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Showing posts from 2012

Remembering 2012 - Top Ten Health

As 2012 draws to an end, EverythingHealthwill reflect on our top 10 health and medicine events to remember.  

1.  The world did not end on December 21 as predicted by the Mayan Calendar,  but a new Age of    Enlightenment may just be beginning!!!   "Be the change"

2.   The Supreme Court upheld the Affordable Care Act ( ObamaCare) and President Obama was re-elected to carry out the most significant health care legislation since the creation of Medicare.

3.   As of this writing the United States "fiscal cliff" has not been averted and an automatic 26.5% cut in Medicare pay for physicians is part of that cliff.  Not good for seniors!

4.   Deaths from fungal meningitis and joint infections continue to be announced as the result of contaminated injectible products from the New England Compounding Center.  More stringent regulations and authority to the FDA will likely result.

5.   Nine Medical Societies published a compendium of 45 clinical tests and procedures that ar…

Hillary Clinton and Subdural Hematoma

Addendum to the post below:  New reports show she may have a venous blood clot in a vein that goes to the brain, rather than a bleed under the skull known as a subdural hematoma.  The treatment is quite different as venous thrombi (clots) are treated with blood thinners.  The information below is still quite accurate but may not apply to Madame Secretary Clinton..... Secretary of State,  Hillary Clinton has been hospitalized with a subdural hematoma after fainting, hitting her head and suffering a concussion less than a month ago.  Here is a repeat of a blog I did a few years ago about "a bump on the head".

Even a minor blow to the head can lead to serious trouble. A close relative of mine is an active, sharp guy in his 80's. He was hospitalized a few weeks ago with an infection and like many older folks, he wasn't aware of how weak he was and he tried to get out of the hospital bed and go to the bathroom and "whoops", he slipped and fell. Hospitals al…

Lactose Intolerance in the Genes

National Public Radio (NPR) reported on a fascinating theory of Mark Thomas, an evolutionary geneticist at University College London.  He points out that we human beings all started out being unable to digest milk's dominant sugar, lactose, after childhood.  In fact, most adult mammals do not drink milk.  But 20,000 years ago,  people of Northern and Central European descent and certain African and Middle Eastern populations began developing lactose tolerance.  He theorizes that there was a strong natural selective pressure to allow those lactose tolerant genes to survive.  Drinking milk was an advantage to our species.

According to Thomas, milk was a "superfood" to early man.  It contains protein, calcium, fat and carbohydrates.  The ability to digest milk without developing diarrhea would give it's drinker an evolutionary edge.  The people who had the lactase mutation genes would survive the harsh winters, famines and even other illnesses that caused early death. …

Happy Healthy Holidays

I Wish That I Could Wrap Up Christmas
I wish that I could wrap up all the love and Holiday cheer That comes along with Christmas and with New Year's every year, Pack it in a pretty box and put it on my shelf And pull it down again each year and give it to myself. I wish that I could tie up all my favorite carols with twine, Wind around some ribbon, too, and for twelve months call them mine Until the next Yuletide came when the sounds again could be unfurled And untie every single one then give them to the world.

Medical Fraud - Lock 'em Up

When most Doctors and care-givers are trying to deliver "value" and keep costs down, it really chaps my hide to read about Medicare Fraud.  Here is the latest:

Dr. Michael Reinstein, psychiatrist in Chicago,  submitted at least 50,000 claims to Medicare and Medicaid, falsely stating that he provided "pharmacologic management" for patients at more than 30 area nursing homes and long-term facilities.  If that weren't enough, he also accepted kickbacks from Novartis, IVAX and Teva Pharmaceutical companies to medicate elderly patients with serious anti-psychotic medication.

The kickbacks go back as far as the 1990's and Dr. Reinstein had more than 1000 patients at a time on a rarely used medication called Clozaril.  Clozaril is typically used only as a last resort in treatment-resistant psychotic patients and is of particular risk to the elderly.  It is extremely rare to have a nursing home patient on Clozaril.   Reinstein was the largest prescriber of Clozari…

Health and Weapons

There have been eight mass shootings in the United States this year and at least 61 since 1982.  The Connecticut community of Newtown is grieving for it's 20 slain children and 6 adults.  The towns of Columbine, Tucson, Aurora, Oak Creek, Minneapolis and Clackamas, to name a few, are still  grieving for their lost children and adults to gun violence.  Now is the time to stop this craziness.

As president Obama said, "Surely we can do better than this."  This cannot be a political, Blue vs. Red, North vs. South, Right vs. Left issue.  It is every one's issue now.  As a nation we are not doing enough to keep our children safe.

The rifle used by Adam Lanza, the mass murderer in Connecticut and by James Holmes, who killed 12 people in a movie theater in Colorado in July and by Jacob Roberts who killed two people in a shopping mall last week,  was an AR-15 semi-automatic weapon. This means it can rapidly fire multiple high-velocity rounds.  These rifles, along with glock…

RxTimer Cap

EverythingHealth get's PR pitches on a daily basis...companies and PR agencies wanting me to cover their latest product, book, speaker or start-up.  You can't buy your way into my endorsement but I have found something that I tried and I want to share it with you.  It is a new smart cap that fits on a regular prescription pill bottle and it is called RxTimer Cap:

I know how hard it is for patients to keep track of their medications and it is the number one cause of preventable medical harm.  Medications are prescribed "once a day", "twice daily", "every 8 hours", "AM and PM with meals or any number of confusing regimens.  Many patients are taking 10 or more prescription medications A DAY!  Of course it is confusing.  I take just one prescription pill a day and even I forget if I already took it or not.  That's where Timer Caps come in.

They come in various sizes and just become the new cap on any pharmacy pill bottle.  Each cap has a buil…


The answer to yesterdays image challenge is #2 - Keratoderma.  This scaly condition affects hands and feet and can be congenital (passed on by genes)  or acquired.  There is a yellowish thickening and scaling of the skin and deep fissures can occur.   There are a number of different types of inherited conditions that have keratoderma and they are difficult to treat.  

Acquired keratodermas can be caused by eczema, lichen planus, psoriasis, Reiter's syndrome, drugs, internal malignancy and AIDS.   Besides treating the underlying disorder, the keratoderma is treated with topical solutions (salicylic acid 5%, lactic acid 10%, urea 10-40%) and topical retinoids.  Ulraviolet A (PUVA) may be needed in severe cases.

Be the Doctor and Make the Diagnosis

The EverythingHealth ever popular image challenge from New England Journal of Medicine is good this week because the photo is so interesting (and challenging).  Be greatful your feet do not look like this.  Please make the diagnosis in the comment section and check back tomorrow for the answer.  Is the condition?

1.    Nephrogenic systemic sclerosis
2.    Keratoderma
3.    Poikiloderma
4.   Punctate psoriasis
5.   Verrucae

You be the diagnostician and have bragging rights at your next cocktail party.

Primary Care - Trying to Do Right

Winter is officially here and  we are in the cold and flu season.  This is the time that patients get sick with viral illnesses and primary care doctors get even more frustrated as they try to do the right thing for patients.  What is the right thing?

 First of all we want to relieve suffering.  But we also want to do that without causing harm.  We  want to practice the best evidence-based medicine.  And evidence shows us that antibiotics and extra testing does not help the time course of a virus.  In fact, overuse of antibiotics drives drug resistance, increases the overall cost of health care and causes unintended side effects. 

I've seen comments on the internet that doctors are part of the "Business of Medicine" and they order tests and use "big pharma" drugs so they can "make money".  Well, folks, Primary Care Doctors make no money ordering tests or prescribing drugs.

 Zero!  In fact, it actually costs us money to do both.  Blood and imaging te…

Differences in Ethics of UK vs. US Physicians

A new report has come out from Medscape comparing marked ethical differences between United Kingdom physicians and US physicians.  The study surveyed over 25,000 US and UK  doctors on their beliefs about futile care, patient confidentiality, full disclosure to patients, and even informing patients about bad doctors.  It was surprising to me that doctors who are trained so similarly, have such divergent views when it comes to ethical issues.

On many of the questions the responses across the Atlantic were similar.  Only 10% (US) and 14% (UK) of physicians would hide information from a patient to bolster their spirit.  About a quarter of doctors on both continents might ration care to a younger, sicker patient rather than an older one.

An analysis of the findings points to differences in how doctors are paid as possibly driving the different values.  US doctors face more malpractice costs and face more litigation.  More US doctors work independently in a "fee for service" …

Hearing Impaired Tattoo

I love the creativity here.  This young lady has bilateral hearing impairment.  Great tattoo!!

Subdural Hematoma-One Patient's Experience

This email came from one of my patients  this morning.
I read your blog about technology helping you and wanted to share this story with you. 
 My husband has had ongoing migraines for weeks that never really stopped. Meds at home were not working to control the pain. He was suffering and his docs recommended a trip to the ER for stronger meds to stop the headache.

Friday night we drove to the Hospital where they got him into a bed right away and soon did a CT scan. The scan showed a large subdural hematoma on the left of his brain. All his symptoms were attributable to the pressure being applied to his brain.

He underwent an emergency left temporal craniotomy on Saturday. The operation was successful, although the origin of the bleed  is not known. There had been no head trauma.

Today he said my name and tonight he was more lucid and wanted to watch 60 Minutes. He could see the wall clock at 6:55 and knew the show was about to begin. I hadn't even been aware of the TV…

Technology and Medicine

I love technology that lets me be a connected doctor and saves my patients time and money.  I got an email from Justin last weekend because his foot was painful and swollen and it included the following photo:

Wow. this was obviously a serious infection that was spreading beyond the big toe to the entire foot.  He needed immediate attention and was sent to the ER.  He was given pain medication, two antibiotics and the toe was drained.  The next photo looked was this:

Clearly better now that it was opened up but the swelling remained and he was not out of the woods.  Rather than  have him come into the office, when he really needed to keep it elevated, I had him check in with me with daily updates:

Clearly improved.  Notice the redness on the other toes is disappearing as is the streak that was going up the foot.  The wound looks really clean.  I advised hot soaks and continued antibiotics and elevation and it continued improving:
All was going well until today.  His pain was gone and…

Americans are Trying to Lose Weight

More than half of Americans (55%) say they are trying to lose weight according to a study by The International Food Information Council Foundation.  From 1960 to 1980 the obesity rate remained stable at about 15%.  Since that time it has risen to 36% in 2010 and is still on the rise.  Despite the fact that we are getting healthier in many other ways, the obesity epidemic stands to wipe out all of the other health gains.

Body weight is the result of genes, metabolism, behavior, environment, culture and socioeconomic status.  But genes and metabolism have not contributed to the rapid obesity rise in the U.S.  The other factors are at play here.

If you think it is from the proliferation of fast, easy available food, cheap junk food calories and the fact that fewer people cook at home anymore, you would be correct.  Just look around at how easy it is to find food.  Every mini-mart, drug store, public place has vending machines and available junk food.  And serving sizes have grown along…

Getting Used to Electronic Health Record

I will start with full disclosure.  I still use paper charts.  While I think my practice of medicine is "uber"-up-to-date...the truth is it could be 1950 when you look at my patient records.  Charts are huge and some  patients I've seen for decades are on volume 3, just to make them manageable.  So this very week I am coming on board with a full blown, state-of-the-art Electronic Health Record.

The government is pushing EHRs and, in fact CMS (Center for Medicare and Medicaid Services) has already imposed a 1% penalty on  doctors  that are  not doing e-prescribing of prescriptions.   The penalty goes up to 1.5% in 2013.  There are also some large incentive dollars connected with "Meaningful Use".  It is a complicated set of criteria put out by CMS that pushes physicians toward investing in the EHR.

With all of these incentives why haven't more physicians converted?  For one it is darn expensive and the best systems require large groups or hospital funding …


The answer to yesterday's medical challenge was #1 angioedema.  The patient had progressive swelling on the face and had previously had swelling of the larynx, trunk and extremities.  A diagnosis of hereditary angioedema was made from a blood test.

Angioedema just means swelling under the skin.  Spots of angioedema are called "hives" and they are usually from an allergic reaction.  Histamines and other chemicals are released by certain types of white blood cells when an allergen is detected.  This can occur because of insect bites, animal dander, pollen, food allergies, and certain medications.  People with hereditary angioedema, a rare condition,  lack a certain protein (C-1 esterase)  that is part of the body's immune system.  The swelling can come on quickly and be dangerous if it limits breathing through the larynx.

For more common hives (urticaria) or angioedema, antihistamines are the best treatment and avoidance of the allergen.

Thanks for your diagnoses.  

EverythingHealth Diagnostic Challenge

Hello Readers,
This weeks Image Challenge from The New England Journal of Medicine is a good one.  Also it is pretty common.  The patients symptoms developed over a few hours and she came to the Emergency Room.  Is it:

1.  Angioedema
2.  Facial palsy
3.  Frey's syndrome
4.  Parotid adenoma
5.  Parotitis

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

Fallen Hero-Lance Armstrong

Reading the daily updates about the Lance Armstrong bicycle team doping scandal is like watching a train crash.  It gets worse and worse and there is no turning back for America's sport hero, Lance.  I read his book "It's All About the Bike" and even wrote a book review on it, praising his true grit story and come-back from being on death's door from testicular cancer.  Lance Armstrong, the boy next store with his good looks, amazing athleticism and cancer charity (Livestrong) has fallen off his pedestal.

The reports that are now being disclosed by his bike team aide, Emma O'Reilly  show that Lance and his team ingested and injected a boatload of illegal substances to improve performance over their entire successful careers.   The one that caught my eye was injectible testosterone, a performance enhancing drug when used in high quantity.  I thought back to his diagnosis of testicular cancer and the rapid spread of the disease before he was even diagnosed.


Different Roles in Health Care

I was working late this week; making patient call backs, filling prescriptions, reviewing labs and finishing charts from the day.  It was dark out and the medical office was quiet and empty.  The janitorial crew started their work of emptying trash, picking up the scattered debris from the busy patient flow and sanitizing surfaces.  I looked up and a beautiful Latin woman, age about 30,  wearing latex gloves, was emptying the overflowing trash can.

"You are working overtime", she said with a heavy Hispanic accent.  I laughed, realizing how late it was and how tired I was and still had more work to do.  Then I stopped and really looked at her.  She was busy putting liners in cans and dusting surfaces.  She was working fast because there were many other offices ahead of her that also needed cleaning.

"You are working overtime too", I said.  "Yes", she replied, "I will work until 12:30"  (that's AM)

"I bet this is a second job for you"…

Knee Replacements on the Rise

According to a new study in JAMA, knee replacement surgery could reach 3.5 million a year by 2030 in the United States.  Wonder why health costs are rising?  We have new expensive technology that improves quality of life but may also break the Medicare bank!

The study showed that the number of knee surgeries performed more than doubled from 1991 to 2010.  Fortunately, length of stay in the hospital (a major driver of cost) decreased from 7.9 days to 3.5 days.  In the 90's more patients were discharged to institutions for  rehab and now patients are discharged to home with home health services.

The researchers attribute the potential increase in demand to aging baby boomers and a rise in conditions that contribute to arthritis - namely obesity.  Also there are more trained orthopedic surgeons that perform the surgery and it is becoming more mainstream.

Total knee replacement (TKR) will be a key driver of health care costs in the future.  Many studies have demonstrated that TKR is …

Skin Rash-Pityriasis rosea

My 17 year old son showed me the strange rash that was developing on his chest and back.  It was itchy and each day seemed to be getting worse and worse.  The rash spread around his back and under the arms but spared his face and arms and legs.  After examining the pattern, I was sure of the diagnosis...Pityriasis rosea.

This strange rash occurs in the spring and the fall and mainly strikes young adults. (I did diagnose it once in a 35 yer old woman).  We think it is a virus but it doesn't seem to spread from person to person and it is usually quite isolated.

The symptoms start with a "herald patch", one larger spot that develops into a wider, pinkish, scaly rash over a week or so.  The red, raised spots can last for up to 12 weeks but usually resolve by 4-8 weeks.  As seen here, it is mainly on the body trunk.

There is no treatment for Pityriasis rosea except patience and antihistamines for itching. 

For you wordophiles- Pityriasis comes from the Greek "bran"…

Obama vs. Ryan at AARP

President Obama and Vice-pres nominee Paul Ryan went head to head at the recent AARP convention in New Orleans and addressed the group on Medicare and the Accountable Care Act (aka: Obamacare).  Their appearances were back to back.

Ryan told the audience,"The first step toward a stronger Medicare is to repeal "ObamaCare" because it represents the worst of both worlds".  He argued that the federal health reform law would "funnel $716 billion out of Medicare to pay for a new entitlement we didn't even ask for."  He also said that Romney's plan to transition Medicare into a premium support program "empowers future seniors to choose the coverage the works best for them" and is "designed to guarantee that seniors can always afford Medicare coverage."

The response from the group was lackluster with little applause and many boos during his speech, according to the Washington Post.

It was no surprise that Obama, who addressed the conv…

Reduce Your Risk of Cancer

Imagine reducing the risk of getting cancer!
There are an estimated 1,638,910 new cases of the dreadful disease diagnosed in 2012 in the United States, not including nonmelanoma skin cancers. Cancer is not just one disease but is a term that represents more than 100 diseases with different causes. The basic unit of life is cells, and cancer always begins in cells. When the normal process of cell growth and division is altered, these abnormal cells divide without control and can form tumors and invade nearby tissue. It is a frightening diagnosis to even think about for most people.
Hundreds of studies link lifestyle and “daily habits” to the risk of developing cancer, and researchers at a recent meeting of the Union for International Cancer Control World Cancer Congress 2012 reported that more than 50 percent of cancer could be prevented if people simply implemented what is already known about cancer prevention.
Some of these are lifestyle changes and some are interventions …

The Battle Sign

The answer to yesterdays NEJM diagnostic challenge was #2 - Fracture of the temporal bone.  This patient has ecchymosis (bruising) behind the left ear.  This is the classic "battle sign" that is seen with underlying trauma to the temporal bone of the skull. 

My patient had struck her head very hard on a metal cabinet...hard enough to sustain a concussion and a small skull fracture with blood that is pulled down by gravity in the tissue plane behind the ear.

These fractures heal by themselves but we need to be on guard for subdural hematoma or any change in mental functioning.

Thanks for your guesses.

What is the Diagnosis?

I love this weeks Image Challenge from The New England Journal of Medicine because I had a patient with these exact findings about a month ago.  You be the doctor and make your best guess for the diagnosis.  Post a comment and check back for the answer tomorrow.

This patient presented with hearing loss and left ear fullness.  What is the diagnosis? (click on the image for a better view)

1.  Cholesteatoma
2.  Fracture of the temporal bone
3.  Ochronosis
4.  Otomycosis
5.  Relapsing polychondritis 

Winner gets bragging rights at your next cocktail party!

The Best Jobs in Health Care

The health care sector is a good place to look for job opportunities and to plan career goals.  The workforce is expected to increase 27% through 2014, compared with 14% for all industries combined, according to the Department of Labor.  But special education is needed to enter the health work force and now CareerCast has posted the top jobs based on stress level, solid job security, work environment, training and income.  Here is how the list came out:

1.  Dental hygienist
2.  Audiologist
3.  Occupational therapist
4.  Physical therapist
5.  Optometrist
6.  Pharmacist
7.  Physician assistant
8.  Chiropractor
9.  Primary Care Physician
10. Registered Nurse

Dental hygienists were first based on a median salary of nearly $70,000/year, low stress, a job growth outlook of 38% by 2020 and a small educational investment in a two year associates degree.  They set their own schedules, work in comfortable environments and never have to take their work home!

Compare that to a Primary Care Phys…

Primary Care Payment Struggles

The way doctors bill and get paid is a byzantine process and it is no wonder the "private practice" doctor is an endangered species.  It takes a keen sense of business, a love of medicine-not money, and a sense of humor to survive.  Here is my latest story.  You can't make this stuff up....

I saw a patient in September 2001  (note the date...11 years ago).  I billed her insurance company, Employers Mutual, LLC for $185.00.  I never got paid.

Now fast forward to September 2012.  I received a document from an attorney who informs me that he is a receiver in a class action suit and $48 million in unpaid claims is being claimed.   It appears I am a Category B creditor and will receive a pro-rata share.  He recovered $16, 559, 576.88 and took $4,831,214.40 in attorney fees.

It looks like in the future (?) I may receive a check for $37.00.  No promises are given.

I remember my practice back in 2001.  I worked about 80 hours a week and never even had enough money to fund a ret…

Bedbug Bites

The answer to yesterday's medical diagnostic challenge is #1 - Bedbug bites.  Bedbugs frequently attack exposed areas of the skin and are attracted to humans' high body temperature.  Cutaneous (skin) reactions to bedbug bites are characterized by erythematous (red) or "hive-like" papules.  Lesions observed in a linear or cluster formation are typical. 

This patient's bites responded to treatment with topical glucocorticoids.