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Showing posts from 2016

How to know if something is infected

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How can you know if an injury is infected?  Patients are often concerned when wounds don't heal right away and this causes them to make needless visits to the doctor or emergency room.  Here is a pic of a wound that is about 6 days old.  My little dog scratched my arm while I was giving her a bath.  (Isn't she cute?)

 Is this scratch infected?

If you said no, it is healing well, you would be correct.  Even though it is still swollen around the scratch and it is obviously red and a little warm, these are signed of normal skin healing. I can picture my white blood cells and monocytes racing to the area to deal with bacteria from the scratch.  The redness and swelling are an inflammatory response that my immune system is producing to contain the bacteria and turn over new cells.

Signs of infection would be redness that continues to extend outside the wound that is worsening over time.  The swelling wouldn't stay the same, it would expand day by day.  The cut it self might st…

Why Can't I Have a Dentist EHR?

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Imagine my surprise and delight when I saw my dentist this week for a check-up and found the electronic health record to be both informative and patient friendly. As I sat in the dental chair, the large monitor screen was swung over in front of me and my dentist was at my side going over it with me. The monitor was not a barrier...it was part of my exam. The print was large, the information on the screen was easy to understand. Together we updated my health history, current meds and corrected errors. She held a small pad and changed things as we spoke. As the exam progressed she was able to swing the monitor over and show me X-rays, a fracture line in my tooth, a hazy spot that needed more investigation. We looked back in time and compared. The computer was a welcome addition in the exam room and the amount of clicking and recording of information was simple and intuitive.


Compare this with the EHR that I use, which by the way, is rated one of the best and is extremely expensive to p…

What is Shingles?

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Thanks to my patient for allowing me to use her photo to talk about a common condition known as Shingles.  The medical name is herpes zoster and it is caused by the re-activation of the chickenpox virus (varicella zoster).  This crazy virus lays dormant in the nerves and something causes it to flare up years or decades later.

This patient noticed a small rash behind her right ear and thought it was insect bites after a camping trip.  She had some tingling (a common sign) and swollen and tender lymph nodes.  Two days later when I saw her, the rash had spread down her neck and shoulder and she definitely had lymph node swelling at the neck and above the clavicle. (nuchal and supraclavicular nodes).  She had no fever but felt a little down.

Most shingles occurs in older people but it is not uncommon in younger folks too, like this patient.
The rash takes about a week to develop and can last about 2 weeks with varying degrees of pain and annoying tingling.  Some patients have pain that …

Transparency Price Tools Did Not Lower Health Costs

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For years experts have been saying if consumers knew the price of certain health care services they would be able to decide what services bring "value" and they could be better "shoppers" of health care.  Since so many patients have large deductibles and copays, it has been conventional wisdom that providing transparent prices would lower overall costs.  As people are spending their own money, giving them prices to compare should make them savvy consumers, right?
Wrong!  The Journal of American Medical Association, JAMA, did a study of employees that were given access to price transparency tools and it did not lower health care spending.
The authors compared the rate of change in health care spending among employees of two employers who offered a tool where they could compare prices of what they would pay out-of- pocket for various physician, lab and hospital services.  Top searches were for colonoscopies, obstetric services, office visits and gastric bypass surge…

Frozen Vegetable Recall

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This week the U.S. Centers for Disease Control announced a huge recall on over 350 frozen vegetable and fruit items because of an outbreak of Listeria monocytogenes bacteria.  Frozen green beans, broccoli, peas, edamame, kale, potato medley and even stir fry packages and fruits sold under 42 brands of U.S and Canadian store labels have been implicated. 
At this time the CDC reports 8 people have been infected. Six in California and one in Maryland and Washington.


Listeria is a fairly rare but dangerous bacteria.  A person with a good immune system can do fine, but it can cause severe sepsis and death if it enters the blood stream.  Immune compromised, older people, infants, and pregnant women are most vulnerable. Listeria can cause miscarriages and stillbirths among pregnant women.


Listeriosis causes muscle aches, fever, diarrhea and GI symptoms. Again, a healthy person can deal with it but it can cause rapid worsening with confusion and sepsis in older adults.  There have been a n…

Are Drugs Past Expiration Date OK?

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Pharmaceutical drugs, both prescription and over-the-counter come with an expiration date.  This manufacturer expiration date applies to unopened containers and many patients think they should discard expired meds or that it will be dangerous to take them. But do they really need to toss the "old" one and buy something new?  Is there a problem with safety?  What about the efficacy...will it still be potent?
The Medical Letter on Drugs and Therapeutic, a well respected and non-biased publication, looked at shelf life extension and the stability of expired medications.  They showed that all drugs they tested were stable for a year past the expiration date, and most drugs stored in unopened original containers were fine for 66 months. (that's 5 years!)  One drug, theophylline retained 90% of potency 30 years past its expiration date. 
Solutions and suspensions are less stable than solid medications. Epi-Pen auto-injectors may lose potency after the expiration date so that i…

Marijuana Use Lowers Metabolic Syndrome

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Marijuana is one of the most widely used drugs in the United States and many states have legalized the medical use of cannabis. Marijuana is legal for recreational use in Colorado, Washington, Alaska and Oregon.  Despite an increasing use of marijuana in different forms, good scientific studies are not often done. A new study on the effects of marijuana on the metabolic syndrome was published in The American Journal of Medicine in February, 2016. This is the first study that examined relationships of marijuana use with the metabolic syndrome across stages of adulthood.  The Metabolic Syndrome is a dangerous combination of hypertension, obesity, high triglycerides, high glucose and low HDL (good) cholesterol. It is a significant risk factor for cardiac disease and diabetes. Until now we have not understood the effects of tetrahydrocannabinol (THC), the active ingredient in cannabis on cardiovascular health. 
The study analyzed marijuana use in persons 20-59 years old, including past a…

Best Practices and When Your Doctor Says No

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The American College of Physicians and the Centers for Disease Control give guidelines (known as high value care advice) to physicians based on the best current scientific evidence. Physicians try to treat patients based on those guidelines even when patients want a different treatment. Here are three that create the most problems when physicians try to do the right thing.


(No antibiotics for acute bronchitis) Acute bronchial bronchitis can last up to six weeks with a    purulent or dry cough. It is one of the most common out-patient diagnoses we see. More than   15 excellent scientific studies show no benefit in treating with antibiotics and a trend toward       adverse complications when antibiotics were used.        All Primary Care physicians and Emergency Department physicians experience the constant request for Z-Pac throughout the winter. "It helped my friend, family, kid." "It's the only thing that works for me." It is hard to see a suffering patient wh…

Zika Pandemic - Early 2016

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The Zika virus was first discovered in a rhesus monkey in 1947.  The Aedes species of mosquito transmits the Zika virus as well as dengue and yellow fever.  This mosquito is found in tropical and subtropical regions around the world. Since Brazil reported Zika virus in May, 2015, infections have occurred in at least 20 countries in Central and South America.  And now, in 2016, it has pandemic potential with outbreaks in the Americas, Africa, Pacific Islands and Southeast Asia.

It's important to know that  80% of Zika virus infection cause no symptoms at all.  The rest have just mild fever, rash and muscle/joint pain.  There is no effective treatment.   But we are seeing other serious effects like congenital neurologic malformations and microcephaly in Brazil and French Polynesia.  Brazil has had 4000 cases of suspected microcephaly in 2015, a 20 fold increase since 2010.  Evidence of the virus has been found in the placenta and amniotic fluid of mothers and in the brains of fetu…

Geographic Tongue

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The answer to yesterdays diagnostic challenge was #1 Geographic Tongue.  Also known as benign migratory glossitis, this is condition has irregular and smooth patches on the tongue.  It is fairly common and can last a long period of time.  It is more common in older people and the cause is unknown.  No treatment is necessary but any lesions or changes in the mouth should be evaluated by your doctor or dentist.


Tongue Image Challenge

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It has been awhile since we have had an image challenge for you to solve.  This is a fairly common condition that we see.  What do you think the diagnosis is?
1.  Geographic tongue
2.  Oral candidiasis
3.  Lichen planus
4.  Oral hairy leukoplakia
5.  Pemphigus vulgaris


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

The Health Benefits of Dry January

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My under 30 year old hairdresser mentioned to me that she was having a "Dry January".  I had never heard that term and she explained that she wanted to be bikini ready for a trip to Maui so she was having no alcohol for the month.  According to a UK magazine called New Scientist, she is on the right track.


According to an article in National Public Radio Online, the staff at the magazine used themselves as guinea pigs and swore off booze to see what the health benefits would be.  Of the 14 staff members, 10 of them gave up alcohol for 5 weeks and 4 continued to drink as they usually do.  Their drinking patterns varied from a "low" of 8 bottles of beer to a shocking 64 beers a week.  (Those Brits do like their pubs!)


They analyzed the results of lifestyle questionnaires, ultrasounds and blood samples and found some remarkable differences in just that short period of time.  The abstainers saw their blood glucose levels fall by an average of 16%.  Blood glucose is a …

Why Did Glenn Frey Die?

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The untimely death of Glenn Frey, one of the talented leads in the famous Eagles band, has left his fans saddened and the music industry has lost another great.  Early reports from his publicist say his death was from Ulcerative Colitis, Rheumatoid Arthritis and Pneumonia. You may wonder how someone dies of pneumonia in 2016.

At the turn of the Century, before we had antibiotics, pneumonia was considered "the old man's friend".  A slight pulmonary infection often led to death and I remember my grandmother saying; "Cover up or you'll catch your death of pneumonia".  In her day it was serious and fatal.  But now we have effective antibiotics to treat pneumonia and it mainly effects people who are very young, immunocompromised or who have multiple other organ failures.  So what may have happened to Mr. Frey?

Both Rheumatoid Arthritis and Ulcerative Colitis are treated with medications that can affect the body's natural immune system.  Because they are bot…

Go Ahead And Eat Grapefruits With Your Statin

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Statins are the most commonly used medications in the U.S. and are used by millions of people to reduce cardio-vascular disease, heart attacks and stroke.  For patients who take the three most commonly prescribed, Simvastatin, Lovastatin and Atorvastatin, the current medical advice is to avoid grapefruit juice while talking these medications. Grapefruits and grapefruit juice increase the concentration of these drugs in the body.  But a new study published in The American Journal of Medicine says we have it all wrong!  Patients who like grapefruits should go ahead and enjoy them with their statins.  Here's what the researchers say:

Fresh grapefruit juice contains bergamottin which has an effect on an intestinal enzyme (CYP3A4 for you chemists) that prevents the breakdown of certain statins.  The consequence is that the blood level of these three statins are increased when taken with grapefruit juice.  We've known about this interaction since is was discovered  by accident in 1…