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.