Monday, April 29, 2013

Poison Oak

Photo from
As the weather heats up and people are hiking and walking animals outdoors, we physicians start seeing the results of a contact dermatitis known as poison oak or poison ivy.  Some of the tell-tell signs for diagnosing this condition is the severe itching, patchy redness that is in certain skin areas only and also notice the linear streak on the top back area of her neck.  That is a classic rhus dermatitis (poison oak) appearance as are clusters of  fluid filled blisters.

Poison Oak is a leafy shrub that grows wild on the West coast.  Poison Ivy grows on the East coast as does Poison Sumac.   It commonly grows like an ivy vine and as summer rolls on the pointed leaves turn orange color.
The rash is caused by a toxic substance in the plant called urushiol.  Brushing against it or touching an object that has brushed against it (dog fur, shoe laces, backpacks, clothing, hats) can cause an extreme allergic reaction.  Like any allergic response, the symptoms get worse with each successive contact and some people are naturally more sensitive.

The insanely itchy rash appears 8-48 hours after contact with the plant but a first time contact can take up to 15 days for a reaction.

Many people with poison oak rash think they are spreading it by scratching because it keeps progressing over days to weeks with new areas of rash.  It is not spread by scratching or touching the skin.  The body is mounting an extreme antibody reaction to the poison and the areas of rash are increasing from the immune response...not from touching it.

The best treatment is avoidance.  Once you have suffered from poison oak/ivy rash, you learn how to be proactive.  But if you do contact it and suffer severe cases on the face, genitals or large parts of the body, it can be treated with corticosteroid medication to block the immune response.  Small areas may respond to steroid creams, antihistamines and cool baths.  Large areas may require an injection or pills.

And never burn poison ivy or poison oak to get rid of it.  The smoke can carry the resin and cause severe inhalation reaction. 
Thanks to patient KM for allowing her poison oak rash to be shared

This site has some good tips on treating poison oak dermatitis.

Wednesday, April 24, 2013

Health Care Reform Confusion

If you think you are confused about ObamaCare and what it will mean to you and your family, you are not alone.  Confusion is rampant and open enrollment for the health exchanges is supposed to start October 1.   Yes that is a mere 6  months from now!  Despite this looming date, the various States still don't know what they will be offering and doctors and hospitals also have no idea how it will work.  There seems to be no plan on how to get the word out to the uninsured public.
Most uninsured people don't even know they will have new insurance options under the Affordable Care Act.   If you have insurance now through your employer, not much will change.

Here are some basics that we do know:

  • The exchanges will start covering patients on Jan 1, 2014.  Each state will have its own exchange for people who don't have employee coverage.  There will also be a plan for small businesses to offer to employees.  The vast majority of people who have health insurance from their jobs will not see a change.
  • There will be three types of exchanges to start: those run by states, those run by the federal government and private partnerships. 
  • Patients will be able to pick from a range of private plans and the government will help eligible people with the premiums.  We have no idea what those premiums will be but if the last few years of rising health insurance cost is any indication, it will not be affordable.  Low income people will be steered to safety-net programs like expanded Medicaid.
  • Only legal residents of the United States will get help with premiums.
  • There are confusing formulas for different plans.  All of the proposed plans have deductibles and co-pays on top of the premiums and people will need to choose their plan based on premium price and deductible.  
  • It is unknown which doctors or hospitals will be within the various exchanges or networks because they aren't even formed yet.  Providers are just as confused right now as the general public.
  • Insurers will be forbidden to deny health insurance for pre-existing conditions or other health status.
  • It is predicted there will be a vast shortage of doctors and clinics to care for the new patients with insurance and the new demands for health care.
  • 48 million Americans (15% of the population) have no health insurance now.
Stay tuned over the next few months.  Hopefully some clarity will start to be revealed.

Saturday, April 20, 2013

Answer to Image Challenge

The answer to yesterday's diagnostic challenge is...drum roll...
# 3.  Psoriasis.

The scattered reddish, scaly, indurated papules on the lower back and buttocks are psoriasis.  The acupuncture needling of the skin produced trauma that caused Koebner's phenomenon and subsequent psoriatic flare.  This is a rare event and it was treated with a steroid cream.

Thanks for your guesses.  This was a hard one.

Wednesday, April 17, 2013

What is the Diagnosis?

Today's image challenge from the New England Journal of Medicine is a tough one.  Full disclosure - I missed it.  (bragging rights: I usually get about 99% right) 

This patient had acupuncture to the area and developed these lesions.  What is the diagnosis?
1.  Herpetic whitlow
2.  Nummular eczema
3.  Psoriasis
4.  Ringworm
5.  Scabies

Click on the image for a closer view and make your diagnostic guess in the comment section. The winner gets a free subscription to EverythingHealth.   Check back tomorrow for the answer! 

Tuesday, April 16, 2013

Fake Drugs

In Africa drugs are sold without proper handling or control
Unfortunately many of the drugs that enter the United States (and other Countries) are fake.  Research shows that more than half of the drugs sold by online pharmacies may be fake. Globalization of the pharmaceutical manufacturing industry and distribution system is contributing to the problems of false and substandard drugs. 

A clinic in Burma with unregulated drugs
And low and middle-income countries are the hardest hit by these falsified drugs.  Many patients in these countries are forced to buy their medications from poorly regulated markets and some of the drugs they buy are useless...or even worse, toxic.  Substandard drugs in developing countries have contributed to the emergence of drug resistant malaria and tuberculosis.

More and more people in the United States are buying medications on-line, hoping for a price break from the exorbitant cost of pharmaceuticals.  The best way to ensure that you are dealing with a reputable pharmacy is to verify it with the NABP (National Association of Board of Pharmacies) Verified Internet Pharmacy Practice Sites.  You can find that website here.

Monday, April 8, 2013

Meat and Heart Disease

We have known for decades about heart disease and the effects of red meat and saturated fats being a cause of elevated cholesterol.  But we've also known that is not the whole story and now surprising new research is pointing to gut bacteria and the actual chemical that is produced by meat as the culprit for heart disease. 

Carnitine is found in red meat and is also used by body builders as a supplement for energy.  Researchers have found that in the intestinal tract, bacteria convert carnitine into a metabolite called TMAO and TMAO promotes thickening of the arteries.  Steak consumption caused subjects in the study to immediately produce large amounts of TMAO.  Vegetarians did not produce the chemical.

Many people who become vegetarian say that they can no longer digest red meat.  It turns out that they actually lose the ability to metabolize carnitine over time because they do not develop the gut bacteria that meat eaters have.

How did the researchers know it was the gut bacteria?  They gave the study participants large doses of antibiotics to wipe out the normal flora in the intestinal tract and then none of the meat eaters or vegetarians produced TMAO after eating steak or taking carnitine pills.

The researchers from Cleveland Clinic, examined record of 2595 patients who had undergone cardiac evaluations and found that patients with high levels of TMAO and carnitine were the most likely to develop heart disease, heart attacks, strokes and death within the next three years.

"Cholesterol is still needed to clog the arteries, but TMAO changes how cholesterol is metabolized-like the dimmer on a light switch," said lead author Stanley Hazen.  "This may explain why two people can have the same LDL level, but one develops cardiovascular disease and the other doesn't."

It would appear that carnitine alone is not the problem but a regular diet of meat creates the gut bacteria that break carnitine down into TMAO.  Vegetarians and meat eaters have very different gut bacteria.  TMAO may be a waste product but it is significantly affecting cholesterol metabolism and deposition into arteries.

What should you take from this study?
  • The Mediterranean diet is still the most heart healthy diet.  (Small amounts of meat and red wine; grains and vegetables in large amounts. Avoid processed foods)
  • Try to eat only organic local farmed meat and chicken.  It takes an effort but is worth the time and money to avoid antibiotics, growth hormones and horrible animal conditions.
  •  Never take carnitine supplements or energy drinks.
  • Small amounts of meat means no more than 4-6 oz.  Think about that the next time you think about steak. 

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...