Sunday, May 30, 2010

Remote Telemedicine is Coming Soon to You

Imagine this, Dear Patient.  You wake up and feel like you were hit by a truck.  Your head aches and when you look in the mirror you are shocked to see a rash running along your left ribcage.  It is slightly prickly and tender and you are freaking out.  To make things worse, you are in day two of a long awaited vacation and hundreds of miles  away from your favorite doctor.

What do you do?  Try to find an emergency room? Go back to bed and hope it is a bad dream?

It won't be long before you can log into your computer (with a polycam), dial up your favorite doctor and have a telemedicine visit.  The physician can get your history and you can even show her the rash.  Of course you have an electronic thermometer with you and you show the doctor that it is just a little elevated.  Your doctor diagnoses Herpes Zoster (shingles) and prescribes medication to be started immediately.  She electronically submits the prescription to the closest pharmacy to your vacation destination.  You click the PayPal button and pay the charge for the visit.

Telemedicine is the next "big thing" that will revolutionize how we practice.  We already use remote monitoring to provide expert care in the ICU of hospitals.  Rural hospitals use telemedicine for specialty consults and some innovation is happening with home monitoring for patients with chronic diseases like heart failure.  Some States are using telemedicine for prison care and to avoid the expense of transporting prisoners to doctors for evaluation.  Using telemedicine to save the time and expense of an office visit for problems that do not require an extensive physical exam just makes sense.

Will online care replace the doctors visit?  Never.  There are some conditions and problems that require face-to-face interaction and physical exam.  But telemedicine can provide quick and easy access for some conditions and the ability to monitor patients at home can keep millions out of the hospital.

I for one, embrace the change.

Saturday, May 29, 2010

Having a Baby in 1930

Flash back to 1930.  Look at this bill for childbirth.  10 days in hospital - $50
Circumcision - $3
Total - $53

According to Forbes, the total charge in 2009 for an uncomplicated birth with 3 day hospital stay at Cedars-Sinai in Los Angeles was $36,625.

That seems a little high but good luck trying to find out the actual charge ahead of time.  You better round up between $7,000 and $15,000 and that will not include the circumcision or prenatal visits, ultrasounds and other modern perks.  It may or may not include the epidural which will likely be billed separately by the anesthesiologist.

Of course the obstetrician pays between $100K and $200K for annual malpractice insurance (depending upon the State) to make sure you have a perfect baby.  Nothing is the same as 1930...except the great depression and the current great recession.

Friday, May 28, 2010

Brush Your Teeth or Risk Heart Attack

The British Medical Journal reported on a study of  toothbrushing and found that people with poor oral hygiene had an increased risk of cardiovascular disease and heart attack.  We have known for the last two decades that inflammation plays an important role in atherosclerosis.  Markers of low grade inflammation like C reactive protein, are also shown to be higher in heart disease.

The Scottish Health researchers looked at the general population (n-11,869) and followed a large subset with questions about their oral health.  They asked about frequency of dentist visits, tooth brushing, and controlled for many co-variables such as general activity, hypertension, smoking, height and weight.  They also collected blood for studies of  C-reactive protein as a marker of inflammation.  They removed from the analysis 3685 participants who were edentulous (no natural teeth) and 386 with existing cardiovascular disease.

This elaborate and lengthy study showed that tooth brushing is associated with cardiovascular disease and subjects who brushed their teeth less than once a day had a 70% increase in heart disease compared with people who brushed twice a day.  The inflammation that periodontal disease causes, is directly related to increased C-reactive protein and increased heart attacks.

Leave it to the Scotts and the Brits to remind us to brush and floss every day.

BMJ 2010;340:c2451

Thursday, May 27, 2010

Viagra and Hearing Loss

A study published in the Archives of Otolaryngology-Head & Neck Surgery reports that men who have taken sildenafil (Viagra) may experience sudden sensorineural hearing loss.  More than 2 dozen reports have indicated an association between sudden hearing loss and taking the phosphodiesterase type 5 inhibitor, Viagra.

This study compared subjects with and without hearing loss and looked at whether the men had used the erectile dysfunction medication before the loss.  During a 2-year period, 11,525 men age 40 and older provided information in 5 total interviews.  They were asked about health, health care activities, prescription medications and any hearing difficulty and use of hearing aids.  The overall incidence of hearing impairment was 17.9% and, as one would expect, it increased with age.

The results showed that men taking Viagra were more than twice  as likely to suffer hearing loss, even after controlling for other health factors.  No hearing loss was associated with Cialis or Levitra, but 80% of the men who used medication for erectile dysfunction took Viagra, so that may have affected the results.

Scientists do not know how or why the hearing loss occurs in some men.  The phosphodiesterase type 5 inhibitors may affect proteins that damage cochlear hair cells.  They may also promote congestion of nasal erectile tissue, which can then elevate middle ear pressure.   There has been an FDA warning on these drugs potentially triggering hearing loss since 2007.

Sales of Viagra, Cialis  and Levitra continue to rise worldwide. 

Wednesday, May 26, 2010

Yoga Helps Cancer Survivors

Patients who carry a diagnosis of Cancer can be heartened by the results of a study that will be presented June 5 at the upcoming American Society of Clinical Oncology Annual Meeting.  The researchers found that the practice of Yoga helped cancer survivors improve sleep quality and reduce fatigue.

The lead researcher, Dr. Karen Mustian, professor of radiation oncology and community and preventive medicine at the University of Rochester in New York,  followed 410 patients who had already completed treatment for cancer but who experienced sleep disturbance that required medication.  Seventy-five percent of the patients had a diagnosis of breast cancer and none had sleep apnea.  The patients who started a yoga program (75minutes twice a week), were able to decrease their use of sleep medication by 21% after just four weeks,  compared with the control group who did not do yoga.  The yoga patients also experienced less fatigue and a reduction in daytime sleepiness.

It seems like a simple thing, but improving quality of life by using complementary medicine is a very important treatment.  There are millions of patients who have been treated for cancer who might benefit from starting yoga.  All physicians who treat cancer patients should recommend yoga, as well as writing prescriptions.

To read the abstract go here.

Photo is Grace Cheng, RN, one of the fantastic nurse volunteers in Haiti,  doing her yoga to stay centered after working all night providing relief medical care.

Friday, May 21, 2010

Answer to Medical Quiz

The answer to yesterday's medical challenge is #1 Basal Cell Cancer. These cancers are often slow growing and have a pearly appearance.   Basal Cell Cancers are easily removed by excision.

This group of Basal Cell Cancer's shows the different ways they can appear. The only way to confirm the diagnosis is by biopsy.

(photo from WebMD)

Thursday, May 20, 2010

Doctor Pricing Upfront and Transparent

A company in the Los Angeles area called HealthyPrice has posted prices on its website for 400 procedures and over 100 physician office visit fees.  For patients without insurance or who have high deductibles, the ability to go online and really "shop" for the best deal is something long overdue.

Here is how it works.  The patient goes online and chooses the provider for the test.  It might be a lab study or an MRI or a colonoscopy.  The patient pays in advance and receives a billing code to bring to the physican's office.  HealthyPrice handles the payment, minus a billing fee, and pays the doctor or lab via check or Paypal.  The doctor has no paperwork to handle and HealthyPrice has an arrangement in place for discounted laboratory testing.

Obviously people are not going to be able to use this type of discount service for emergencies, nor does it guarantee any type of quality care.  But for blood tests, imaging tests or even some procedures, knowing what it will cost upfront and being able to chose is great.  The idea that patients have no idea what something will cost until after the fact is crazy.  I do think U.S health care is the only "industry" that can get away with this.  Alternatively, for the doctor,  U.S. health care is the only industry that can get away with not paying the bill at all AFTER the service is rendered.  It is a system that is set up to benefit no-one except the middle man.

I have long been an advocate of price transparency in health care.  This is a small  step in the right direction.

Skin Lump - You Be the Doctor

This 71 year old man comes to the office with a lesion on his cheek that has been there for several years. He thinks it is getting larger and it does not bleed or hurt.  You are the doctor.  What is your diagnosis?

1. Basal cell carcinoma
2. Squamous cell carcinoma
3. Wart
4. Seborrheic keratosis
5. Melanocytic nevus

Make your diagnosis in the comments and the answer will be posted tomorrow.

(Image from Consultant, May 2010)

Tuesday, May 18, 2010

What Women Should Know About Fibroids

Fibroid tumors are benign growths on the muscular wall of the uterus.  They can be tiny in size, like a marble or grow huge and fill up the entire uterine cavity.  Some fibroids are as large as a five month pregnancy.  Here are some facts that women should know about fibroids:
  • Fibroids can occur at any age but are most common between ages 40-50.
  • Common symptoms are prolonged or heavy periods, pelvic pain and pressure, abdominal swelling, pressure on the bladder leading to frequent urination, pressure on the bowel leading to bloating and infertility  (note: these can also be the symptoms of ovarian cancer so seeking a diagnosis is critical).
  • Fibroids are almost always benign (non cancerous). Fibroids do not increase the risk of cancer.
  • There is a possible link between fibroid tumors and estrogen production and 40% of women over age 35 have fibroids.
  • Women who are African-American or who have a mother with fibroids are more likely to get fibroids.
  • Women who are overweight or eat red meat are at higher risk for fibroids
  • Fibroids are diagnosed with an ultrasound and sometimes MRI.
  • Uterine fibroids can be treated with surgery like hysterectomy or myomectomy (removal of just the fibroid).
  • Embolization is another way to treat fibroids and has an overall success rate of 94%.  It is done through a small incision and an agent is injected into the artery that cuts off the blood supply to the fibroid.  The fibroid shrinks away
Women can learn more about fibroids by visiting here and learn more about treatment with embolization by visiting here .

Saturday, May 15, 2010

What You Can Do to Lower Cholesterol

Your doctor has just informed you that you have "hyperlipidemia"  or high cholesterol.  She is mentioning lipid lowering drugs (statins) but you said you want to try some things on your own first.  She agrees and you will recheck the blood levels in 3 months.  What are you going to do?  The advise is all over the ballpark and your google searches come up with various supplements and diets that are confusing and overwhelming.

EverythingHealth is here to give you specific recommendations, based on evidence,  that will help you lower cholesterol.
  1. Decrease saturated fats in your diet to less than 7% of your calories and increase your polyunsaturated and monounsaturated fats instead.  Start reading labels. Teach your kids to read labels.
  2. Eat more fiber, for instance 3oz of oats a day or use a psyllium supplement.
  3. Eat almonds, walnuts or pecans every day. (only 1-2 oz which is about 10-12 nuts)
  4. Increase your soy protein like tofu or soy foods to replace meat.
  5. Limit alcohol drinks to 1-2 a day.
  6. Increase consumption of plant stanols and sterols by substituting  (1 oz) buttery spreads for butter or margarine in your diet.
  7. Follow a Mediterranean diet where the main dietary fat is olive oil. The mainstay of Mediterranean is vegetables, whole grains, fish and tree nuts with small amounts of red meat, dairy, eggs and poultry.  Look at your plate.  If meat or poultry is the largest item, it is not Mediterranean.
  8. Increase Omega-3 fatty acids in the diet by eating salmon or tuna twice a week or using a supplement on other days.  Why? Go here and here for details and evidence on the heart healthy benefits of Omega-3.
  9. Do aerobic (sweating, heart pumping) exercise for 120 minutes a week or more.  (that is 17 minutes a day or divide it up into several longer exercise segments)
There it is.  When you doctor says the key to health is "diet and exercise" this is what she means.

Friday, May 14, 2010

The Winners!

Announcing the winners for the Subway gift cards.  Congratulations to SML,  Anon2 and Craig.  Each of you will receive a gift card in the mail if you will contact me and send me your address.  Enjoy the free healthy meals from Subway and EverythingHealth.

Thursday, May 13, 2010

Keeping Kids Safe On Social Networking Sites

My mom came from the McCarthy communist hunt era.  She would always say,"don't write anything you wouldn't want everyone to read and don't sign anything without reading might be admitting you are a communist".  As a kid, I had no idea what she was talking about but those words stuck with me.  I am careful about what I write and I am careful with emails and the internet too.  Unfortunately our kids don't have the same concerns and they need help to stay safe on social networking sites.

Kids as young as 10 are now on Facebook or other sites where they sign up and communicate with their friends and strangers.  It's time to have the "safe network" talk...even before you have the "safe sex" talk. Here are a few tips to help:
  1. Only join sites where you can control the users or "friends" who view your information. Help kids with the security settings to control the restrictions and information.
  2. Keep information private.  Don't post your address, phone number, any private numbers like social security.  Even names of the school or where you hang out or work should be kept private.
  3. Pick a different screen name. Don't pick one with sexual innuendos.
  4. Post only information that you would want a teacher, employer, college recruiter, grandmother to see.  Even restricted sites are not guaranteed.
  5. One something is posted, it cannot be taken back.  "Delete" is not guaranteed and posts can be copied and reposted on other sites.  The internet is forever.
  6. If you post a photo, make sure it is one that is tasteful.  Photos can be altered but there isn't much you can do about that except not post a photo.
  7. Never flirt with strangers.  Period.
  8. Never meet someone in person that you don't know.  If you consider this rule you have broken rule number 7.
  9. If something seems wrong on line, trust your gut and tell an adult.  Cyber-bullying, scams, hoaxes are everywhere and should never be on social networking sites.
  10. Never click on ads or other appealing pop-ups.  This is a way to open up your computer to viruses and to let others get at your private information.
I think Social Networking is here to stay.  Kids never use the telephone or email any more.  They text their friends and chat on the computer to large groups of friends.  For more information check out
On Guard Online, or Get Net Wise, or  Wired Safety.  They provide good info for parents in keeping kids safe on social networking sites.

Wednesday, May 12, 2010

Working Overtime Linked to Heart Disease

The European Heart Journal studied 6000 British civil servants and followed them for 11 years.  They found that working an extra 3-4 hours a day is associated with increased coronary heart disease.  The researchers controlled and adjusted for lifestyle, cardiac risk factors and other factors that would skew the results and still found that people who worked 3-4 extra hours a day had a 60% increase in risk for heart disease.

These results were for both women and men (ages 39-61) and the outcome measure was fatal myocardial infarction (heart attack) and non-fatal MI and proven angina.  Other risk factors like smoking, elevated lipids, diabetes made no difference in the results.

The conclusion:  "Overtime work is related to increased risk of incident coronary heart disease independently of conventional risk factors. These findings suggest that overtime work adversely affects coronary health".


Check it Out

Two things:  Head over to The Examining Room of Dr. Charles for this weeks Grand Rounds roundup and also scroll town a bit and enter the Subway free card give-away. is good for your health.

Monday, May 10, 2010

Some Gender Stereotypes are True

I get good info from my blog followers and SJ sent me a link that was pretty interesting.  Here are some gender stereotypes that have a basis in science that might be a surprise to you. 
  1. Women spend lots of time with colors, calling them mauve, pure ivory and ecru.  Men see pink, white and yellow.  Are women just color obsessed?
 Science tells us that color blindness only happens in men because the gene for seeing red is on the X chromosome.  Women have 2X's and consequently have a 40% chance of having a wider range of color perception.  We really do see those differences in color.

    2.  Women love to talk and process and talk some more.  Men get to the point and talk only to  solve problems (or clam up completely...right ladies?) 

Science tells us that the brain locus for language is 17% larger in women than in men.  The corpus callosum may also be larger in women (there is some debate about this) and this connects the right and the left hemisphere, allowing for more language processing.

     3.  Women can't hold their liquor.

Science tells us women metabolize alcohol differently than men and it isn't just because of size.  It is because women have less water to fat content in their bodies and when men slam down drinks, they are diluting the alcohol with some of their body water.  Women also produce less alcohol dehydrogenase, the substance that breaks down alcohol in the body.  They feel drunk more quickly and stay intoxicated longer.

    4.  Women are more emotional than men. 

Science tells us that women have a larger brain deep limbic system than men and this allows them to be in touch with their feelings and to express emotion.  Women connect better and it also opens women up to depression during times of hormonal shifts.

There are other ways men and women are different that are not based on science.  For a lighter look at the differences...go here

Have a thoughtful day!


EverythingHealth Giveaway Contest

We all know how important a healthy breakfast is.  But what do you do if you are on vacation? Or have a kid rushing to an early morning soccer or band practice?  What about those times that mom is just not available to get it together?   EverythingHealth loves a contest with a free healthy giveaway and here is your chance to win!

Subway (yes, that fast food subway!) has introduced a nutritious fast breakfast egg  wheat muffin melt that will solve those times when you just want a breakfast "on the go".  The Egg White Muffin Melt has 140 calories and 3.5 g of fat.  The Black Forest Ham Egg White Muffin Melt has 160 calories, no transfats and 4g of fat.   Add apple slices and Dannon Light Yogurt and you are starting the day off right.

So tell us why you want to win a Free $5 Subway eat fresh gift card and we will award three (yes three) winners.  Comment below and the winner will be announced Thursday so check back every day.

Sunday, May 9, 2010

Older Mothers

An EverythingHealth blog fan requested that this post from 2007 be reposted in honor of Mothers Day.   I've updated it a bit and here it is:

Something has dramatically changed in the appearance of parents from the 1960s and the parents of children in the 21st century. Looking around at the adults with kids at schools, parks and ballgames, I can't help but think, "Gee, is that the parent or the grandparent?" Most of the time, it is the parent. The older parent (gray-haired, donned in Dockers, holding a cup of Starbucks coffee) who is holding hands with a fourth grader or pushing a stroller,  seems to be the norm these days at least in the Bay Area.. Perhaps I am more aware of this phenomenon because I am one of these older parents. But I have an unusual perspective because I was also a "young mom" in 1969 when I had my first child, a daughter. There is a 26-year time lapse between my two children, as my son was born in 1995.   I feel distinctly qualified to give one perspective on being an older mother.

Most medical journals and lay articles regarding older mothers (defined as over 35!) address conception and childbirth. We know about the aging ovary, increase in multiple births and c-section rates. That's all well and good, but what about the lifetime that occurs after the baby is born?

I listen to questions from my female patients who are in their late 30s or 40s and want to get pregnant but have concerns and fears. Since I've experienced childrearing at both ends of the reproductive spectrum, I thought it might be helpful to address common myths and urban legends about older parenting.

Myth #1 - The older mom won't have the energy or patience for childrearing.
The sleepless nights during the first few months and sleep deprivation while waiting for your teen to come home are just as difficult whether you gave birth at 20 or 45. There is no proven data that "energy" declines with age, and in fact, an older, wiser parent might focus and conserve her energy better than a young mom. The wisdom that comes with life experience lends itself to more patience and acceptance, not less.

Myth #2 - The older mom will be less playful and more rigid.
Of course this depends on the personality more than the age, but many older moms are highly educated, have an understanding of childhood development and are more willing to participate in their child's growth stages. I spend more time building Legos, playing Stratego and reading with my son as an older mom than I did with my daughter as a young mother.

Myth #3 - The older mom will miss her "me time" because she is more used to being with adult friends.
Not true. Older moms have already traveled, stayed out late, and hung out with friends and they are often ready to be less selfish and focus time on a child. Also, the older mom is more likely to have better finances so she can afford more child care and assistance than the younger parent. I have many more options now and much better help than I did when my daughter was young.

Myth #4 - The older mom will be a more anxious mom.
The older mother probably has a more realistic view of life based on the experiences of her 20s and 30s. She knows what can go wrong, but she also has the experience of how to deal with challenges. She may well be less anxious than a young mom who is distracted by competing issues.

 Myth#5- The older mom will have health problems that interfere.
 There is no evidence that older parents' age-related health issues interfere with their parenting in comparison to young parents. Many older moms are more health conscious and knowledgeable about diet and exercise and have already stopped practices that incur harmful health risks. I have no data, but I bet older moms use seat belts, exercise and floss more regularly than younger moms.

There are hundreds of variables that combine to make a "good parent," and age is low on the list. As an older mother, I am more focused, aware and emotionally present than I was in my 20s. My actions now are more deliberate and I have many more resources at my disposal.  I don't feel alone because in the Bay Area so many parents look my age.  I think I'm a better parent now than I was 26 years ago and the joy I experience has been enhanced, not diminished, with age.

Mothers Day

Happy Mother's Day to all of us who are mothers or who have a mother.  That is everyone!!!  For some touching thoughts, check out today's Post Secret.  It's  Mom's Day tribute.

Saturday, May 8, 2010

Things Your Kids Will Never Know About

The one thing we can all agree on is that nothing stays the same. We marvel at the customs and habits of our great grandparent's era and everything looks so grainy and antique.  Here are a few things that we took for granted that our kids and grandkids will never see, except in old photos:

  • a phone book
  • a rotary phone, a pay phone stand and eventually any land line phone
  • a record or turntable (so far preserved by D.J.s in clubs)
  • a car radiator
  • an instant (kodak) camera
  • a typewriter
  • carbon paper
  • sony walkman 
  • thick polyester pants (we hope)
  • glass reusable syringes
  • library dewey decimal system cards
  • the milkman, or iceman (I did see an ice-cream man the other day)
Let me know what I've missed. What are some things your kids (grand kids) will never know about?

Thursday, May 6, 2010

Gulf Coast Oil Spill

On Day 17 of the tragic oil spill from the drilling rig in the Gulf of Mexico, this is what it looks like from the air.  Oil continues to pour into the Gulf from the undersea well at about 210,000 gallons per day.  The pinkish oil is now at the shore of New Harbor island, a national wildlife refuge and nesting ground for sea birds.  West of the mouth of the Mississippi River, hundreds of dead jellyfish were seen.  Shrimping has been suspended in the area.

Louisiana's secretary of wildlife and fisheries is credentialing out-of-state veterinary specialists to help rescue oiled birds and animals.  There is concern that the slick could spill around Florida into the Atlantic Ocean and foul beaches and kill marine life on the East Coast.

There has been no success in stopping the flow of oil at this time.

(photo: NYT)

Tuesday, May 4, 2010

Men With Penis Enlargement Banned From Police Work

Ok, leave it to EverythingHealth to bring you news you can use.  Look, I scour the health news so you can be up to date and informed without leaving the comfort of your computer chair.  Papua is the largest province of Indonesia and men there use a local technique to achieve penis enlargement.   They wrap the penis with leaves from the "gatal-gatal" (itchy) tree which causes the penis to swell.  When a man applies to the police force he is asked whether or not his organ has been enlarged and if it is, he is considered unfit to join the police or military.  The ban was applied since the unnatural size causes "hindrance during training", according to a police spokesman in Jakarta.

Many of the men in Papua New Guinea wear Penis Sheath Gourds for ceremonies.  I wonder how the police verify if a man has used the penis enhancer.  I can see how the gourd might get in the way of meaningful work but most likely it is a way of making sure the local natives do not get the plum jobs.

Sunday, May 2, 2010

Your Genes Determine Which Diet Works

Why do some diets work better than others?  Why can your best friend lose 10 lbs with a low carb diet and your weight just hovers?  Why can some people eat just about everything, and still stay skinny?  It's all in the genes.  Mindy Dopler Nelson, Ph.D., of Stanford U. reported the results of her study at the American Heart Associate conference.  She found that a single nuceotide polymorphism caused women to loose 5X as much weight on the Atkins diet, compared with women who did not have the gene.

(A single nucleotide polymorphism is a DNA sequence variation that can create a copying error for proteins that change how a gene works and can be the site of certain disease processes)

Dr. Nelson studied women on 4 popular weight loss diets.  (Atkins, Zone, Learn and Ornish)  Within each of the diet groups, there were women who had lost over 15kg as well as people who gained 5 kg.  These women had no statistically significant differences in body mass index, blood pressure, cholesterol levels, insulin or glucose.  The only difference was the genotype.

Remember, that everyone loses weight when you limit calories.  But how you get those calories seems to make a difference in how much weight you lose over time. Some of us are low-carb losers and some are low-fat losers.  At this time there is no way to know which one you may be if you don't know your genotype.  Will this be the wave of the future? 

Dr. Nelson acknowledged that the trial was relatively small and that the findings need to be confirmed in a larger trial.  For now if you aren't seeing your weight loss with one type of diet, it might be time to switch to another. 

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...