Saturday, September 10, 2016

How to know if something is infected



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 start oozing under the scab that is forming.  If any of that occurred, it would be time to get it checked out.

As we get older (ahem!) we heal more slowly.  Cuts and lacerations might take weeks to heal, rather than the days of healing that occurred when we were youths. This is normal also.

The best thing to do when you get a scratch or cut is to wash it with regular soap and water.  Antimicrobial soaps do not offer any advantage and sterile water is not needed.  Cover the wound with a bandaid or clean gauze.  If it is a deep cut that continues to bleed, that is a sign that sutures (stitches) might be needed.  Otherwise just let your body do its magic and heal.`


Wednesday, July 6, 2016

Why Can't I Have a Dentist EHR?



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 purchase, install, and maintain.  The user interface is so busy and non-intuitive that to show it to a patient would be distracting and eye-numbing. The number of clicks, scrolling and entries needed to see even one piece of information makes it nearly impossible to use as education for a patient. In fact it is so time consuming and such a burden in the exam room that an entire new industry has sprung up to deal with the EHR called "scribes". It an attempt to free up the beleaguered physician and restore patient-physician eye contact and connection, many doctors are paying for a 3rd person to be there in the room just to record the visit notes and do the electronic paperwork.


My dentist was done charting by the time I left the exam room. I, on the other hand, face hours of after visit typing into my EHR, often long into the night. Even a simple ordering of an e-prescription requires about 6 clicks, entering diagnoses, proper ICD-10 codes,  dealing with alerts that tell me that diagnosis does not qualify to be covered by Medicare, secure sign-ins and special authorizations needed for schedule 2 and 3 drugs, and on and on. That's just one function and one medication. Multiply that my thousands.


No doctor wants to go back to paper charts but we shouldn't accept the current stock of medical electronic health records.


The dental EHR was clealy developed for true dentist workflow and user satisfaction. The medical EHRs were developed for billing, coding and government requirements. I want what the dentists have. And I bet my patients do too. 

Tuesday, May 24, 2016

What is Shingles?

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.

The first signs of the rash
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 lasts in the nerves long after the rash has resolved.

We treat Shingles with antiviral medication (Valcyclovir ) and pain control.  People over the age of 60 are recommended to get Zostavax vaccine to help prevent an outbreak.  It reduces the chances of Shingles by 51% and even higher reduction of post-herpetic neuralgia pain.

No special tests are needed to make the diagnosis. This is another reason everyone should have a primary care physician who can make the diagnosis and get the patient started on treatment.

Monday, May 16, 2016

Transparency Price Tools Did Not Lower Health Costs

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 surgery.  The majority of searches was for services over $500 and more than  half had price estimates over $1250.  They compared the spending of people who had access to these price estimators and those who did not.  They even found that people who had the price estimators, had increased out-of-pocket health care spending compared to those who did not. The study matched the two groups for age, sex, health condition and type of insurance plan.

What can we make of this strange result? First, only a small percent of employees who were offered the tool even used it.  Obviously it has to be used to be effective.  Maybe it was too cumbersome or difficult to use. Another reason may be patient perception of quality. Other studies have shown that patients erroneously think higher price means higher quality. If patients think a lower cost health service is inferior, they might shy away from it.  And since most of the searches were for expensive services, patients might think they were already using their entire deductible so they may as well go for the expensive ("perceived higher quality") medical service.  

It is also quite possible the health care is NOT like going to the grocery store or other retail purchases. Patients may not like price shopping and comparing when it comes to something as important as their health.  A recommendation from one's trusted physician about who to see and where to go may override a price comparison website.  Health care can be scary and baffling to many people and the risk of making the wrong choice is much more serious than buying the wrong Ketchup at the market.

This important study showed that we may need to look at other ways than price transparency tools to help patients bring down the cost of health care in the United States.

JAMA, May 3, 2016,Vol 315

Friday, May 6, 2016

Frozen Vegetable Recall



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 number of outbreaks in the recent past in milk, cheese, ice-cream and even caramel apples. The largest outbreak was from cantaloupes in 2011.  The current frozen vegetable outbreak has been tracked to CRF frozen foods packing plant in Pasco, Washington.  Since May 1, 2016 approximately 358 consumer products sold under 42 separate brands were recalled.


What can you do?  For now, I would advise you not to purchase frozen fruits or vegetables unless you know the source.  Both organic and non-organic were involved. The affected products have the "best by" dates or "sell by" dates between April 26, 2016 and April 26,2018 so check what is in your freezer and toss them if these are the dates. 

Monday, May 2, 2016

Are Drugs Past Expiration Date OK?

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 is one that should be replaced if expired.

So the answer to the above questions about using expired medications are here:
1.   Is there a problem with safety?  No. There are no reports of toxicity.
2.  Will it still be potent?  If the medication is in a cool, dry place in the original container, it is probably 90-100% potent and good for at least a year after expiration and maybe even up to 5 years later. Exceptions would be Epi-Pen, liquid antibiotics and insulin.


 

Monday, April 4, 2016

Marijuana Use Lowers Metabolic Syndrome


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 and present use and how much marijuana they used. They also looked at race, socioeconomic level, cigarette and other drug use and age. They found that 60% of the subjects used marijuana at some point in their lifetime, 20% used within the last 30 days. The majority (53.2%) of middle-aged adults were past users.

The results showed a lower mean waist circumference (a measure of dangerous obesity) among marijuana users compared to those that never used. Despite the fact that marijuana contains cannabinoids and appetite-stimulating compounds that attach to receptors in the brain and other parts of the body, weight gain was not increased in users. The study also showed higher (good) HDL cholesterol levels in users compared with never users and lower glucose levels in past and current users. The one element that differed was systolic blood pressure that was higher in marijuana smokers, compared to non-smokers.

 In summary, current and past users of marijuana were associated with a lower prevalence of metabolic syndrome and most of its components, except for systolic blood pressure. Older adults that previously used cannabis had significantly less metabolic syndrome and younger adults who currently used were 54% less likely than never users to have metabolic syndrome.  

This study does not answer the big question "Why". We need to look at biologic pathways to figure out those relationships. But the more we know about the effects of this commonly used plant on our health, the better decisions can be made about legalization or medical use. 


Sunday, March 20, 2016

Best Practices and When Your Doctor Says No


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 who wants to be helped and resist the request. That is why 70% of patients with acute bronchial bronchitis get an antibiotic.

  •  (No antibiotics for pharyngitis unless testing positive for Strept) Only 15% of acute sore throats are caused by bacterial infections. The remainder are viruses that do not respond to antibiotics.
  •   (No antibiotics for acute rhinosinusitis AKA: Sinusitis) More than 4.3 million adults are diagnosed with sinusitis annually and 80% receive antibiotics despite the fact that it is usually a self limited illness caused by a virus, allergy, or irritant that causes inflammation in the tissue in the nose and sinus cavity. A bacterial cause usually lasts longer than 10 days and is associated with fever.
Doctors are often put between a rock and a hard place if they follow evidence-based guidelines. We want to please them and help them and when we don't, patient satisfaction scores go down.  But some studies are showing that doctors who offer symptomatic relief and take the extra time to explain why antibiotics are not needed can still get good survey scores.

According to the Annals of Internal Medicine, reducing inappropriate antibiotic use will improve quality of care, decrease health care costs and preserve the effectiveness of antibiotics.
           

Saturday, March 5, 2016

Zika Pandemic - Early 2016


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 fetuses and newborns.  New research shows that the Zika virus affects developing cells in the brain's cortex.

The Zika virus can live in semen longer than blood and we believe it can be sexually transmitted from an infected man to a partner.  We don't know if women can transmit it and we don't know if it can be transmitted orally.  Pregnant women or women trying to get pregnant are advised not to have sex with  partners from endemic areas without protection.

At this time there are no reports of Zika being spread from animals.  At this time there are no reports of Zika transmission in the United States and the only Zika infection is from travelers from endemic areas.








Saturday, February 13, 2016

Geographic Tongue



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.


Wednesday, February 10, 2016

Tongue Image Challenge

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.

Thursday, January 21, 2016

The Health Benefits of Dry January


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 key factor in the development of diabetes.  They also found that those who stopped drinking for 5 weeks lowered their liver fat (seen on ultrasound and blood tests) by 15-20%.  Fatty liver is caused by obesity and excessive alcohol intake and is a major health problem and cause of chronic liver disease. 


And what about people who want to lose weight, like my beach bound hairdresser?  It turns out her "Dry January" was the thing to do.    There are about 120 calories in a 5oz glass of white wine.  Only 1.5oz of tequila or vodka contains 96 calories.  A 12oz bottle of beer is 150 calories.  By cutting out alcohol, you eliminate thousands of empty calories.  Some abstainers reported more energy and that means more activity, which also sheds pounds.


The researchers don't know if one month off alcohol translates into long term better health.  We know from other studies that the key is making changes that last and are part of our lifestyle.  Rather than a dry month, it would be better for our health if we cut back on alcohol consumption all year.  

Monday, January 18, 2016

Why Did Glenn Frey Die?


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 both "auto-immune" diseases, effective medications turn off the body's cells that cause the disease but these same medications also turn off the white cells and macrophages that fight infection.  It is always a delicate balance when we use medications that affect the same cells that cause certain disease flare-ups  as well as prevent infection from taking hold.

It is just speculation without knowing  Mr. Frey's medical history, but he may have been too immune compromised to fight off the pneumonia...even with the best antibiotics.  Rheumatoid Arthritis and Ulcerative Colitis can be life altering themselves, but death from infection (pneumonia) is often what happens if a person is very ill.

It is important for older people or persons with chronic diseases to get a pneumonia vaccine.  Babies are also immunized with this vaccine.  This vaccine is effective in nearly 100% of Streptococcal Pneumonia strains of bacteria.   But there are dozens of other bacteria and viruses that can infect the lungs also and cause pneumonia and in a person who is immunocompromised, as I suspect Glenn Frey was, the body can become overwhelmed with infection and sepsis.  Even the most heroic advances in medicine can fail in some cases.

Glenn Frey was a wonderful musician and has left behind a great body of work that continues to bring joy to the listeners.  RIP, Mr. Frey


Thursday, January 14, 2016

Go Ahead And Eat Grapefruits With Your Statin



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 1989 when researchers were studying another drug that is affected by this enzyme.  Since that time, patients have been advised to avoid grapefruit juice.  But since we know that standard doses of these medications reduce LDL (bad) cholesterol by 37%, doubling the dose reduces it by 43%.  So we should think of grapefruit juice as an enhancer of Statins.  Each reduction of LDL in the blood further reduces risk of heart disease.

The perception that grapefruit juice is contraindicated for people on statins is misleading and the conclusion from this study is that it can enhance the positive effects of these three statins.  Grapefruits are low in calories and high in Vitamin A and C and with a low glycemic index they have a positive effect on blood sugar.  This is good news for people who like grapefruit juice and who take statins.
There is no reason to avoid them.

(brand names are Zocor, Mevacor and Lipitor)