown to reduce the number of ovarian cancer deaths.

Keep in mind that these recommendations do not apply to the following women.  Studies show these woman would benefit from thos…

Blame Bunions on your Genes

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There is good news for women who love high heels and pointy toe shoes.  Contrary to what we've been told, they don't cause bunions.  A new study published in Arthritis Care & Research shows that bunions, hammer toes and other toe deformities can be blamed on your parents.  Yes, like so many disorders, it's all in the genes.

The medical name for bunion is hallux valgus and up to 60% of people get foot disorders and foot deformities in later life.  By using heritability software that performs genetic analysis of familial data, the researchers found out that these conditions are genetically passed down.

Before you throw away those Birkenstock sandals, however, remember there is always an interplay between genetics and environmental factors that affect our bodies.  One look at the feet of dancers shows that constant trauma or strange positioning of the foot structures can cause permanent change.

My advice to women who love heels is to walk barefoot in the sand as much as…

Few Americans Understand Basics of New Health Care Law

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I wrote last week about the massive confusion about ObamaCare ( the Affordable Care Act) but it seems that it is much worse than I thought.  The Kaiser Family Foundation came out with a poll that shows 42% of Americans don't even know that ObamaCare is the law.  Seven percent of people think the Supreme Court struck it down and 12% think Congress repealed it. 

I understand that there is confusion about the way it will work and who will be affected.  But my advice to Americans is TURN OFF THE DAMN TV.  Really, we are blessed to live in an age where information about any subject is available with the click of a mouse and  people seem to know more about the Kardashians than they do about a health care law that is as important as Social Security or Medicare legislation.

I'm not surprised, however that most Americans said they don't have enough information to understand how ObamaCare will affect them.  The Administration should have hired the same marketing firm that did the …

Poison Oak

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As the weather heats up and people are hiking and walking animals outdoors, we physicians start seeing the results of a contact dermatitis known as poison oak or poison ivy.  Some of the tell-tell signs for diagnosing this condition is the severe itching, patchy redness that is in certain skin areas only and also notice the linear streak on the top back area of her neck.  That is a classic rhus dermatitis (poison oak) appearance as are clusters of  fluid filled blisters.

Poison Oak is a leafy shrub that grows wild on the West coast.  Poison Ivy grows on the East coast as does Poison Sumac.   It commonly grows like an ivy vine and as summer rolls on the pointed leaves turn orange color.
The rash is caused by a toxic substance in the plant called urushiol.  Brushing against it or touching an object that has brushed against it (dog fur, shoe laces, backpacks, clothing, hats) can cause an extreme allergic reaction.  Like any allergic response, the symptoms get worse with each successive…

Health Care Reform Confusion

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If you think you are confused about ObamaCare and what it will mean to you and your family, you are not alone.  Confusion is rampant and open enrollment for the health exchanges is supposed to start October 1.   Yes that is a mere 6  months from now!  Despite this looming date, the various States still don't know what they will be offering and doctors and hospitals also have no idea how it will work.  There seems to be no plan on how to get the word out to the uninsured public.
Most uninsured people don't even know they will have new insurance options under the Affordable Care Act.   If you have insurance now through your employer, not much will change.

Here are some basics that we do know:

The exchanges will start covering patients on Jan 1, 2014.  Each state will have its own exchange for people who don't have employee coverage.  There will also be a plan for small businesses to offer to employees.  The vast majority of people who have health insurance from their jobs w…

Answer to Image Challenge

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The answer to yesterday's diagnostic challenge is...drum roll...
# 3.  Psoriasis.

The scattered reddish, scaly, indurated papules on the lower back and buttocks are psoriasis.  The acupuncture needling of the skin produced trauma that caused Koebner's phenomenon and subsequent psoriatic flare.  This is a rare event and it was treated with a steroid cream.

Thanks for your guesses.  This was a hard one.

What is the Diagnosis?

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Today's image challenge from the New England Journal of Medicine is a tough one.  Full disclosure - I missed it.  (bragging rights: I usually get about 99% right) 

This patient had acupuncture to the area and developed these lesions.  What is the diagnosis?
1.  Herpetic whitlow
2.  Nummular eczema
3.  Psoriasis
4.  Ringworm
5.  Scabies

Click on the image for a closer view and make your diagnostic guess in the comment section. The winner gets a free subscription to EverythingHealth.   Check back tomorrow for the answer! 


Fake Drugs

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Unfortunately many of the drugs that enter the United States (and other Countries) are fake.  Research shows that more than half of the drugs sold by online pharmacies may be fake. Globalization of the pharmaceutical manufacturing industry and distribution system is contributing to the problems of false and substandard drugs. 

And low and middle-income countries are the hardest hit by these falsified drugs.  Many patients in these countries are forced to buy their medications from poorly regulated markets and some of the drugs they buy are useless...or even worse, toxic.  Substandard drugs in developing countries have contributed to the emergence of drug resistant malaria and tuberculosis.

More and more people in the United States are buying medications on-line, hoping for a price break from the exorbitant cost of pharmaceuticals.  The best way to ensure that you are dealing with a reputable pharmacy is to verify it with the NABP (National Association of Board of Pharmacies) Verified…

Meat and Heart Disease

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We have known for decades about heart disease and the effects of red meat and saturated fats being a cause of elevated cholesterol.  But we've also known that is not the whole story and now surprising new research is pointing to gut bacteria and the actual chemical that is produced by meat as the culprit for heart disease. 

Carnitine is found in red meat and is also used by body builders as a supplement for energy.  Researchers have found that in the intestinal tract, bacteria convert carnitine into a metabolite called TMAO and TMAO promotes thickening of the arteries.  Steak consumption caused subjects in the study to immediately produce large amounts of TMAO.  Vegetarians did not produce the chemical.

Many people who become vegetarian say that they can no longer digest red meat.  It turns out that they actually lose the ability to metabolize carnitine over time because they do not develop the gut bacteria that meat eaters have.

How did the researchers know it was the gut bacter…

Unhappy Nurses

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I am sad to read that a new survey reported in Forbes shows that nurses are the 4th most unhappy profession in the US.  The survey evaluated 10 factors of the workplace including  work environment, relationships with co-workers, compensation, and control over one's daily responsibilities.  They required at least 50 employee reviews to qualify in a category.


Careerbliss  found out that associate attorneys are the most unhappy followed by customer service associates, clerks  and coming in 4th on the unhappy scale was the registered nurse.  Equally sad was that teaching came in 5th on the unhappiness scale.

What workers were most happy?  Number one was Real estate agent followed by Senior Quality Associate Engineer.  Sales Reps and Construction Superintendents were also happy in their jobs.

Overwork, lack of opportunity for advancement and poor workplace culture were the biggest factors in the dissatisfied categories.  Nurses were most unhappy with the workplace culture and the peop…

Tuberculosis Made Easy

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Tuberculosis (TB) is a contageous infection that is caused by a bacterium called Mycobacterium tuberculosis. One third of the world population has been infected with TB and it caused over 1.5 million deaths in 2010.  We don't hear as much about TB in the developed world but new infections in third world countries occur at a rate of about 1 per second.    Risk factors for TB are:
A weakened immune system such as diabetes or HIVWorking in health care or refugee campsTraveling to countries where TB is endemicLiving in overcrowded situations or extreme poverty  The disease usually affects the lungs and is spread when people cough or sneeze and spray moisture droplets.  In the old days, TB was called "consumption" and at the turn of the century it was treated by isolating patients in sanitariums for months to years and hoping they recovered. In the 19th Century, TB killed more people in New England than any other disease.


Active TB is when a person has symptoms (fever, cough,…

Ten Sleep Facts That May Surprise You

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I think we all know that sleep is not only beneficial for good health, but lack of sleep can lead to a number of serious disorders and diseases.   Here are ten sleep facts that may surprise you:

1.    When we are awake our brain cells produce adenosine as a byproduct. The build-up of adenosine in the brain is thought to be one factor that leads to our perception of being tired. (Incidentally, this feeling is counteracted by the use of caffeine which blocks the actions of adenosine in the brain and keeps us alert.)

2.    Older adults need about the same amount of sleep as younger adults (7-9 hours) but seniors go to bed earlier and wake up earlier than when they were younger.

3.     We dream only during REM (Rapid Eye Movement) sleep but get the deepest sleep during non-REM cycles.

4.     It is not only important to get sleep to learn, but it is also important to get good sleep after we learn something new to process and retain that knowledge.

5.     Insomnia is the most common …