keep-Health

10 New Year’s Resolutions For Doctors And Patients

2011-08-24T00:53:00.000-07:00

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#1 Doctor: Resolve to let patients speak without interruption and describe their symptoms.

Patient: Resolve to focus on the problem I am seeing the doctor about and not come with a list of 10 complaints for a 15-minute office visit.

#2 Doctor: Resolve to keep a pleasant tone of voice when answering night and weekend phone calls from the answering service, patients, or nurses.

Patient: Resolve to get my prescriptions filled during office hours, not forget my medications while traveling, and to use night and weekend phone calls for emergencies only.

#3 Doctor: Resolve to exercise a minimum of??four times a week for better health.

Patient: Ditto.

#4 Doctor: Resolve to train my staff and model excellent customer service for patients.

Patient: Resolve to understand that getting an instant referral, prescription, note for jury duty, or letter to my insurance company??from??my doctor is not my God-given right and I will stop??[complaining] if it doesn’t happen the day I request it.

#5 Doctor: Resolve to give at least one compliment a day to my office staff, child, and spouse.

Patient: Ditto.

#6 Doctor: Resolve to apologize when I am late seeing a patient who has been waiting.

Patient: Resolve to understand that when the doctor is late?? another human being needed attention. It might be me in the future who needs extra time.

#7 Doctor: Resolve to do one new thing a month that is novel (??See a??play? Travel? Do a special activity with a child or spouse? Learn a new computer skill? Play music? See a friend?)

Patient: Ditto.

#8 Doctor: Resolve to review all insurance payers and drop contracts that are not paying market rates for my skills and education. I will not go bankrupt.

Patient: Resolve to try and understand the medical economics that require my doctor to drop my insurance. If my doctor isn’t worth paying a little more for the visit, I will find a new doctor.

#9 Doctor: Resolve for each new prescription I write I will explain five things: The name of the medication, the reason for the medication, the side effects, how to take it, and how long to take it.

Patient: Once the doctor has prescribed a medication, I will take it as prescribed or let the doctor know right away if I am stopping it.

#10 Doctor: I will give thanks that I have a wonderful profession where I can help people in a special way.

Patient: I will not underestimate the many years of training and sacrifice my doctors have gone through and I will appreciate that they are trying their hardest to help me stay healthy.

Your Hydration Needs Monitored By An Intelligent Water Bottle

2011-08-24T00:52:00.001-07:00

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Imagine a water bottle that knows how hard and how far you are running, how much you’re drinking, what’s the outside temperature, and, based on all these variables, the device calculates when you need to have a drink. Cambridge Consultants have developed the i-dration bottle that does just that.

From the press release:

Intelligent sensors in the i-dration bottle can be used to monitor the external temperature, drinking frequency and quantity, and this data is then sent via Bluetooth to its usera??s smartphone. The phonea??s inbuilt accelerometer and gyroscope can measure exercise levels, and by “fusing” the data from a heart rate chest-band and information pre-entered using the smartphone interface (such as height, age and weight), the application can perform an assessment of a usera??s hydration levels. The i-dration bottle then responds accordingly by flashing a blue light if the athlete needs to drink more.

i-dration demonstrates the work that Cambridge Consultants is currently undertaking in bringing mobile applications to life. a??Most people still perceive an a??appa?? to be something that performs a certain task, whether ita??s checking the weather or the latest sports results, in a virtual world. However, we believe that in the next 12 to 18 months we will see a plethora of new dedicated a??hardware apps,a?? such as the i-dration drinks bottle, that will work in tandem with a smartphone to enhance a range of consumer products and services ,a?? said Rachel Harker, Business Development Manager at Cambridge Consultants.

Press release: Real-time hydration advice from new ‘smart’ drinks bottle …

The Key To Killing Common Warts: Patience

2011-08-24T00:51:00.001-07:00

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Ia??m sure I dona??t see as many patients with common skin warts as my family practice or dermatology colleagues, but these patients still make it to my office.?? Sometimes ita??s the primary complaint, sometimes ita??s an afterthought.?? In reviewing the topic, it occurred to me that most patients dona??t need to see any of us for this problem.?? They mostly need to accept the fact that the treatment takes TIME.?? So if you will persist, then you will often be successful without the expense of seeing a doctor.?? (photo credit)

Common warts (Verruca vulgaris) are caused by the human papillomavirus (HPV).?? Warts on the hands or feet do not carry the same clinical consequences of HPV infection in the genital area.?? It is estimated about 10% of children and adolescents have warts at any given time.?? As many as 22% of children will contract warts during childhood.

Common warts can occur anywhere on the body, but 70% occur on the hand.?? Often they will disappear on their own within a year.?? Even with treatment, warts can take up to a year to go away.

Before heading to the doctor, there are treatments you can try at home:?? salicylic acid or duct tape.

When using the 17% salicylic acid gel (one brand name: Compound W), it must be applied every day until the wart is gone.?? Only apply to the wart, not the skin around the wart.?? This treatment is enhanced by covering the wart with an occlusive water-proof band-aid or duct tape after applying the acid.?? It can also be enhanced by gently filing the wart with an emery board daily to remove the dead cells prior to applying the salicylic acid.?? Treatment can take weeks to months.?? Dona??t give up early.

Duct Tape can take weeks or months to be effective.???? Apply the duct tape to the wart and?? keep it in place for six days.?? After removing the tape, soak the wart, and pare it down with a filing (emery) board.?? Repeat the above until the wart disappears.?? Once again, dona??t give up early.

The two?? treatments (salicylic acid and duct tape) can be combined.?? Apply the salicylic acid liquid to the wart before bedtime.?? After letting it air dry for a minute or so,?? then apply the duct tape over the wart, completely covering the area. Remove the duct tape the following morning. Each time you remove the tape, you will be debriding some of the wart tissue. Repeat the application each night, until there is no remaining wart tissue.?? As with using only one treatment, dona??t give up early.

If the above dona??t work or you just dona??t want to take the time, then you may wish to see your physician for removal.?? He can use cryotherapy to destroy the wart.???? This method may involve repeated treatment over several weeks.?? You can do the following to a??get the wart ready for removala?? and make the cryotherapy more effective:

Every night for 2 weeks, clean the wart with soap and water and put 17% salicylic acid gel (one brand name: Compound W) on it.

After putting on the gel, cover the wart with a piece of 40% salicylic acid pad (one brand name: Mediplast). Cut the pad so that it is a little bit bigger than the wart. The pad has a sticky backing that will help it stay on the wart.

Leave the pad on the wart for 24 hours. If the area becomes very sore or red, stop using the gel and pad and call your doctor’s office.

After you take the pad off, clean the area with soap and water, put more gel on the wart and put on another pad. If you are very active during the day and the pad moves off the wart, you can leave the area uncovered during the day and only wear the pad at night.

If none of the above work, then your wart may need to be removed surgically.?? Remember the above all take time, so give them time to work.?? Even if the wart disappears with any of the above treatments, it may recur later.

Sources

Treatment of Warts; Medscape Article, May 27, 2005: W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD

What Can Be Done About a Hand Wart That Keeps Reappearing After Removal?; Medscape Article, May 31, 2007; Richard S. Ferri, PhD, ANP, ACRN, FAAN

Duct tape and moleskin equally effective in treating common warts; Medscape Article 2007; Barclay L.

Duct Tape More Effective than Cryotherapy for Warts; AAFP, Feb 1, 2003; Karl E. Miller, M.D.

Brush Up On Heart Health

2011-08-24T00:50:00.001-07:00

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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’ve 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 and followed a large subset with questions about their oral health.??They asked about frequency of dentist visits, toothbrushing, 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 participants who had no natural teeth (edentulous) and??those with existing cardiovascular disease.

This elaborate and lengthy study showed that toothbrushing is associated with cardiovascular disease, and that subjects who brushed their teeth less than once a day had a 70 percent??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.

REFERENCE: British Medical Journal, 2010; 340: c2451.

New Research On Alzheimer’s Disease

2011-08-24T00:48:00.000-07:00

Data presented at the International Conference on Alzheimer’s Disease in Honolulu this week indicated that exercise and adequate vitamin D levels could help reduce risk for the disorder. Framingham Heart Study researchers found that risk for dementia was halved in “moderate to heavy exercisers” compared with more sedentary people, while researchers on a separate study found that vitamin D deficiency can greatly increase risk for mental impairment.

Another study found that injecting the compound florbetapir into the brain of patients with dementia and then performing a PET scan could help pinpoint the size and location of plaques.

Researchers also reported that tea consumption was linked to a slower rate of cognitive decline in older adults without cognitive impairment, but there was no dose response and more studies will need to be done to determine a definitive link. (CBS News, Wall Street Journal, Medscape)

Driving Safe Cars Can Save Lives

2011-08-24T00:47:00.000-07:00

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New England Patriots NFL quarterback Tom Brady was on his way to practice when he crashed into a minivan which allegedly ran a red light.??His Audi S8 car T-boned the other vehicle a few blocks from his home.??A relieved New England Patriots owner Bob Kraft noted after the accident:

“[Tom] arched and prepared himself and we’re just lucky with the glass and angles. We have a lot to be thankful for. It was really a miracle…We’re very, very lucky. Patriot Nation is lucky he had his seatbelt on.”

Was it simply luck or good car design and mechanical engineering???Crumple zones and the passenger cage of a car when built for maximum safety decrease injury.??Yet, unfortunately, there is significant variability among safety in cars.??Brady walked?? away from the accident for a variety of reasons.

As a future hall of fame quarterback, Brady has lightning fast reflexes when analyzing defensive blitzes and options when throwing the football.??Quickly bracing himself for impact may have helped.??Wearing a seatbelt definitely helped. What may have helped the most was the type of car he drove.

Audi cars were recently recognized by the Insurance Institute of Highway Safety as Top Safety Picks with the manufacturer recognized with more models than any other luxury German car brand. Earning a Top Safety Pick requires that the vehicle receive a good rating in each of these categories — high-speed front and side crash tests, a rollover test, and protection against neck injuries after rear impact with evaluations of seat/head restraints.??Perhaps had celebrity Dr. Frank Ryan driven a top safety pick car despite his vehicle’s rollover, he might be alive today.??There is tremendous variability in a vehicle’s ability to protect its occupants which vary among manufacturers as well as models and model year.

Driving a safe vehicle should be as important as exercising regularly, eating healthy, and maintaining a good weight.??Much like quitting smoking or losing weight, the goal is to prevent premature death or disability.??Unintentional injuries are the leading cause of death for those under the age of 34 and the third leading cause of death for people between ages 45 to 54.??Motor vehicle accidents account for the majority of unintentional injuries.??In that moment, all of those healthy habits become meaningless, even for a superstar athlete.??You can do everything right, like Dr. Oz, and discover that you still can have a precancerous colon polyp.

Life happens.??Simply bad luck???Perhaps.??What can you do to mitigate the risk or bad luck further?

Plan for it the best you can.??In this case, having a car brand that is among the safest in the world, helps.??His car saved his life and saved his career.??It protected him from needing an emergency room visit and evaluation.??As a result, Brady simply walked away from the accident.??He made his practice a little while later and finished his drills with teammates.??He displayed no sign of injury or diability.

Was all of that worth the time and effort to find a car that is fun to drive and yet incredibly safe? You bet.??Don’t believe me? Ask his wife, Gisele Bundchen, and his sons Benjamin and John.??I’m sure they are glad to have him home safe and sound, even as he takes his hits on Sunday as the premier quarterback in the NFL.

Nutritional Supplements: Do They Really Help Prevent Disease?

2011-08-24T00:46:00.000-07:00

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(Guest post submitted by MD Anderson Cancer Center)

Aisles in grocery stores and pharmacies are stacked with vitamins, minerals, herbs or other plants that you take in pill, capsule, tablet or liquid form. And, many of us buy these supplements and take them regularly, hoping to lower our chances of getting cancer and other diseases.

But do supplements really work wonders? Should you take them to help prevent cancer? Our experts say beware.

a??Dona??t be fooled by the label on the bottle,a?? says Sally Scroggs, health education manager at MD Andersona??s Cancer Prevention Center. a??Researchers are still unsure about whether or not supplements actually prevent cancer.a?? Some studies have suggested that supplements may actually increase cancer risk by tilting the balance of nutrients in the body.

Results from the Womena??s Health Study and The Physiciansa?? Health Study II found that vitamins E and C do not prevent cancer. The Selenium and Vitamin E Cancer Prevention Trial showed similar results, suggesting these supplements didna??t help prevent prostate cancer.

a??If you eat lots of vegetables, fruits, whole grains and beans, you should get the nutrients, including fiber, vitamins and minerals, your body needs to lower your chances of getting diseases like cancer,a?? Scroggs says. a??Taking a pill cana??t replace a healthy diet.a??

Not sure which foods get the job done??? See our list of recommended foods packed with cancer-fighting nutrients.

Supplements may benefit some

More research is needed to truly understand the relationship between supplements and cancer risk, according to the American Institute for Cancer Research.

Still, there are some situations when taking a supplement might do your body good. This is especially true for men and women who are not getting enough nutrients because of food allergies, genetics or chronic illnesses.

Here are a few examples of when supplements may be right for you:

Women who are pregnant or breastfeeding

People at risk for vitamin D deficiency

People at risk for osteoporosis

People at risk for B-12 deficiency

People age 50 or older

Vegans who consume no animal foods

Get professional advice

Thinking about taking supplements?

Speak with your doctor or a registered dietitian first. He or she can decide which pills you really need and what dose you should take. Keep in mind that there is no vitamin or supplement thata??s good for everyone.

A registered dietitian also can tell you what to look for on supplement labels. This is important because some supplement labels can be confusing or misleading. Many companies claim their pills can cure cancer when, in fact, they dona??t, according to a recent Congressional study.

a??Remember, supplements are just that a?? supplements,a?? Scroggs says. a??Even if your doctor recommends them, your top priority should be getting the nutrients you need from the food you eat.a??

Do your research and talk to your doctor before you add supplements to your diet

This article originally appeared on MD Anderson Cancer Centera??s Focused on Health e-newsletter. To read the full newsletter, click here. To subscribe to future issues, click here.

REFERENCES:

American Institute of Cancer Research

Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). Journal of American Medical Association. 2009 Jan 7; 301(1):39-51.

Herbal Dietary Supplements: Examples of Deceptive or Questionable Marketing Practices and Potentially Dangerous Advice. U.S. Government Accountability Office. 26 May 2010.

Downloaded at http://www.gao.gov, 13 September 2010.

Physiciansa?? Health Study II: Vitamin E, Ascorbic Acid, Beta Carotene, and/or Multivitamins in Preventing Cancer and Cardiovascular Disease in Older Healthy Male Doctors

Vitamin E in the primary prevention of cardiovascular disease and cancer: the Womena??s Health Study. Journal of American Medical Association. 2005 Jul 6, 294 (1): 56-65.

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We would love to hear from you.?? Do you take vitamin and supplements??? Do you eat fresh fruits and vegetables??? How do you maintain a healthy diet?

[Image:?? Provided by MD Anderson Cancer Center]

When Your Teen Starts Dating

2011-08-24T00:45:00.001-07:00

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After you get over the urge to run and hide, lock your teen in the bathroom, shave his or her head, and save yourself, take a deep breath and think about what is important here. You are likely panicked because you know that sooner or later someone will break your teens heart - and there is nothing you can do about it, or is there?

Talk to your teen and share what you are feeling as well as what you know. Being new to the world of love/lust/hormones, there are some really great conversations to be had now about balance, friendship, and healthy relationships! First, your teen may be overwhelmed with how wonderful it feels to be in love and you can help remind your teen about balance, and the importance of not losing themselves for love. Your teen needs to stay “true to self” instead of becoming an appendage to the new love. Encourage your teen to stay connected to friends, school, outside activities, family, and sports, while making room for the new love.

You might mention that if that becomes an issue, you can help by setting limits on the amount of hanging out at home, phone, text, and computer time, to help her learn to balance life and love/lust/hormones. This is not a threat - just a supportive way to help your teen transition in the world of love!

Together you can set the expectations that honor this new part of life, make your teen feel listened to and involved with the new contract - the new couple spends time with the family, grades stay up, activities continue, chores, whatever else her life includes must all continue - because your teen has to be a “person” first before a girlfriend or boyfriend. The We’re Talking web site has a great section called the abcs of healthy relationships, which will provide many reminders about knowing when a relationship is not healthy.

Along those same lines, it is important to talk about the importance of friendship - and how you want the first few months together to be spent with family - because early in relationships the goal is to learn to trust each other, find things that you have in common, and become parts of each others lives. Friendship is stronger in the long run than hormones - and if either member of the couple is motivated by anything else other than love - s/he will not make it through the “getting to know all about you” phase.

P.S. Remember that the greater the age difference, and the more time alone they share, the more likely teens will take new love to sexual realms, so be aware and good luck!

This post, healthline.com/blogs/teen_health/2009/06/when-teens-start-dating.html" >When Your Teen Starts Dating, was originally published on
healthline.com/" target="_blank">Healthine.com by Nancy Brown Ph.D..

How To Track Epilepsy Online

2011-08-24T00:44:00.001-07:00

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Ia??ve written about several sites that let users track parameters related to their health management.

Here’s another example, SeizureTracker.com, that tracks seizure activity, appointments, and medication schedules through a simple calendar interface. You can download printable seizure logs or receive customized reports which include graphs comparing seizure activity and medication dosages.

SeizureTracker.com is dedicated to providing people living with epilepsy and their doctors with free comprehensive tools to help understand relationships between seizure activity and anti-epileptic medications.

Our hope is that this website will empower people with epilepsy to become active leaders in their own treatment, working hand-in-hand with doctors.

The reports generated by SeizureTracker.com become a valuable communication aid when meeting with doctors because all the necessary information is in one brief report.

Same Sex Vs. Opposite Sex: What’s The Rule On Friendship?

2011-08-24T00:42:00.000-07:00

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I’m stealing a post from Jay at Two Women Blogging entitled “Was Harry Right?” Here’s their post, and I discuss it below:

Was Harry Right?

Bluemilk got me started thinking about this. I first heard Harry’s thesis advanced by the resident I worked with on my med school psych rotation. She assured me that while I might think I had platonic friendships with men, the men didn’t see it that way. I was pretty sure they did see it that way. I wasn’t naive, I was engaged to be married and had done my share of dating and flirting — I knew what it felt like when a man was interested in me sexually and I knew the difference. I still know the difference, and I still have men friends. For most of my life, my closest friends have been men.

I had a best girlfriend growing up, but we weren’t together very much — she lived in a different neighborhood and had a lot of afterschool activities and we weren’t usually in the same class at school. We didn’t trade sleepovers and call each other to check our outfits and have long closed-door talks like Eve does with her friends. My day-to-day best friend, the person I hung out after school with and rode bikes with and watched TV with and waded in the creek with, was the boy across the street. We were inseparable until he moved away when we were ten.

During that same psych rotation, we had a lecture on child development in which I learned that “all children” had a same-sex best friend during latency. I asked the lecturer afterwards what would happen if a child had an opposite-sex best friend during that period, and she said “gender development would become abnormal.” Perhaps that explains it.

I started to seek out and cultivate female friendships when I was in med school, but I find I still gravitate toward friendships with men. I am blessed, now, with wonderful women friends, and I’m deeply grateful for them, but I still think my psych resident — and Harry — were wrong.

************************************************

I picked this post to blog about because 1) I like the “When Harry Met Sally” clip and 2) these kinds of black-and-white statements about??”how life works”??come up all the time in therapy.

In the case above, the teacher tells the student that during latency one must have a same-sex best friend. “Must.” If not, the person grows up to be “abnormal” in their gender development. Show me the science. but first define for me “normal” in terms of gender development. And who out there has “normal” gender development? What’s the goal — Martha Stewart? Barbie? Elana Kagan? J Lo?

What comes up more often in therapy is the question of can you be friends with an ex-girlfriend or ex-boyfriend? An ex-husband or ex-wife? I tend to think that it’s usually hard, but there are people who do it, so counseling that “you can’t be friends with an ex” or “you can’t be friends with a member of the opposite sex” — or pretty much any??absolute –??seems, well, not evidence-based.

My personal favorite piece of advice to give along??this line is to tell people to stay away from the person they are so painfully breaking up with for a good long time, at least until all parties are no longer in love and have moved on with their lives. Now all I need is a movie scene.

Consider Medical Conditions Before Jumping On The New Year’s Resolution Diet-And-Exercise Bandwagon

2011-08-17T18:41:00.000-07:00

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The first week of January was full of news reports of giving advice on your new diet and exercise program to help you lose the weight you’ve always wanted to. In a previous post and video I talk about some do’s and don’ts when planning for your weight loss New Year’s resolution.

In the video below, I talk about some medical issues to keep in mind before starting your program. For example,??do you have??a family history of medical problems like high blood pressure or diabetes? If so, you may want to schedule an appointment with your personal physician before jumping on the diet and exercise bandwagon.

If you find??this video helpful, I invite you to check out other TV interviews at MikeSevilla.TV. Enjoy!

5 Tips On How To Be A Healthcare Survivalist

2011-08-17T18:40:00.000-07:00

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There are plenty of a??survivalistsa?? out there who stock their basements with canned goods, getting ready for some unexpected (and unlikely) apocalypse. Meanwhile there are things that are much more likely to happen to you — like getting sick — which many of us dona??t prepare for at all. So to help you get started, here are five important tips on how you can become a healthcare survivalist:

1.?? Take care of your chronic conditions. Whether ita??s high blood pressure, diabetes, high cholesterol, depression, asthma or any other kind of ailment, do what it takes to manage your own care.??Take your medications and follow your doctorsa?? instructions.??Why? Because if you dona??t, your condition can get worse and lead to even more serious problems.??As much of a pain as it may (literally) be, therea??s a reason the old saying a??an ounce of preventiona?? still resonates today — because ita??s true.

2.?? Live a healthy lifestyle. Everyone gives you this advice, but with studies showing that 42% of Americans will be obese by 2050, it doesna??t seem to be getting through.??Denial can wonderfully appealing;?? but when it comes to your health, it can also kill you.??Stop smoking, exercise, and eat right.??You may find that your employer has programs in place that will help you do all of those things, and many of them work. Why not give one of them a try???You cana??t improve your life all at once, but you can start.??Your life will be happier if you keep yourself healthy.??So rather than whistling past the graveyard, jog past it.

3. Make sure you are well-insured. You may not have the greatest insurance plan through your job, but there are things you can do to protect yourself on your own. For example, most insurance doesna??t pay the full cost of long term care.??This is the kind of care you might need if you end up needing home nursing care or have to live in an assisted living facility.??That can be very costly.??You should buy long-term care insurance to cover these expenses and serve as a cornerstone of your health care survival plan.??Studies show that 60% of seniors will need long-term care at some point in their lives — and Medicare doesna??t cover it.??Oh, and ita??s not just a problem of the elderly.??About 40% of people getting long-term care are between 18 and 64.

There are other kinds of insurance you can buy, too, depending on the state in which you live.??These might be plans that supplement your health coverage, or cover other expenses of illness.??The best advice:?? Research your options, find an insurance broker you trust, and figure out a plan that helps protect you from the financial toll of illness.??Also keep in mind that your employer may offer, on a voluntary basis, a number of these kinds of programs at cheap prices — check them out and see if they make sense for you.

4.?? Know your family history. Ita??s a little hard to believe in the 21st century, but it turns out that an old-fashioned knowledge of your familya??s medical history can be some of your best protection.??It can help your doctor know whether you have a higher risk for certain illnesses.??And it can also help him or her know whether that symptom youa??re complaining about is a sign of something other than what it seems to be.??A surprising study recently showed that a family history can be better than even genetic testing at predicting your likelihood of disease.????The Surgeon General has a neat tool that can help you get started. The more you know about your familya??s medical past, the better off you and your doctors will be in your medical future.

5.?? Ask Questions. No matter how well you prepare and try to protect yourself, at some point you may still end up seriously ill. Hopefully, if youa??ve taken good care of yourself and have all of your information in order, youa??ve put yourself in the best position to make it through.??But therea??s still so much more you can and should do.??The world is full of well-intentioned, highly skilled, and hardworking doctors.??The trouble is, they work in a system that makes it very difficult for them to do their jobs.??So, ask questions, and use every resource available to you to make sure youa??re getting the right medical care.

Got GERD? Find Out If You’re At Risk For Esophageal Cancer

2011-08-17T18:39:00.000-07:00

If you’re from a Western country, there’s a 10-20 percent chance that you suffer from classic symptoms of??acid reflux: chronic heartburn and/or acid regurgitation.

But if you don’t have those classic symptoms you may still have acid bubbling up from the stomach into the esophagus, a condition called “gastro-esophageal reflux disease” (GERD). Over the past decade, research has suggested that acid reflux can cause atypical symptoms such as cough, hoarseness, sore throat, asthma, and even chronic sinusitis.??GERD can also cause chest pain, especially if the acid causes the muscle in the esophagus to go into spasm.

As an internist and gastroenterologist, I’ve seen patients who have suffered for years with atypical symptoms of GERD get better with treatment. Although I usually prescribe acid-reducing medication, I try to avoid an approach that relies exclusively on “better living through chemistry.” In fact, my goal is to treat the symptoms with life-style adjustments alone if possible. Smoking and obesity both increase acid reflux and must be addressed. I tell my patients to limit alcohol, caffeine, chocolate, peppermint, and fatty foods (I know, basically anything that gives them even an iota of pleasure in life). I also suggest keeping a food diary to try to identify culprits such as tomato-based products or certain spicy foods. If their symptoms resolve then they can try to reintroduce the things they miss the most. Elevating the head of the bed can sometimes help.

The most serious consequence of chronic acid reflux is??esophageal cancer. About ten percent of patients with long-standing acid reflux develop changes in the swallowing tube that increase the risk of developing adenocarcinoma, a deadly cancer with a 5-year survival rate of less than fifteen percent. The condition is called “Barrett’s esophagus. “Fortunately, only about??one in 200 patients with Barrett’s esophagus develops cancer each year. And over the last year a treatment called??”radiofrequency ablation” has been found to be extremely effective in treating Barrett’s esophagus that is starting to show signs that it may turn into cancer.

It’s estimated that almost??15,000 Americans will die from esophageal cancer this year. Fifty years ago, more than 95% of esophageal cancers were “squamous cell” - the kind caused by smoking and excess alcohol use. As smoking has declined, the incidence of squamous cell carcinoma has dropped. But for reasons that are not clear, esophageal adenocarcinoma - the kind linked to acid reflux (and smoking) - has dramatically increased over the past forty years and now accounts for about half the cases of??esophageal cancer. From??1975 to 2001 there was a 600 percent rise in??esophageal adenocarcinoma. The obesity epidemic may well be playing a role by??increasing the number of adults with acid reflux.

Gastroenterologists can diagnose acid reflux by slipping a thin, flexible instrument (endoscope) through the mouth and down the esophagus. It’s a lot easier than it sounds. Patients are usually given sedation and the back of the throat is sprayed with numbing medicine to avoid gagging. There’s no problem breathing because the tube doesn’t go into the breathing tube (the trachea). Biopsies can be taken from the last part of the esophagus to look for microscopic evidence of Barrett’s and inflammation (esophagitis) caused by acid reflux.

There is currently a controversy about who should be endoscopically screened to look for evidence of Barrett’s esophagus. Only a fraction of the millions of patients with chronic reflux will ever develop Barrett’s. And many patients with Barrett’s have no symptoms at all. In a??study in Sweden, 1.6% of the population had Barrett’s but only about 40% had heartburn. And only about half of??esophageal adenocarcinoma is estimated to be a result of reflux.

The American College of Gastroenterology??recommends against screening the entire population but says it may be appropriate in certain populations at higher risk - such as Caucasian males over 50 with longstanding heartburn. That would be me. So for this week’s episode of CBS Doc Dot Com, I underwent an upper endoscopy, explained and performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at New York-Presbyterian Hospital/Weill Cornell Medical Center. For more information about the Jay Monahan Center,??click here.

For information about GERD from the American Society for Gastrointestinal Endoscopy,??click here.

To watch my upper endoscopy,??click here:

Watch CBS Videos Online

Mammography And Jack Black’s “Boob Saver 5K”

2011-08-17T18:38:00.000-07:00

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This video has been available for months, but I just saw it for the first time. I suspect many women would get a chuckle from seeing the always buffed, ripped, and jacked comedian Jack Black partially disrobe to put his breast in a mammography machine — or as he calls it, the “Boob Saver 5K.”

Holding Hands Is Good For The Heart

2011-08-17T18:37:00.000-07:00

A trained observer is what most electrophysiologists are. And being a trained observer carries over into real life, as would the handiness of??a plumber, or the strength of??a brick layer, or the wordsmithing of??a journalist.

Will and I drive??past our house.

“Where are we going now,” he asks in the exasperated tone of a 13 year old.

I need to take a picture.

Why?

Because middle-aged patients who’ve recently realized that their life is half over often seek clues to longevity.

Let’s take stressed-out, middle-aged patients who’ve??somehow been rendered free of AF (maybe by a skillful ablation, or more likely just happenstance). Let’s also say they don’t smoke, drink excessively, have normal blood pressure, normal blood sugar, and aren’t obese. Is there anything else they can do to live longer, they often ask? Yes, I believe there is.

It’s pictured here:

If the final common pathway of successful aging lies in soothing the effects of life’s inflammation, this picture speaks volumes. These two neighbors have been happily married for nearly 65 years. They walk by our house hand-in-hand nearly every day. They talk to each other and they like each other. Trained observer or not, this is obvious.

He’s had significant heart disease for a very long time, but miraculously it has remained strikingly dormant.

There are oodles of websites proclaiming that healthy relationships are a key component of longevity. This I believe. The anti-inflammatory effect of real companionship cannot be mathematically measured as yet, but it’s likely as equally potent as statins or beta blockers, and surely greater than stents.

You can stomp through life like Philip Roth’s??”Everyman” (who perhaps is not-so-ironically ravaged by vascular disease) or you can choose the picture above. Choices. Always, there are choices.

JMM

All About Hands: Guidance And Germs

2011-08-17T18:36:00.000-07:00

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Some interesting items this week involving hands.??The one which has gotten much news coverage is the issue of handwashing. Take a look at some of the headlines:

High five! Handwashing on rise (Chicago Sun-Times)

For Many, ‘Washroom’ Seems to Be Just a Name (The New York Times)

93% of women wash their hands vs. 77% of men (USA Today)

All the above are reporting on the same study, but the difference in presentation is amazing to me.

The study doesna??t involve handwashing in a hospital or doctora??s office setting.??The JAMA article (2nd reference below) does, but this article focuses on whether public reporting of handwashing compliance is helpful or not.??Do we inflate our numbers to make ourselves look better?

Public reporting creates an incentive to maximize performance but does not specify the manner in which this is achieved. Broadly speaking, 2 approaches are possible. Hospitals can adopt evidence-based strategies designed to improve patient outcomes that will also improve the publicly reportable indicator, or they can adopt indicator-based strategies designed to improve the reported indicator that may not improve outcomes and may even cause harm. Evidence-based improvement strategies would be favored in an environment in which organizations focus on improving patient outcomesa??when such strategies exist and are easy to implement. Conversely, indicator-based improvement strategies would be favored in an environment in which the hospital focuses on protecting its reputation, when evidence-based improvement strategies are unproven or resource intensive, or when measurement of the indicator is easily manipulated to show improvement.

I wish copyright laws would allow me to reproduce the entire essay from a recent issue of JAMA (first reference below).??The essay is written by Ariela Zenilman about her fathera??s hands.??An excerpt:??

Between the scrapes from paper cuts, the finger on which a ring is worn, and the color of nail polish, the hands of the human body tell a story. They are the most mysterious reflection of character. The hands…surgeons are blessed with steady hands for a reason: They reduce the trembling in the hands of worried family members, counteract pain and destruction, and alter creation for the better by fixing fault and disease within the body. A surgeon has the remarkable gift of a set of multifunctional and dexterous hands.

I have always admired my father’s hands. From a very early age I could tell his grace and dedication to detail were apparent in how he moved and touched, felt and experienced the world around him. His hands seemed inexplicably and effortlessly linked to his every thought: as a young child I always dreamed of having hands like his.

When I see my father’s hands…his hands are a mere reflection of his heart, an attribute I hope to see in my hands as I follow in his footsteps.

Hands reflect ability, accomplishment, and passion. I have learned to trust my instincts, follow my heart, and, most of all, not to underestimate the power of my own hands.

??I love hands.??I have been in love with the anatomy and mechanics of hands since medical school. Before then I just loved to watch them work (my mother making biscuits, my teachera??s writing, basketball players shooting baskets, pianists, etc).??

For the general public, wash your hands — flu season is upon us.

For us involved in patient care, wash your hands before and after each patient.??This is one — if not the best — of the best lines of defense in preventing the spread of infection.

REFERENCES:

The Hands That Guide Me; Ariela Zenilman; JAMA. 2010;304(10):1049. doi:10.1001/jama.2010.1291

Public Reporting of Hospital Hand Hygiene Compliancea??Helpful or Harmful?; Matthew P. Muller; Allan S. Detsky; JAMA. 2010;304(10):1116-1117.

Finger and Wrist Exercises (April 19, 2010)

Friends And Searching For Health Information Online

2011-08-17T18:35:00.001-07:00

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Turning to friends for online information is the hot topic within the Web world, and in Mondaya??s New York Times Technology and Business section, Jenna Wortham writes about how a??Search Takes a Social Turn.a??

Online sites are taking notice of what people like.??Web companies are trying to make searching online for information more useful by tapping into the inner thoughts of what people like:

After a decade when search engines ruled supreme a?? tapping billions of Web pages to answer every conceivable query a?? many people now prefer getting their online information the old-fashioned way: by yakking across the fence.

Turning to friends is the new rage in the Web world, extending far beyond established social networking sites and setting off a rush among Web companies looking for ways to help people capitalize on the wisdom of their social circles a?? and to make some money in the process.

Listening and communicating

Listening and communicating with our friends can prove to be invaluable at times, and often they are our springboards for sharing our latest woes or trumpeting our successes.??Whatever the case, friends are ruling the social networking world and frankly their opinion matters. Friends can be invaluable, and the geniuses behind new technology companies are taking notice and creating online sites focused on what friends are sharing with friends.

Trust and better recommendations

We trust our friends, and one company taking notice of the friendsa?? trust factor and creating its content based on smart recommendations is a New York City start-up company, Hunch.

a??Hunch, a start-up based in New York, wants to go beyond cataloging the places and products for which your friends have already expressed affection. With some complex software, it tries to use that information to predict what other things you might like, even if nobody you know has ever offered an opinion on those things before,a?? writes Wortham.?? a??The service pulls in data about articles, topics and people that you and your friends have a??likeda?? on Facebook or follow on Twittera?|a??

Friendsa?? offer valuable information

While we value our friendsa?? opinions for the latest recommendations in movies, restaurants, hotels, TV shows, electronics and more, I was curious to find out if they are talking about health.

Health category

I dug a little deeper into Hunch and indeed, the health category is covered.??Sparingly, but people are talking about health.

From a??Ways to De-stress,a?? to a??Healthy Eating Habits,a?? to a??Exercises for Losing Weight,a?? and from Blood Pressure Monitors,a?? and a??Diabetes Monitoring Devices,a????to a??Cancer Specialist Hospitals,a?? to a??OTC Allergy Remedies,a?? and a??Yoga DVDs ,a?? to name a few; friends on are sharing their opinions, and Hunch has tapped into that.

The long-term goal is for Hunch is for a??a user to be able to come to Hunch looking for a smart recommendation on just about any topic, and after answering a handful of questions, get as good a recommendation as if she had interviewed a group of knowledgeable people or done hours of careful research online,a?? stated on the companya??s website.??a??Eventually, when Hunch gets good enough, we hope users will trust its recommendations without having to turn to lots of external time-consuming sources of information.a??

Friends are offering good recommendations to De-stress.??Take a vacation, read a good book and listen to music are the first three suggestions that round out the 49 recommendations.??Additionally, a??prosa?? and a??consa?? in some instances are mentioned and by clicking a??Learn morea?? you can find where the recommendation originates from.

Number 23 is from Andrew Weil, M.D. and offers the recommendation for a??Breathing exercisesa?? and thata??s a great tip to De-stress.

Be cautious

Caution comes when you get to number 49.??a??Take a Lorazepam,a?? that is the recommendation to De-stress.??While there is a a??cona?? listed that states, a??Cons: This is a powerful anti-anxiety pill that should not be taken unless a person has clinically diagnosed anxiety. There are very serious side effects including withdrawal once stopped,a?? it makes sense for you to be in charge of your health and research a little further.

Along the same line is a??OTC Allergy Remedies.a????While your friends may be taking something to help their allergies, it doesna??t mean ita??s right for you.

Finding out from friends about the best movies, restaurants and travel is extremely helpful.??Finding health information can be very useful as well, however you should always check with your healthcare provider before diving into uncharted territories.

Friendly reminder

Our friendsa?? opinions are important to us, but ita??s also helpful to go to more than one source when searching for health information.??There are excellent health sites and blogs online that offer extremely useful and accurate information.??Always take the extra step when it comes to your health to find out whata??s right for you.??Be in charge and be an empowered health consumer.

Turning to friends

Clamoring with our friends about the latest gadgets, the hottest fashions, the best movies, favorite places to visit and health topics have captured the attention of technology companies, so remember your suggestions can impact many, many people in the social world.??What you like is impacting the way companies are creating technology.??Simply, your opinion matters.

Your turn

How important do you think your suggestions and recommendations are to your friends?

[Image - iStockphoto]

How Much Calcium Do Teen Girls Need?

2011-08-17T18:34:00.001-07:00

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I went to a great grand rounds the other day about health-alliance.com/living/Women/women_05-01.html" >osteoporosis and learned that all teenage girls should be taking about 1,500 mg of calcium with Vitamin D a day in addition to a multivitamin. Three glasses of milk provide about 1,200 mgs, but most teens are not drinking that much milk. Dark green vegetables are another good source of calcium. Exercise and weight-bearing activity is also important in the prevention of osteoporosis.

Calcium is a mineral that gives strength to your bones. Calcium is also necessary for many of your body’s functions, such as blood clotting and nerve and muscle function. During the teenage years (particularly ages 11-15), your bones are developing quickly and are storing calcium so that your skeleton will be strong later in life. Nearly half of all bone is formed during these years.

Women develop most of their bone strength before they are between 25 and 35. After that, bone is broken down faster than it is created, leading to a small loss of bone mass every year. For women, bone loss accelerates during menopause, but slows again around age 60.

There are specific risk factors for osteoporosis that teens should know:

Being white;

Having irregular periods;

Doing little or no exercise;

Not getting enough calcium in your diet; Being below a normal weight;

Having a family history of osteoporosis;

Smoking; and

Drinking large amounts of alcohol.

Osteoporosis can be prevented, but teens need to start early.

This post, healthline.com/blogs/teen_health/2009/06/teenage-girls-and-calcium.html" >How Much Calcium Do Teen Girls Need?, was originally published on
healthline.com/" target="_blank">Healthine.com by Nancy Brown Ph.D..

Treating Depression And Panic Disorder Via The Internet

2011-08-17T18:32:00.000-07:00

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According to a doctoral thesis to be presented by Jan Bergstr??m at the Karolinska Institutet in Sweden, cognitive behavioral therapy (CBT) via the Internet is just as effective in treating panic disorder as traditional group-based CBT. It’s also apparently efficacious for the treatment of mild and moderate depression.

Access to conventional CBT is limited in Sweden, so an Internet-based CBT was developed in which the patient undergoes an Internet-based self-help program and has contact with a therapist by email.

In a randomized clinical trial of 104 patients with panic disorder, both treatments worked very well and there was no significant difference between them, either immediately after treatment or at a six-month followup. Internet treatment was more cost-effective than group treatment.

Analysis of the results for the treatment of depression show that Internet-based CBT is most effective if it’s administered as early as possible. Patients with a higher severity of depression or a history of more frequent depressive episodes benefited less well from the Internet treatment.

Karolinska Institutet: Panic disorder and depression can be treated over the Internet…

Bergstr??m’s thesis: Internet-based Treatment for Depression and Panic disorder : From development to deployment…

One Critic’s Take On The “Multigrain” Scam

2011-08-17T18:31:00.000-07:00

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Freelance journalist and author Suzanne Schlosberg wrote because she was so upset over a New York Times story, “The Chip That Stacks Adds a Multigrain Twist,” that she wanted us to review it. I thought anyone who feels so strongly about something should review it herself. So she did. Here is Suzanne’s guest post:

**************************

I was flabbergasted when I read healthy-sounding%20Pringles&st=cse" >this New York Times piece on Procter & Gamble’s new entry into the potato-chip market: multigrain Pringles. The story accepts at face value P&G’s misleading marketing pitch — that “multigrain” is equivalent to “healthy.” When I sent a link to my nutritionist friend Cynthia Sass., M.S., R.D., she replied: “Did you notice it says ‘advertising’ in the top left corner? It must be a paid ad that resembles an article.”

Actually, it’s not. It’s a business story that ran in the “Media & Advertising” section. Though the story didn’t appear on the health pages, it should have made clear that “multigrain” simply means that more than one grain is included in the product — not that the product is necessarily nutritious.

What’s more, the story confuses “multigrain” with “whole grain,” here:

Mr. Bergsma (Pringles marketing director) said that the multigrain Pringles campaign was devised to appeal to people 35 and older, a group that tends to be more aware of calories and sodium content and that also looks to keep the pounds off with whole grains.

Even more egregious: It’s not until the 11th paragraph, and only in parentheses, that the story mentions that — oh, by the way — the new Pringles actually aren’t any more nutritious than original Pringles. (Even so, multigrain Pringles, which are made from rice, corn, wheat and black beans in addition to dehydrated potatoes, have about the same amount of sodium and calories as regular Pringles.)

The story might also have mentioned that multigrain Pringles, like original Pringles, have 1 measly gram of fiber.

Cynthia Sass told me that misleading articles like this one have a real impact on her clients’ perceptions about what’s healthy and what’s not. She said: “Whether it’s sugar-free, low-fat or multigrain, when processed foods are being presented as ‘healthy’ they become perceived as healthy, even if they’re not. Foods that earn a health halo, deserved or not, are often consumed more frequently or without regard to calories, let alone overall nutritional value. I think it can lead to people truly thinking they’re eating healthfully then wondering why they aren’t losing weight or don’t have energy.”

*****************************************

Thank you, Suzanne, for your contribution and for joining us in the quest to help consumers scrutinize claims made for new treatments, tests, procedures, products??– and potato chips.

Big Breakfast, Big Calories: Rethink Your Morning “Fuel Up”

2011-08-14T23:57:00.000-07:00

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Haven’t we all learned that breakfast should be our biggest meal???”Start the day with ‘fuel’ and you can burn it off as the day goes on.” “Eat a big breakfast and you’ll eat fewer calories all day long.”

This advice is probably not true, and in fact a new study published in the??January 17th issue??Nutrition Journal shows that people ate the same at lunch and dinner regardless of what they had at breakfast.??If a person ate 1,000 calories at breakfast??(which is easy to do with bacon, eggs, toast, hashbrowns, and??juice),??he or she??had a total increase in calories eaten throughout the day by 1,000 calories.

This doesn’t mean we should be skipping breakfast.??The problem may be what we historically think of as an “American” breakfast.??It might have worked for the farmer in the past or the laborer hauling lumber, but it’s just too many calories for our current level of activity.

But there’s nothing wrong with a “European” breakfast of whole-grain cereal and fruit.??Or yogurt and fruit.??Or one egg and toast.??Or cheese and bread (whole grain, of course) like the French do it.

What about coffee and a muffin from Starbucks??? The blueberry muffin carries 470 calories, with almost half of them coming??from fat.??The Starbucks coffeecake is a whopping 630 calories. A??tall latte adds another 204 calories (or 90 to 126 calories for a non-fat latte).

If you’re happy with your weight, you can ignore this article because you’ve probably already learned the appropriate caloric intake for your level of activity. But if yor’re one of the millions of readers who are trying to lose weight, this study shows that overweight??people should pay attention to breakfast calories, eating less as a way to reduce total calories for the day.

November Is American Diabetes Month

2011-08-14T23:56:00.000-07:00

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November is American Diabetes Month, and??in the video below I talk with a local TV news reporter about risk factors, complications, and ways to prevent diabetes. The interview??was only about??two minutes and there’s much more to??be covered, so check out the American Diabetes Association’s website for more information.

If you find this video helpful, I invite you to view more of my TV interviews on my YouTube channel. Happy November!

Strange Symptoms Without A Diagnosis? It Might Be Celiac Disease

2011-08-14T23:55:00.001-07:00

Watch CBS News Videos Online

There’s a disease that American doctors are absolutely terrible at diagnosing. It’s estimated that three million Americans have celiac disease and only a small percentage of them know it. In celiac disease, a component of wheat, rye, and barley called gluten sets off an immune reaction that attacks the intestine and can affect the entire body.

Patients are unable to properly absorb essential nutrients because the absorptive fingers (villi) in the small intestine have been damaged or destroyed. Doctors usually miss the diagnosis because they don’t realize how variable the disease can be. Here is a list of associated symptoms and problems:

Diarrhea, abdominal pain, bloating, gas, distention, weight loss, constipation, irritable bowel syndrome, failure to thrive in infancy, vomiting, short stature, iron deficiency with or without anemia, poor performance in school, delayed puberty, infertility, recurrent miscarriage, osteoporosis, vitamin deficiencies, fatigue, tooth discoloration and dental enamel defects, skin disorders, elevated liver enzymes, Down syndrome, Sjogren’s syndrome, aphthous ulcers (canker sores), arthritis, depression, nerve and ??balance problems (peripheral neuropathy and cerebellar ataxia), irritability in children, seizures, and migraines. Patients with other autoimmune diseases such as type 1 diabetes and thyroiditis are at increased risk for celiac disease.

Click here for the National Institute of Health’s information on celiac disease.

There appears to be a slight increase in the risk of lymphomas and gastrointestinal cancers that, in one study, returned to normal after five years of a gluten-free diet.

The diagnosis is usually missed because doctors don’t think of it. ??I was taught in medical school thirty years ago that patients always have dramatic symptoms such as diarrhea and weight loss. Wrong. We now know that about half of patients have atypical symptoms that are included in the long laundry list above. Although doctors are??becoming more aware of the illness, it takes an average of more than four years for the correct diagnosis to be made in the small percentage of patients in whom the diagnosis is not missed altogether.

New England Journal of Medicine on Celiac Disease.

There are simple blood tests that can detect celiac disease over 90 percent of the time and that only rarely give false positives. The diagnosis is then confirmed by an upper endoscopy. With the patient sedated, a small, flexible tube is slipped into the mouth, down the esophagus and stomach and into the first part of the small intestine (duodenum), where biopsies are taken and subsequently examined for changes seen in celiac disease.

Treatment is a gluten-free diet - easier said than done, especially for a child who wants to be like everybody else and eat pizza, cookies, and cake at birthday parties. Patients have to be extremely vigilant because gluten is in many unexpected foods, such as soy sauce, candy, and malt flavoring.

Consultation with an experienced dietitian is crucial because some older materials distributed by doctors, dietitians, and nutritionists are out of date and cause patients to avoid certain foods unnecessarily. There are many Web sites that provide excellent information about diet (see below). There’s research into developing a pill that would help people with celiac disease, but it’s not ready for prime time yet.

The key to improving our dismal rate of picking up celiac disease is to increase awareness both in physicians and patients. One study found that general practitioners actively looking for the disease increased their rate of diagnosis by 43 fold.

Anybody with any of the long list of symptoms or problems listed above should consult a doctor and discuss whether testing for celiac disease is appropriate.

There are many ways that celiac disease can disguise itself. Here are four to especially look out for:

a?￠ A child with behavior or learning problems

Celiac disease can cause cognitive difficulty that has been called “brain fog.” The causes are unclear but may include nutritional problems, inflammation, or immunologic damage in the brain. It’s well known that children with iron deficiency - with or without anemia - do worse in school. ??Researchers suspect celiac disease may be linked to developmental delay and ADHD.

a?￠ Irritable bowel syndrome

There is an increased risk of celiac disease in the 10-15 percent of adults who carry the diagnosis of “irritable bowel syndrome” (IBS). Many of the symptoms of IBS such as diarrhea, constipation, bloating, and abdominal pain also occur in celiac disease.

a?￠ Iron deficiency

A simple blood test will detect low iron, a relatively common condition that is usually not from celiac disease. However, low iron may be the only clue to celiac disease, so it’s important to maintain a high index of suspicion. Remember that some patients can have both a relatively innocent cause of iron deficiency (such as poor dietary intake or menstrual blood loss) AND malabsorption of iron due to celiac disease.

a?￠ Osteoporosis

Untreated celiac disease - with its associated low vitamin D and decreased calcium absorption - increases the risk of osteoporosis. Although there is disagreement among experts, some researchers have advocated that all patients with osteoporosis be tested for celiac disease.

Others say to reserve routine testing for men and pre-menopausal women with osteoporosis because osteoporosis is less frequent in these groups compared to postmenopausal women and therefore it’s important to look for unusual causes such as celiac disease. In any case, all patients with osteoporosis should be considered for celiac testing on an individual basis.

It is unacceptable that millions of people are suffering from a disease that can usually be easily treated with diet. Patient and physician education is crucial. If you send this blog to one hundred of your friends, the odds are that one of them will have celiac disease and not know it. You could change somebody’s life.

For this weeka??s CBS Doc Dot Com, I discuss celiac disease with a world expert, Dr. Peter Green, Professor of Clinical Medicine and Director of the Celiac Disease Center at Columbia University Medical Center.

For online celiac disease resources:

The Celiac Disease Center at Columbia University

National Library of Medicine

Celiac Disease Foundation

Celiac Sprue Association

For more information on gluten-free diets for celiac disease:

www.celiac.com

Celiac Chicks

Glutenfree.com

Kinnikinnick Foods

Foods By George

About.com: Celiac Disease

Prostate Cancer: What You Should Know

2011-08-14T23:53:00.000-07:00

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When Dennis Hopper died of prostate cancer at age 74, my husband asked me: “Hey, I thought prostate cancer is slow-growing and doesn’t??kill men.”

Well, he’s right??about it usually being slow-growing, but prostate cancer is still the??second leading cause of cancer death in men. His question made me realize that there are some facts that everyone should know about prostate cancer.

Prostate cancer is very rare in men under age 40 and the incidence increases with age.??African-American men are at higher risk and Asian and Latin men are less likely that white guys to get it.??We don’t know why these ethnic differences occur.

Family history is important and men with an affected brother or father are twice as likely to get prostate cancer. Although genes are undoubtedly responsible, there are no genetic tests that can predict it.??Some studies show obese men and men who eat large quantities of red meat and dairy products are more at risk.??A vasectomy doesn’t seem to matter, nor does exercise or prior prostatitis.

Prostate cancer grows slowly and the prostate specific antigen (PSA)??test or a digital rectal exam can screen for an enlarged prostate. The PSA test can be false positive for many reasons and the only way to diagnose suspected prostate cancer is by a biopsy.

The most important marker for a cancer in the prostate is the Gleason score.??This grade (on a scale of 1 to 10) tells us how advanced or aggressive the cancer is.??The pathologist can see if the cells are suspicious for atypical changes or are high-grade.??The extent of the tumor determines the stage.

Once a cancer has been diagnosed, graded and staged, the confusing choices of treatment come into play. Because most prostate cancer occurs in older men and it is slow growing, many men choose “watchful waiting.” By following PSA tests and ultrasounds, we can determine if the cancer is growing.

For many men nothing more needs to be done because the cancer causes them no problems. For younger men or men with high Gleason scores, treatment is usually surgical removal of the prostate or radiation of the prostate gland.??Radiotherapy can also occur with seed implantation of radioactive material. Hormone therapy or cryoablation is also used less often.

The Prostate Cancer Foundation and the Mayo Clinic have?? more good information if you wish to delve further.

Rest in peace, Dennis Hopper. I think I’ll take a stroll down memory lane and rent “Easy Rider” again.??I haven’t seen it in 40 years!

Live Longer With Strong Social Ties

2011-08-14T23:52:00.000-07:00

A study published in the July PLoS Medicine is getting a lot of press for its conclusion that strong social networks are related to increased lifespan.

The meta-analysis of 148 studies involving 308,849 people found that those with stronger relationships were 50 percent??more likely to survive over 7.5 years of follow-up. What’s more, the researchers reported that a lack of strong social ties is as bad??healthwise as drinking or smoking, and worse than not exercising or being obese.

But although the association between strong social ties and improved longevity seems robust, other factors could be at play, and applying the findings in clinical practice could be difficult. And sorry, Facebook fanatics: Online “friendships” aren’t thought to count as much as in-person ones do. (PLoS Medicine, New York Times, TIME, The Atlantic)

Diabetes Criminals And Diabetes Police

2011-08-14T23:51:00.000-07:00

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At TCOYD??[Taking Control Of Your Diabetes], one of the sessions I attended was about Diabetes Police (Healthcare Providers) and Diabetes Criminals (People With Diabetes).??And I was a little taken aback by the title of the session, but we used it to our advantage when we walked into the session a few minutes after it had already started.

“Okay, we see a few late stragglers in here.??It’s not like they had to be on time or anything,” Dr. Edelman quipped from the front of the room, giving us a smirk. ??

“I’m sorry we’re late.??But what do you expect???We’re the criminals, man!”??I shot back at him.??And the crew of us “criminals” took up the last few rows, our smartphones at the ready to Tweet out the best of the session.??(We were the total nerd row.

The charismatic team of Dr. Bill Polansky and Dr. Steve Edelman were running this session, and it was packed with both PWDs [people with diabetes], caregivers, and medical professionals.??Bill and Steve took to the white board, asking first for complaints that PWDs have about healthcare providers.

The list that was compiled ran the familiar gamut:

HC providers are always late.

They dona??t work together (one doc may recommend a treatment that contradicts a specialist’s recommendation for another condition you may be living with).

Docs set unreasonable goals.

Patients are blamed for blood sugar numbers (the whole “good numbers/bad numbers” discussion).

Patients want positive feedback, too, not just the negative stuff.??(Stacey brought up a good example of her most recent A1C being the lowest she’s ever achieved, and her doctor said, “Nice job!!”??It feels good to get patted on the back when you deserve it.)

Docs say that they dona??t have enough time to answer all the questions.

Audience member:??a??[My blood sugar numbers were] creeping up for a long time, but a??all of a sudden I was diabetic.a???? Where was the preventative measure to bring them down?a??

One patient summed up the “seven minutes we get” sentiment with this statement:??a??Ita??s so hard to believe hea??s paying attention because his hand is always on the doorknob.a??

But it wasn’t all patients ranting about healthcare professionals.??The HCPros had their time to voice their frustrations, too:

Insurance companies actually grade us on the number of diabetes patients that make it a??to goal” — regardless of the advancements that patients make, even if they dona??t hit a??goal.a??

One doc asked:??”Why cana??t patients ‘get to the point’ and bring the most diabetes-related issues to the table???I want to help, but I can’t help with every issue they have.”

Hearing the statement a??You dona??t know what ita??s like to have diabetes.a????Hard to make improvements suggestions because they arena??t taken seriously. (a??I am an RN and my son thinks I cana??t prick his finger, but his girlfriend can prick his finger.a??)

a??I ran out of my meds.a????Patients need to remember to renew/order/take their medication.

When patients dona??t update their medication list.??a??You know what Ia??m on.a??

When patients dona??t know their own A1Cs

a??You never told me I was borderline diabetic.a????Frequently, patients arena??t very honest about what theya??re eating.??(Bill:?? a??So theya??re also liars?a??)??Going on another medication costs too much, they dona??t want a second med, etc.??(Bill:?? Jokingly points to the word a??idiotsa?? on the sign.)

Patients make up numbers on their logbooks, but the downloaded blood sugars form their meters tell a different story.

It was a good natured discussion, but some important points were raised by both sides.??It’s not just the PWDs who are grappling with the healthcare system — doctors and nurses and CDEs are tackling issues, too. “We’re graded on how many patients we have that make that goal [the A1C target set by the American Diabetes Association], even if the patient has made tremendous advancements towards good health.”

(This issue resonated for me, because I’ve always struggled for an A1C under 7%.??That pre-pregnancy goal took me a long time to achieve, and I conceived my child at an A1C of 7%.?? It dropped immediately and stayed very low and steady throughout my pregnancy, but for me, a goal of 6% pre-pregnancy was near impossible for me to hit without harrowing lows.?? My doctor and I had to take the blanket recommendations into account, of course, but we also had to tailor goals to my individual diabetes needs.)

I want this tattooed on my face.

The most refreshing moment of the session was near the end, when Bill took the microphone and offered this story as almost an aside. ??

a??I realized Ia??ve told patients to keep 3 days of food records, but Ia??ve never done it, myself.??So I tried it.??And I lied.?? I lied on my food record, to myself.??I was like: a??I ate one Oreo.a????But I ate a whole sleeve of cookies.a??

The doctor-patient relationship is just like any other — filled with dissenting opinions, moments of high triumph, and personal emotions.??Living with diabetes, our disease requires our detailed attention every moment of every day.??My hope is that healthcare professionals left this session understanding that their patients are more than their A1Cs, and that patients walked away knowing that healthcare pros are people, too.??And that there’s a way we can meet in the middle and improve our diabetes health.

A Doctor’s Letter To Patients With Chronic Disease

2011-08-14T23:47:00.001-07:00

Dear Patients:

You have it very hard — much harder than most people understand.??Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I, too, cana??t understand what your lives are like.??How do you answer the question, a??How do you feel?a?? when youa??ve forgotten what a??normala?? feels like???How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue???How do you decide when to believe them or when to trust your own body???How do you cope with living a life that wona??t let you forget about your frailty, your limits, your mortality?

I cana??t imagine.

But I do bring something to the table that you may not know.??I do have information that you cana??t really understand because of your unique perspective, your battered world.??There is something that you need to understand that, while it wona??t undo your pain, make your fatigue go away, or lift your emotions, it will help you.??Ita??s information without which you bring yourself more pain than you need suffer. Ita??s a truth that is a key to getting the help you need much easier than you have in the past.??It may not seem important, but trust me — it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death.??I am not talking about doctors being afraid of the limits of their knowledge.??I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from — that we are normal, fallible people who happen to doctor for a job.??We are not special.??In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help.??We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic, unsolvable disease stands square in our way.??You dona??t get better, and it makes many of us frustrated, and it makes some of us mad at you.??We dona??t want to face things we cana??t fix because it shows our limits.??We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different.??You see us getting frustrated.??You see us when we feel like giving up.??When we take care of you, we have to leave behind the illusion of control, of power over disease.??We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress.??You are the rock that proves how easily the ship can be sunk.??So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge.??You know more about your disease than many of us do a??- most of us do.??Your MS, rheumatoid arthritis, end-stage kidney disease, Cushinga??s disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder a??- your defining pain — is something most of us dona??t regularly encounter.??Ita??s something most of us try to avoid.??So you possess deep understanding of something that many doctors dona??t possess.??Even doctors who specialize in your disorder dona??t share the kind of knowledge you can only get through living with a disease.??Ita??s like a parenta??s knowledge of their child versus that of a pediatrician.??They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor a??- especially one youa??ve never met before -a?? you come with a knowledge of your disease that they dona??t have, and a knowledge of the doctora??s limitations that few other patients have.??You see why you scare doctors???Ita??s not your fault that you do, but ignoring this fact will limit the help you can only get from them.??I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand.??You encounter doctors intermittently (more than you wish, perhaps). I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors.??There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:

Dona??t come on too strong a??- yes, you have to advocate for yourself, but remember that doctors are used to being in control.??All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion.??Thata??s a good thing in the long-run, but few doctors want to be greeted with that reality from the start.??Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.

Show respect a??- I say this one carefully, because there are certainly some doctors who dona??t treat patients with respect, especially ones like you with chronic disease.??These doctors should be avoided.??But most of us are not like that — we really want to help people and try to treat them well.??But we have worked very hard to earn our position — it was not bestowed by fiat or family tree.??Just as you want to be listened to, so do we.

Keep your eggs in only a few baskets a??- find a good primary care doctor and a couple of specialists you trust.??Dona??t expect a new doctor to figure things out quickly.??It takes me years of repeated visits to really understand many of my chronic disease patients.??The best care happens when a doctor understands the patient and the patient understands the doctor.??This can only happen over time.??Heck, I struggle even seeing the chronically sick patients for other doctors in my practice.??There is something very powerful in having understanding built over time.

Use the ER only when absolutely needed a??- Emergency room physicians will always struggle with you.??Just expect that.??Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home.??They might not fix your pain, and certainly wona??t try to fully understand you.??Thata??s not their job.??They went into their specialty to fix problems quickly and move on, not manage chronic disease.??The same goes for any doctor you see for a short time — they will try to get done with you as quickly as possible.

Dona??t avoid doctors a??- one of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address.??I cana??t work that way, and I dona??t think many doctors can.??Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made.??Ita??s OK to keep a list of your own problems so things dona??t get left out a??- I actually like getting those lists, as long as people dona??t expect me to handle all of the problems.??It helps me to prioritize with them.

Dona??t put up with the jerks -a?? unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you.??Some docs are not cut out for chronic disease, while some of us like the long-term relationship.??Dona??t feel you have to put up with docs who dona??t listen or minimize your problems.??At the minimum, you should be able to find a doctor who doesna??t totally suck.

Forgive us a??- Sometimes I forget about important things in my patientsa?? lives.??Sometimes I dona??t know youa??ve had surgery or that your sister comes to see me as well.??Sometimes I avoid people because I dona??t want to admit my limitations.??Be patient with me a??- I usually know when Ia??ve messed up, and if you know me well I dona??t mind being reminded.??Well, maybe I mind it a little.

You know better than anyone that we docs are just people a??- with all the stupidity, inconsistency, and fallibility that goes with that a??- who happen to doctor for a living.??I hope this helps, and I really hope you get the help you need.??It does suck that you have your problem — I just hope this perhaps decreases that suckishness a little bit.

Sincerely,

Dr. Rob

Free iPhone App For Cancer Patients: A Must-Have Tool From ASCO

2011-08-14T23:35:00.000-07:00

Cancer.net, an oncologist approved cancer information site from the American Society of Clinical Oncology (ASCO), has released a free iPhone and iPad app a?? full of handy features for cancer patients.

The free app allows cancer patients and their family members to look up??pertinent??information based on cancer type and download a wealth of oncology related information in the form of videos, podcasts, and up to date articles.

Where the app truly shines is in there key features: Ability to store questions, medications and symptoms. ??The way this app implements these key features is absolutely stunning, and makes the application a must have for cancer patients and their family members.

This review will explore these features and how your patients can use this app.

Questions

Questions can be assigned to particular physicians, and the app brilliantly includes a a??suggestionsa?? area a?? where patients can see questions they might want to ask. ??This is taking patient empowerment to a significantly greater level. ??Whata??s more, you are given the option of storing your answer in voice form!

Why is this important? Many patients undergoing chemotherapy have peripheral neuropathy, making it difficult for them to type on even a touch keyboard. ??Allowing them to record their voice, or possibly even asking their physician to record their answer, makes this feature very useful.

Medications

The Medications section allows patients to store their various prescriptions in detail a?? you are able to assign a dose, frequency, start date, and the provider who prescribed the medication to you. ??This section could definitely be made more useful. ??Many chemotherapy regimes are very structured, and enabling patients to put start and end dates on a calendar would have been very useful. ??Another key area to add would be radiation therapy a?? something many cancer patients undergo in conjunction with their chemotherapy regimes.

Symptoms

The Symtoms section has a great user interface, enabling patients to choose from various severities, and time stamping their symptoms.??Youa??re given the ability to put in ancillary notes within this section as well.

Literature Content

The app provides a wealth of oncology related information in the form of articles, news, and videos. You are able to download this content within the app, and some of the information is natively provided as well.

Conclusion

Cancer.net Mobile is a must have application for cancer patients and their family members. ??Ita??s provides a wealth of oncology related information that the American Society of Clinical Oncology (ASCO) signs off on, assuring you of the legitimacy of the content.

While the multimedia content itself makes the application very valuable a?? the ability to store questions in an innovation fashion, along with a medication and symptoms section, makes the application one of the best in the App Store for patients.

iTunes Link to Cancer.net Mobile:??http://itunes.apple.com/us/app/cancer-net-mobile/id433501257?mt=8

Dense Nasal Hair May Reduce Asthma Risk In Allergy Sufferers

2011-08-12T01:25:00.000-07:00

Researchers in Turkey found that there is an association between nasal hair density and risk of asthma developing in patients with seasonal rhinitis patients. No joke… They published their findings in the International Archives of Allergy and Immunology in March 2011.

The rate of asthma found in patients with little or no nasal hair was 44.7% whereas only 16.7% of patients with a dense forest of nasal hair had asthma.

They hypothesize that increased nasal hair improves allergen filtration thereby preventing the allergens from irritating the airway. The assumption here being that allergen irritation of the airway can potentially cause asthma.

IF this is true (and that’s a big if)… patients with allergies should be encouraged to grow nice thick nasal hair to prevent future asthma!

Read the research abstract here!

Reference:

Does Nasal Hair (Vibrissae) Density Affect the Risk of Developing Asthma in Patients with Seasonal Rhinitis? Int Arch Allergy Immunol. 2011 Mar 30;156(1):75-80

Muscle Strain: Should You Treat It With Hot Packs Or Cold Packs?

2011-08-12T01:24:00.001-07:00

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Along with blisters and sprains, muscle strains are among??the most common afflictions for active persons in the outdoors. Common medical??dogma is to use the a??RICEa?? ??approach for??sprains and strains ofa??rest, ice (application of cold), compression, and??elevation.

This is more applicable to sprains (e.g., an ankle sprain) than to??strains, because the sprained body part is usually a limb (ankle, knee, wrist)

that is amenable to this approach. Strains more often involve larger muscle

groups, such as those in the back, chest, thigh or abdomen, or??difficult-to-approach areas, such as the neck or groin.

Prevailing theory for treatment of a muscle strain is that??one applies external cold for 24 to 48 hours, and discontinues it after 72??hours, at which time one begins application of external heat. The rationale is

that swelling (from leakage of blood and tissue fluid) and inflammation prevail??in the first two days, and that after three days, one wishes to increase local??circulation and augment reabsorption of the fluid that has collected. There is??some science to this, and these recommendations have been around for as long as??I can recall.

I just read a paper entitled a??Heat or Cold Packs for Neck??and Back Strain: A Randomized Trial of Efficacy,a?? authored by Gregory Garra and??his colleagues (Academic Emergency??Medicine 2010;17:484-489). The purpose of the study was to compare the??pain-relieving benefit of heat versus cold in the treatment of back and neck??strains. The authors started out with the scientific hypothesis that there??would be no difference between the two temperature modalities. Patients??included in the study were 18 years of age or older. All of the patients??received 400 milligrams of ibuprofen orally and then were assigned in a random??fashion to receive 30 minutes of either a heating pad or a cold pack applied to??the injured body region. A variety of methods were used to assess pain before??and after therapy.

There were 31 patients in the heat-treated group and 29??patients in the cold-treated group. In the final analysis, there was no??difference between the groups either in their demographics or in response to??the therapies. The authors admitted that pain relief may have been due to the??painkiller anti-inflammatory drug ibuprofen, and not to the heat or cold??therapies. However, if there was an additional beneficial effect from the heat??or cold, no difference between the two was noted.

So, what can we conclude from this study? Really, not much.??The confounding factor of administration of ibuprofen interferes with any??direct conclusion about the heat and cold, other than that in combination with

ibuprofen, neither appears to offer an advantage over the other.?? Indeed, there wasna??t even a control group,

which in this case would have been ibuprofen administration alone without??adding heat or cold. What if ibuprofen alone generated the same amount of??improvement? Furthermore, how about a longer duration of heat/cold therapy???Might that have yielded more or less improvement? What about time to complete

resolution of symptoms? It would have been interesting to follow these patients??until their pain was completely resolved, to determine if despite the rapid??effects upon pain relief, there were any implications to time to total resolution??of symptoms (and presumably, healing).

Based on this particular study, I really cannot draw any??conclusions, so will stick with the dogma until someone reports something to??make me change the traditional approach. My advice to the readers is to stick??with cold first for acute muscle strains, then transition to heat after 72??hours.

This post, Muscle Strain: Should You Treat It With Hot Packs Or Cold Packs?, was originally published on
Healthine.com by Paul Auerbach, M.D..

A New Way To “Blow Up” Twitter: Tweet Fit App Tweets For You While You Exercise

2011-08-12T01:21:00.000-07:00

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Tweet_Fit is an amazing idea that is similar in nature to Kickbee. Here are the details:

Developed by a UK design student, the connected gym accessory attaches to the end of a standard dumbbell and sends updates to your Twitter account when you start and stop your workout. Take it offline and it guides you through the perfect curl. Tweet_Fita??s designer points out that it offers a novel way for trainers to keep track of their clients, and can be used to spur healthy competition between friends.

A New DNA Test For Skin Cancer: Scotch Tape?

2011-08-12T01:20:00.001-07:00

a??I hate needles.a?? Patients say this to me everyday. When you think about it, who a??likesa?? needles?

Skin biopsies are relatively painless, but they still involve the dreaded needle and always leave scars. The trouble is we dermatologists cannot guarantee??that a mole isna??t skin cancer without sending a biopsy for pathology. That is, until now.

Although it is not available in clinic yet, an almost incredible new innovation might allow us to determine if a mole is cancerous by testing the DNA of the mole. It sounds like ita??s from an episode of CSI, but ita??s real.

Melanomas have DNA (messager-RNA to be exact, but ita??s a little complicated) that differentiate them from normal moles, so testing the mole for melanoma requires only a tiny sample of skin. Fortunately, no needles are needed a?? in fact, no sharp objects are necessary at all.

In order to check if a mole is skin cancer, the doctor will stick a pice of tape to the mole and pull it off. Although those of us with hairy chests might think it scary, ita??s painless. The material that sticks to the tape is tested to see if there is evidence of melanoma.

So far, the test seems remarkably accurate. While it takes us doctors up to 40 skin biopsies to find one melanoma, the tape might find melanoma nearly every time. This is potentially an efficient (and cost-effective) way to diagnose skin cancer. I hope it inspires more innovations that provide increased patient comfort, accurate diagnoses, and cost savings.

May is melanoma awareness month. Have you checked yourself or someone you love for melanoma? Do it??in May!

Tips To Reduce A Physician’s Risk Of Being Sued

2011-08-12T01:17:00.000-07:00

A few pearls from a session on legal risks and mitigation strategies from an HM a??11 session by Harvarda??s Allen Kachalia, MD, JD:

–A relatively small number of injured patients actually file claims and get compensation.

–Many filed claims do no have actual errors in them, but the majority do.

–Poor outcomes are correlated with claims, and so is patient satisfaction. Satisfied patients are less likely to file.

–There is no evidence that hospitalistsa?? risk of having claims filed against them is higher than primary care internists.

To protect yourself against claims, document well. Dona??t go back and change a record (you can addend, but dona??t alter). Document as contemporaneously as possible. Also, a??as simple as it sounds, dona??t abandon your patient, and dona??t stop providing necessary care,a?? he said.

When an error occurs and it comes time to have the disclosure talk with the patient, dona??t go it alone. Call Risk and/or Safety to help, a??just like youa??d call cardiology for ST elevations, even though you pretty much know what to do.a??

In the disclosure conversation, be sincere and honest; state the facts; do not lay blame; assure all facts will be gathered. You can say you are sorry for the bad outcome, and that the hospital will find out what happened. Assure the patient and family that steps will be taken in the future to prevent this from happening again. And finally, document the family discussions.

Contraception i-Pocketcards: Med Student Cheat Sheets For iPhone

2011-08-12T01:16:00.000-07:00

a??A baby crying is the best birth control.a?? a?? Anonymous

Despite a world full of crying babies, access to effective and timely contraception remains a pressing womena??s health issue.

All students in the health professions learn the basics of contraception.?? Most health care professionals will prescribe contraception at some point in their training or clinical practice.?? Some clinicians make contraception and family planning the primary focus of their practice.

Contraception i-pocketcards is a resource for each of these health care providers a?? from the medical student working his first gynecologic clinic to the experienced ED doctor wondering which emergency contraceptive method to use in her patient with a history of DVT.

Reviewed on the iPod Touch.?? Also available on the iPhone and iPad.

If you visit a medical book store, you may notice the rack of medical pocket cards: EKG interpretation, 2011 Antibiotic guide, medical Spanish, and many others.?? As a medical student, these cards may have been your lifeline a?? they were mine.?????? Likely among these cards is one related to prescribing contraception. Contraception i-pocketcards, like many good medical apps, is one that effectively replaces another white-coat-cluttering object.?? For $3.99, this app contains all of the information about contraception found on six pocket cards.

Organization

Content is viewed in two ways.?? The classic view (seen above) is what the physical pocket cards look like.?? The table of contents (TOC, seen below) view is more adapted to a mobile device, allowing the user to navigate through menus instead of zooming in and out of pocket card images.?? Unfortunately, the TOC view still requires some zooming.

Content

The content in Contraception i-pocketcards is surprisingly complete for an app in this price range, and the breadth of information makes this app useful for beginning learners and experienced clinicians alike.

Content includes:

Contraceptive Methods:

A table comparing the effectiveness of various contraceptive methods.?? For those times in clinic when a patient asks a??which pill is the most effective?a??

Oral Contraceptive Pills:

The basics.?? General prescribing information about contraceptive pills, their use and safety.

CIs for Estrogen Contraception:

A list of contraindications for estrogen-containing contraceptive methods.

Contraception in Special Cases:

Answers questions like: Which pill is safe in nursing mothers??? How much estrogen is safe in older women?

Emergency Contraception:

A table comparing three common methods for emergency contraception.

Intrauterine Contraception:

Indications and general information about IUDs.

Quickstart Algorithms:

Directives from www.reproductiveaccess.org on how to initiate contraception on request.

WHO Eligibility Criteria:

A table of World Health Organization guidelines for contraceptive safety in women with various co-morbid conditions (e.g. HIV, cirrhosis, breast cancer) or who are taking medications with potential drug interactions (e.g. antiretrovirals, anticonvulsants).

OCP Formulations:

A table matching the oral formulation with brand names, categorized by contraceptive class.

Non-Oral Formulations:

Characteristics of injectable, implantable, transdermal, and ring contraceptive devices.

Likes:

Adequate citation of sources and inclusion of national and international guidelines.

Broad audience: this app is useful at many levels of medical training and in many clinical settings.

Broad content: includes basic information on most contraceptive methods, and in-depth information on oral contraception.

Tables make information quickly accessible.

Unlike physical pocket cards, this one-time purchase gets updated periodically.

Dislikes:

User interface could be improved.?? A drawback of the table views is the small text that requires zooming in to see small text.

Important contraception topics are missing or sparsely mentioned, including: postpartum contraception, sterilization, and algorithms for initiating emergency contraception.

In future versions, I would like to see more information to help patients and clinicians choose a method (non-contraceptive benefits, side effects, key questions to ask patients).

Conclusion:

Providers looking for a mobile alternative to more exhaustive resources (like Managing Contraception For Your Pocket or a??The Red Booka??) will find this appa??s content incomplete.

Nonetheless I recommend this app to students learning the basics of contraception and primary care and emergency physicians who prescribe emergency contraception or OCPs.

At $3.99, this app provides a wealth of information a?? the nuts and bolts of contraception a?? and replaces the physical pocket card that we might otherwise carry.

Link to the App Store: Contraception i-pocketcards ($3.99)

Food Allergies: Treating Severe Allergic Reactions

2011-08-12T01:15:00.000-07:00

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An allergic reaction in an outdoor setting can rapidly become a life-threatening emergency. While most of us think of food allergies as annoyances, they can be quite serious or even life threatening. Itchy skin rashes can progress to breathing difficulty, swollen soft tissues (e.g., lips, tongue, throat) that compromise the airway, and low blood pressure or even shock. Therefore, ita??s important to be familiar with the signs and symptoms of severe allergy and to be prepared to respond rapidly in the event of an emergency.

An EpiPen (an epinephrine auto-injector)

The National Institute of Allergy and Infectious Diseases has released Food Allergy Guidelines for healthcare professionals to help guide the care of patients with life-threatening food allergies. The full guidelines can be found at http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx. Here are??some key points:

Emergency Care

The first-line treatment for a very severe allergic reaction (anaphylaxis) is an injection of intramuscular (IM) epinephrine (adrenalin). Failure to administer epinephrine early in the course of treatment has been repeatedly implicated in fatalities from anaphylaxis.

IM epinephrine (given in the front or side of a big muscle of the thigh, e.g., the vastus lateralis muscle)??is recommended over injection into subcutaneous tissues because this method of injection provides a more rapid increase in bloodstream and tissue concentrations of epinephrine.?? When a 1:1,000 epinephrine solution (this is a standard preparation) is used, the recommended dose is 0.01 mg/kg with a maximum dose of 0.5 mg. Autoinjectors, such as the EpiPen, typically are preloaded to deliver 0.3 mg for adults and 0.15 mg for children.

Epinephrine has an onset of action within minutes but is rapidly broken down in the body. Therefore, the effect is often short-lived?-?-a??repeated doses may be necessary. If a patient responds poorly to the initial dose or has ongoing or progressive symptoms despite initial dosing, repeated dosing may be required after five to 15 minutes. 10 percent to 20 percent of persons who receive epinephrine will require more than one dose before recovery from symptoms.

Additional Medications

These medications are often given at the same time as epinephrine. They are not meant to be given sequentially as listed, with the exception of epinephrine as first-line treatment.

Antihistamines

a??H1a?? antihistamines are useful only for relieving itching and the raised red rash (wheals) of an allergic reaction. They do not relieve airway obstruction caused by tissue swelling, shortness of breath, wheezing, gastroenteric symptoms, or low blood pressure. Therefore, they should be considered additional therapy and should not be substituted for epinephrine.

Bronchodilator Medications

For the treatment of bronchial spasm that is not responsive to IM epinephrine, inhaled bronchodilators, such as albuterol, should be used as needed and should be considered to be additional therapy to the administration of epinephrine.

Corticosteroids

Very little information is available to support or refute the use of corticosteroids (a??steroidsa??) for the treatment of acute anaphylaxis. However, their use is prevalent and supported by many health care professionals. Corticosteroids are not helpful in the treatment of acute anaphylaxis due to their slow onset of action (four to six hours). These agents often are given because of their anti-inflammatory properties that benefit recovery from allergic and inflammatory disease, and also because they may help prevent waxing and waning, or prolonged, reactions, which occur in up to 20 percent of afflicted persons.

IV fluids

Many patients with severe allergic reactions require infusion of intravenous (IV) fluids. Massive fluid shifts can occur rapidly in anaphylaxis due to leaky blood vessels.?? Any patient whose low blood pressure does not respond promptly and completely to injected epinephrine should receive large-volume fluid resuscitation, with normal saline being the preferred treatment. Large-volume fluid resuscitation should be initiated immediately in patients who present with a severe drop in blood pressure when moving from the lying-down to the upright (standing) position, low blood pressure in any position, or incomplete response (with respect to blood pressure) to IM epinephrine.

Supplemental Oxygen Therapy

Oxygen should be administered initially to all patients experiencing anaphylaxis.

Patient Positioning

The patient should be placed in a lying-down position (if tolerated) with the lower limbs raised. Persons with breathing difficulty or vomiting may not tolerate a recumbent position.

Anaphylaxis

Anaphylaxis has many different symptoms, and can even look like a severe asthma attack (even for those not diagnosed with asthma). Symptoms include:

Heart: drop in blood pressure (anaphylactic shock), fainting, chest pain, paleness

Respiratory: swelling of the throat, hoarseness, choking, difficulty breathing, coughing, wheezing

Ear, nose and throat: mouth tingling, itching, swelling; watery, red, itchy eyes; runny itchy nose, nasal congestion

Abdomen: nausea, vomiting, diarrhea, abdominal cramps, uterine cramps

Skin: hives, flushing, itching, swelling

Neurological: a sense of impending doom, anxiety, headache

Allergic reactions do not always present with skin symptoms; most often they are multi-system, but can also present with only a single organ system being affected?? (e.g., with only severe airway constriction).

This post, Food Allergies: Treating Severe Allergic Reactions, was originally published on
Healthine.com by Paul Auerbach, M.D..

Does “I Know CPR” Mean You Can Do CPR?

2011-08-09T00:14:00.000-07:00

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While I was browsing the produce section of my grocery store the other day, the sound of a panicked voice coming over the storea??s loudspeaker made me jump. a??Does anyone in the store know CPR? Anyone? CPR? We need you in baked goods!a??

I froze. In theory, I know how to perform CPR — cardiopulmonary resuscitation. I took a two-hour course on it nearly 25 years ago. But I hadna??t given it much thought since then and I certainly hadna??t practiced what I learned.

My mind started whirling as I tried to remember the sequence of steps. Theya??d changed the rules a few years back — I knew that much — so I wouldna??t have to do mouth-to-mouth resuscitation. But where exactly on the chest was I supposed to push? Should I form a fist and push down with my knuckles, or use the ball of my hand?

Suddenly, sirens wailed outside the store. The rescue squad had arrived. Too late, as I learned afterward, for this man, who was a victim of a sudden cardiac arrest. This type of heart attack strikes so fast that there usually arena??t any warning signs. You might see someone grasp his or her chest, collapse, twitch and gasp a few times, and then lie deathly still.

At that point, every minute counts. Enough oxygen remains in the persona??s bloodstream to nourish the brain for several minutes — but a bystander has to circulate oxygenated blood to the brain and other organs by pushing down on the chest hard and fast, mimicking the heartbeat.

Ia??m a health writer. I knew this intellectually. But until those agonizing moments in the grocery store, I never really understood on a gut level just how important every minute is.

The first thing I did when I got home that day was look up an article on CPR published in the Harvard Heart Letter. Herea??s the gist of what I learned about doing CPR for a sudden cardiac arrest:

Call 911, or have someone else do it.

Place both of your hands, one on top of the other, over the middle of the persona??s chest.

Press down hard enough to make the chest move inward about 1.5 to 2 inches.

Relax to let the chest rebound.

Repeat this press-and-relax motion quickly, almost twice a second if you can. (Try keeping time to the old Bee Geea??s song, “Stayina?? Alive.”)

Dona??t stop if the person seems to gasp or move! Keep pushing until help arrives.

Final piece of advice: Be prepared! In an emergency, ita??s hard to think straight — something Ia??ve learned the hard way. So take a refresher course or watch this video on CPR once in awhile so youa??ll remember what to do should the need arise. (Ia??ve even started to practice the CPR a??hand-and-arm movesa?? as part of my daily exercise regimen.)

Today, only about 5 percent??of people survive a sudden cardiac arrest. Bystander CPR more than doubles an individuala??s chances of surviving. Wouldna??t you want to a??lend a handa?? to help someone in cardiac distress? I know I would — and next time I hope to be better prepared.

- Ann MacDonald, Editor, Harvard Health Publications

How Much Vitamin D Do You Need?

2011-08-09T00:13:00.001-07:00

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How much vitamin D is enough, and whata??s the best way to get your daily dose of the so-called sunshine vitamin? It depends who you ask.

I just attended the latest Forum at the Harvard School of Public Health. The title, a??Boosting Vitamin D: Not Enough or Too Much?a?? was a tip-off that we werena??t going to get a simple take-home message. (Watch a??video of the event beginning Wednesday, March 30.)

Some background: Vitamin D isna??t really a vitamin. Ita??s a hormone. The body makes it when sunlight strikes the skin. This converts a cousin of cholesterol into a substance that ultimately becomes vitamin D. It is best known for helping the digestive system absorb calcium and phosphorus, so it is important for bone health. New research suggestsa??emphasis on suggestsa??that vitamin D may also be involved with regulating blood pressure, fighting cancer, and improving the immune system.

In November 2010, a panel of experts assembled by the Institute of Medicine presented its recommendation for vitamin D: 600 international units (IU) for everyone aged 1 to 70, and 800 IU for those over age 70. This was a substantial boost from the previous recommendation of 400 IU. JoAnn E. Manson, an IOM panelist, told the Forum that the new recommendations would help make sure that an estimated 97.5% of Americans were getting enough vitamin D to keep bones healthy.

Walter C. Willett and Bess Dawson-Hughes challenged that coverage, saying that the IOMa??s recommendations would leave millions of people with too little vitamin D in circulation. Ita??s a valid concern, since a growing number of Americans dona??t, or cana??t, get enough vitamin D from the sun. People prone to having too little vitamin D in circulation include those who:

are dark skinned

are obese

dona??t get outside

wear sunscreen or protective clothing

have digestive problems like celiac sprue or inflammatory bowel disease, which make it difficult to absorb vitamin D.

Willett and Dawson-Hughes say the evidence from large follow-up studies shows that taking higher amounts of vitamin D is safe and will help prevent disease.

All of the talk focused on taking vitamin D pills or fortifying food with it, not about getting it the way humans have for millions of yearsa??from the sun. Ita??s a hot-button issue, since too much exposure to the sun can cause skin cancer.

So herea??s my take from the Forum: If youa??re between the ages of 1 and 70, get at least 600 IU of vitamin D a day, or at least 800 if youa??re over 70. Food is the best way to get most vitamins, but not vitamin D. Only a few foodsa??salmon, tuna, sardines, milk, and fortified cerealsa??can give you more than 100 IU per serving. Supplements are the simplest, safest way to get vitamin D.

Being of sound mind and body, and responsible for my actions only, I also get my vitamin D the old-fashioned way. Ita??s a sunny afternoon, and Ia??m going out for a walk.

CT Scans For Kids: Is The Radiation Exposure Dangerous?

2011-08-09T00:12:00.001-07:00

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There was an interesting study published this week in the journal Radiology:

Rising Use of CT in Child Visits to the Emergency Department in the United States, 1995a??2008 (Abstract)

The results are not surprising to anyone who has been working in medicine in the US over the last fifteen years. Basically, in 1995, a kid visiting the ER had a 1.2% likelihood of getting a CT scan, and by 2008, that number was 5.9%.

I had written about this general phenomon not too long ago, in defense of the general increase of CT utilization in the ER, largely on the basis that CT is a better tool: it provides diagnoses in a rapid and timely manner, and excludes many potential life threats, saving lives and mitigating malpractice risk. That was largely relevant to the adult population, though, and kids are not, as they say, just little adults. The increase in scanning children is more dramatic, especially given the generally lower incidence of disease in kids compared to adults and the chonrically ill.

The experience I have had in the ER was comparable to the study findings. When I started training in the mid ’90s, CT scans were time-consuming, offered less than excellent images and were relatively uncommon to get in general, let alone in pediatric populations. By the time I started practice in 2000, things had changed dramatically. The image quality and diagnostic information a scan provided was way better. The development of high-speed helical scans made it much easier to get them on kids without sedation, which greatly lowered the operational barrier to getting them. The overall accessibility and use of scans were rising and the pediatric use rose in lockstep. There was little concern about the risks of radiation or the downside of getting a scan on a kid if there seemed to be a clinical indication. This was largely (but not entirely) driven by percieved malpractice risk, especially in the hot-button liability scenarios of head injuries and potential appendicitis. The feeling was that the consequences, both human and financial, in missing an epidural hematoma in a child were so gargantuan, and the risk inferent in the radiation so trivial, that why not do it? We ordered scans willy-nilly, it seems in retrospect.

Appendicitis is a little different. There is the fact that you had other options, including ultrasound, observation, and surgical consultation. So CT was not used quite as profligately for potential appendicitis. But for some cases (and some docs) it did become the test of choice. Ultrasound is frustratingly insensitive, time-consuming and operator dependent. Surgeons are difficult to get to come to the ER for a consult. And, especially in the malpractice insurance crisis in the early part of the decade, many docs were uncomfortable with the risk inherent in watchful waiting. This is not to excuse, but to explain why CT rates shot up, at least in my experience.

But a very welcome countervailing trend has definitely arisen over the past four years or so, especially in but not limited to the pediatric population, as the risks of radiation with regard to lifetime cancer incidence have become better understood and better publicized. This has spurred a change in practice in our ER, driven by the clinical leadership in concert with our radiologists and pediatricians. I don’t have numbers, but it seems like the use of scans for kids has slowly dropped and dropped over this time frame.

We have been assisted in this by the development and validation of some good decision-making rules for selecting the kids with head trauma who are likely to benefit from a CT scan. There’s also increased awareness and acceptance amoung patients and their families. It used to be that parents had an expectation of and even advocated for CT imaging. I’ve always been more of a diagnostic minimalist, and back in the day I would have to really go out of my way to convince some parents that a CT scan was not necessary. Now it seems all I have to say is that “We have learned that this is a lot of radiation to focus on a growing brain/set of genitals,” and the parents are nodding and very accepting of my explanation that their child is not likely to benefit from a scan. We have also developed algorithms for the evaluation of abdominal pain which make it pretty clear that CT scans are discouraged unless there is a darn good reason. So things are changing, and for the better.

I recall a couple of years ago I blogged about a difficult diagnosis of appendicitis and the need to scan a young boy. It was complicated by the fact that the parents, from the Ukraine, has a remarkable fear of radiation, due to the Chernobyl incident. I had reassured the parents that “I had a five-year-old son, and if it were my son with the same pains, I would not hesitate to put my son in the scanner.” At the time, that was true. I’m not so sure that I would make that assurance today. Now, I am much more likely to treat kids with observation (either in house or at home).

The pendulum swings, but ever so slowly.

Morgellons: When People Mistakenly Believe They Have Parasites

2011-08-09T00:10:00.001-07:00

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I saw a patient recently for parasites.

I get a sinking feeling when I see that diagnosis on the schedule, as it rarely means a real parasite.?? The great Pacific NW is mostly parasite free, so either it is a traveler or someone with delusions of parasitism.

The latter comes in two forms: the classic form and Morgellons. Neither are likely to lead to a meaningful patient-doctor interaction, since it usually means conflict between my assessment of the problem and the patients assessment of the problem.?? There is rarely a middle ground upon which to meet. The most memorable case of delusions of parasitism I have seen was a patient who?? I saw in clinic who, while we talked, ate a raw garlic clove about every minute.

a??Why the garlic?a?? I asked.

a??To keep the parasites at bay,a?? he told me.

I asked him to describe the parasite.?? He told me they floated in the air, fell on his skin, and then burrowed in.?? Then he later plucked them out of his nose.

At this point he took out a large bottle that rattled as he shook it.

a??I keep them in here,a?? he said as he screwed off the lid and dumped about 3 cups with of dried boogers on the exam table.

To my credit I neither screamed nor vomited, although for a year I could not eat garlic.?? It was during this time I was attacked by a vampire, and joined the ranks of the undead.

I have seen the occasional earthworm thought to be an intestinal parasite. Sometimes people start to pay attention to their stool, often for the first time, and note?? tube like structures?? that move in the water.?? Most likely mucous or undigested fiber wafting in the gentle currents of the toilet water.?? Doesna??t that sound romantic? The contents of the average stool, like hot dogs and laws, are better left unexamined.?? In those patients, an examination of the stool for worms and worm eggs is usually unrevealing and makes me glad I am not a microbiology technician.

Morgellons is, as best I can tell, a variant of delusions of parasitism.

Here is a thing about germs in general and parasites specifically: they have patterns and can be seen. There are patterns of disease and patterns of their life cycle.?? You can tell when a disease is probably delusional because the a??organismsa?? have no understandable pattern in the life cycle, the disease, the physiology, the anatomy or the epidemiology.

And germs can be seen. Well, most germs.?? Single celled organisms can be tricky and may require special stains to be seen under the microscope.?? Viruses are, of course, too small to be seen by a lab microscope. But parasites? Worms? These wee beasties are multicellular.?? They are big. Not a long way to the chemists big, but sizable, not hard to see with a microscope unless they have Romulan cloaking technology.

So what is Morgellons?

Before we continue, I would like to clarify one thing. I see patients self diagnosed with Chronic Candida Syndrome or Morgellons or Chronic Lyme or some other process.?? I do not doubt these people are ill and have symptoms that can be severe and life altering.?? What I may disagree with the patient is the reason for these symptoms.?? As best I can tell none of the above are due to an infectious disease.

Unfortunately when the patient is convinced they have an etiology for their symptoms and I think that their reason is nonsense, it does not lead to a therapeutic physician-patient interaction.?? I try and phrase it as gently and non-judgmentally?? as possible, but it rarely leads to a good time in the clinic.

Morgellons has existed as a disease since about 2002 and is an internet phenomena right up there with Rebecca Black.?? See.?? For a 54 year old man, I am hip. Morgellons received its name from a paper from 1935 called SIR THOMAS BROWNE AND THE DISEASE CALLED THE MORGELLONS By C.E. KELLETT, M.D., M.R.C.P. and published in Annals of Medical History, n.s., VII (1935), 467-479,?? where it refers to a disease from the 1600a?2s (yes 1600a?2s) described by said Thomas Browne.

a??Hairs which have most amused me have not been in the face or head, but on the Back, and not in Men but Children, as I long ago observed in that endemial Distemper of little Children in Languedock, called the Morgellons, wherein they critically break out with harsh Hairs on their Backs, which takes off the unquiet symptoms of the Disease, and delivers them from Coughs and Convulsions.a??

Who know what these hairs/worms really were; the 1600a?2s were not a time noted for its diagnostic accuracy. Unlike the modern disease, it was usually a disease of children and often fatal, so whether these a??hairsa???? had anything to do with the disease or were actual living creatures, one cannot say.

In?? 1715 when the first microscopist, Leuvenhoeck, took a look at the bristles and thought them a??inanimatea??, starting a long tradition of looking at the detritus presented by Morgellons patients and seeing nothing.?? I, for one, always look at the fluff brought in by Morgellons patients and have yet to see anything resembling a living creature. Diseases have come and gone in the past, like the English Sweating Sickness, so maybe there was a plague of virulent hairs (thata??s hair not hare, it was not a virulent bunny, for which Hef is undoubtedly grateful), but no longer.

Fast forward 400 years.?? Round about 2002 this disease was described on the net in regards a child with the symptoms now referred to as Morgellons, and since others have had the disease.?? It is transmissible as an internet meme, but not spread person to person.

What are the distinguishing characteristics of Morgellons??? Here are features as noted from the Morgellons Research Foundation

1. a??Filamentsa?? are reported in and on skin lesions and at times extruding from intact-appearing skin. White, blue, red, and black are common among described fiber colors. Size is near microscopic, and good clinical visualization requires 10-30 X. Patients frequently describe ultraviolet light generated fluorescence. They also report black or white granules, similar in size and shape to sand grains, on or in their skin or on clothing. Most clinicians willing to invest in a simple hand held commercial microscope have thus far been able to consistently document the filaments.

2. Movement sensations, both beneath and on the skin surface. Sensations are often described by the patient as intermittently moving, stinging or biting. Involved areas can include any skin region (such as over limbs or trunk), but may be limited to the scalp, nasal passages, ear canals, or facea?|and curiously, legs below the knees.

3. Skin lesions, both (a) spontaneously appearing and (b) self-generated, often with pain or intense itching. The former (a) may initially appear as a??hive-likea??, or as a??pimple-likea?? with or without a white center. The latter (b) appear as linear or a??pickinga?? excoriations. Even when not self-generated (as in unreachable regions of babiesa?? skin), lesions often progress to open wounds that heal incompletely (e.g., heal very slowly with discolored epidermis or seal over with a thick gelatinous outer layer.). Evidence of lesions persists visually for years.

4. Musculoskeletal Effects and Pain is usually present, manifest in several ways. Pain distribution is broad, and can include joint(s), muscles, tendons and connective tissue. Both vascular and a??pressurea?? headaches and vertebral pain are particularly common, the latter usually with premature (e.g., age 20) signs of degeneration of both discs and vertebrae.

5. Aerobic limitation is universal and significant enough to interfere with the activities of daily living. Most patients meet the Fukuda Criteria for Chronic Fatigue Syndrome as well (Fukuda, Ann. Int. Med., 1994). Cardiology data and consistently elevated heart rates suggest a persistent myocarditis creating lowered cardiac output that has been partially compensated for by Starlinga??s Law.

6. Cognitive dysfunction, includes frontal lobe processing signs interfering with logical thinking as well as short-term memory and attention deficit. All are measurable by Standard Psychometric Test batteries.

7. Emotional effects are present in most patients. Character typically includes loss or limitation of boundary control (as in bipolar illness) and intermittent obsessional state. Degree varies greatly from virtually absent to seriously life altering. a??

It is the filaments.?? Over the years I have?? seen a smattering of Morgellons and they bring in the filaments and I look at them under the microscope. I see hairs, and threads, and non-specific detritus, but never anything that resembles the results of a living creature. I have looked carefully at the skin of these patients, and have never seen an intradermal fiber.

So you can see why I am skeptical that this is anything but a version of delusions of parasitism.?? In one series of 25 patients

Most patients in this study (23 out of 25) had prior psychiatric diagnoses (most determined by specialists) as follows: 11 out of 25 bipolar disease; 7 out of 25 Adult ADD; 4 out of 25 Obsessive Compulsive Disorder (OCD); and 1 out of 25 Schizophrenia.

The same study had a hodgepodge of lab abnormalities, but there were not compared to matched controls. It may well be that the patients have some underlying inflammatory process that causes skin lesions and a feeling of the creepy crawlies and are misidentifying standard environmental material as associated with the diseases.?? But I am skeptical.

Against this hypothesis are the case reports where Morgellons is cured with Pimozide, an antipsychotic.?? Delusions of parasitism is often treated with olanzapine, another antipsychotic, but others have suggested pimozide is superior.?? Most infections would be unlikely to respond to antipsychotics, but I have never been satisfied with response to treatment as a means for confirming a diagnosis, that is a path better not followed without good reason. In my world docs often think if patients are improving on antibiotics the response is considered evidence of infection.?? I know better. But given the lack of a demonstrable parasite, a response to psychiatric medications is certainly suggestive.

So response to anti-psychotics would suggest patients with Morgellons could have?? a psychosis, but I keep in mind it does not necessarily extrapolate to all patients.?? I try to bear in mind that when patients present with odd symptoms that they attribute to worms and parasites, it may be simple misunderstanding.

As of this entry, no one has fulfilled Kochs postulates with Morgellons.

For those not immersed in infectious diseases, Koccs postulates were a series of criteria to demonstrate the causality of infections,?? Here there are, with the word filament substituted for microorganisms:

1) The filament must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.

2) The micro filaments must be isolated from a diseased organism and grown in pure culture.

3) The cultured filament should cause disease when introduced into a healthy organism.

4) The filament must be re isolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.

So far proponents of the disease are 0 for 4.

But if this disease is due something that can be visualized with the naked eye or a magnifying glass, it should be simple enough to characterize.?? Lets say you are a DNP and a member of ILADS. Well, I have to admit that you have lost some credibility with me.?? But lets say you saw a series of patients with Morgellons and you could see the fibers.?? There, right there. You can see them.?? Would you not biopsy the fibers??? Would you not try to characterize them??? Nope.?? So aggravating. It boggles the mind that someone could have a diagnostic coup right in front of them and let it pass.

Delusions of parasitism can be nosocomial. Well, not truly delusions, but patients can be convinced they have parasites when, in fact, they do not, and waste serious amounts of time and cash in pursuit of an imaginary diagnoses.

I recently saw a patient who had unexplained abdominal pain for a year and a half.?? The patient had an extensive evaluation and no explanation for the symptoms, and,?? looking for answers,?? eventually wandered into the arms of a naturopath.

One of the shows my eldest liked to watch was I Love the 80a?2s on VH1.?? The 80a?2s was the decade I was in medical school, residency and fellowship.?? When I watched I Love the 80a?2s I recognized virtually nothing of popular culture of time.?? Not the TV shows, the hair styles, the music. Nothing.???? It really brought home how consuming becoming a doc and a subspecialist is.?? A decade of my life was spent understanding medicine and infectious diseases. I am not complaining, mind you.?? There are lots of reasons people go to an alt med provider, but I do not think gullibility is on the list.

The patient with the abdominal pain and their spouse are educated people, why would they see a naturopath?

Looking for answers.?? Their areas of knowledge are totally removed from medicine and science, and while it is popular to bemoan the science illiteracy of the US population, and it is sorry, if your career arc was law, or finance or auto repair, or stoner at the 7/11,?? are you going to find time to become literate in medicine??? Doubt it.?? I cana??t design a bridge or fly a jet.?? Why would I expect someone who has mastered these tasks to understand medicine??? There are just so many hours in a day to accomplish tasks.

I have, as a further example, zero idea if my mechanic is giving me good diagnostic and repair advice on my car.?? I have to take everything he says on faith.?? I have neither the time or inclination to become expert in car repair, and most people do not have the time to become fluent in medicine.?? Am I gullible??? I do not think so.

I had my epiphany years ago when I told a father of a meningitis patient, your daughter has an infection in the fluid that surrounds her brain and he replied, could you phrase that in a way I can understand it??? He had no idea of basic brain anatomy or infections, and why would he? So I drew him a picture.?? It helped.

So anyway, the patient wandered?? into the lair of a naturopath and was diagnosed with parasites.?? Now mind you, the patient did not have symptoms that could be reasonably ascribed to parasites or worms, and, more importantly, had no risks for parasites or worms.?? The industrialized West is reasonably free of worms and their brethren.?? The naturopath did not do serology or blood work or even a simple stool study looking for the eggs of various worms.?? It is how I, along with a history and physical looking for the pattern of disease that marks a parasite, come to a diagnosis. No, he or she (I do not remember the pronoun used at the time) proudly used electrodiagnosis.

Proudly.?? As my patient related it to me, the naturopath, a graduate of Bastyr, (if there is an legitimate opportunity for a deliberate mispronunciation, it is with Bastyr) considered herself to be an expert in parasite treatment and diagnosis.

What is electrodiagnosis you ask?

There are many devices out there, so I do not know precisely which one the patient used.

My patient said they held an electrode in each hand, the naturopathic expert in parasitology twirled a dial, and told them that the reading indicated parasites. Really.?? I am proud that I did not burst out laughing during the interview, as from my perspective it was a?? ludicrous joke.?? But, as I mentioned, not everyone knows what I do, and EEGa??s and EKGa??s can also diagnoses a variety of medical problems, so why not parasite infestation?

Electrodiagnosis are said to measure disturbances in the bodya??s flow of a??electro-magnetic energya?? along a??acupuncture meridiansa?? but are expensive galvanometers that measure electrical resistance of the patienta??s skin when touched by a probe. Two pseudosciences in one.?? I have seen better. ?? It is sometimes called electroacupuncture according to Voll, or EAV, and was pulled out of Dr. Volls backside in the 1950a?2s.

a??The basic concept for all of the ElectroDermal screening devices, was the invention of Dr. Reinhardt Voll[1], who in the 1940s, discovered that the electrical resistance of the human body is not homogenous and that meridians existed over the body which may be demonstrated as electrical fields. Furthermore, he showed that the skin is a semi-insulator to the outside environment. By the 1950s Voll had learned that the body had at least 1000 points on the skin which followed the 12 lines of the classical Chinese meridians. Each of these points, Voll[2] called a Measurement Point (MP). Working with an engineer, Fritz Werner, Voll created an instrument to measure the skin resistance at each of the acupuncture points, patterned after a technique called Galvanic Skin Resistance (GSR). This was named Point Testing. In 1953, Voll had established the procedure that became known as Electro-Acupuncture according to Voll.a??

There is zero validity to making any diagnosis this way. Except, of course, the E-Meter of Scientology.?? I wouldna??t want to cross the them there Scientologists. Oh no, uh uh. No way.?? E-meter forever. But those other electronic diagnostic devices? Pure bunkum.?? I could not say it better than Quackwatch:

a??The devices?? are used to diagnose nonexistent health problems, select inappropriate treatment, and defraud insurance companies. The practitioners who use them are either delusional, dishonest, or both.a??

That the?? American Association of Naturopathic Physicians has a position statement on electrodiagnosis that considers it experimental is another sign that naturopaths have no business taking care of people.?? To quote their position paper

a??There are three levels of electro-diagnosis:

a. Meridian testing: Readings are interpreted in indicate strength of specific meridians, organ strength or physiologic function.

b. Remedy testing: Variations in readings are interpreted when remedies are given to the patient either orally, to hold or put on a a??testing platea?? wired to the electrodiagnostic equipment. Interpretations may include sensitivities, nutritional enhancement, or improved function.

c. Energy medicines: Electrodiagnostic equipment interprets information and manufactures an energy medicine which is given to the patient to take orally.

THEREFORE IT IS THE POSITION OF THE AANP THAT:

It is appropriate that the naturopathic profession pursue scientific research regarding the reproducibility and reliability .a??

There is nothing on the Pubmeds on the validity of electrodiagnosis, and, on basic principals and prior probability, to suspect that electrodiagnosis would have any utility in the diagnosis of parasites?? or anything other disease.

Despite this, my patient received prolonged courses of mebendazole, thiabendazole and praziquantel, all at half doses, and all out of pocket.

Uncertain of which parasite to kill, the naturopath tried to kill them all with under-dosed medications.?? Good thing, come to think of it, that he did not use his infernal contraption to diagnose cancer, who knows how many anticancer treatments would have been prescribed.

And what is an energy medication and how does one manufacture them? Besides a triple shot of espresso??? The principals of EAV have been expanded for

a??BioScan (remote DNA resonant testing) a?? This procedure utilizes extremely sensitive EAV computerized equipment to accurately measure stressors in the body. It bombards the clients sample DNA (usually hair) with up to 10,000 frequencies to locate bacteria, viruses, pesticides, heavy metals, industrial pollutants, chemicals, parasites, foods, allergies, dental materials, trees, weeds, pollens, inhalants, molds, yeast, fungus and many other substances that poison the environment today. These stressors and related deficiencies are identified in print form for the client along with the organs and glands affected by the stressors. Supplements are suggested that resonate with the test subject and homeopathics are customized to support the body to remove the stressors and return to homeostasis.a??

Only 275 dollars, plus 5 dollars shipping and handling.?? And they recommend a minimum of 4 evaluations.

Try as I might, I cannot write a satisfying concluding paragraph to this entry, so I will just stop.

iPhone App Offers Sufficient CT Image Resolution To Diagnose Strokes Remotely

2011-08-09T00:09:00.001-07:00

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Researchers from the University of Calgary have shown that doctors can make a stroke diagnosis using an iPhone application just as accurately (and faster) than they can on a traditional computer. In a study recently published by Journal of Medical Internet Research, two neuro-radiologists looked at 120 consecutive noncontrast computed tomography (NCCT) scans and 70 computed tomography angiogram (CTA) head scans. One used a diagnostic workstation and the other using Calgary Scientific‘s ResolutionMD Mobile app. The study results showed that using the ResolutionMD app is between 94%-100% accurate in diagnosing acute stroke, compared to a medical workstation.

In addition to accurately diagnosing a stroke, the app was also praised for its ability to handle a large number of images seamlessly and to detect subtle, but potentially critical findings in CT scans. Moreover, the mobile nature of the app gives doctors the ability to analyze and diagnose strokes from practically anywhere.

ResolutionMD Mobile was released last April and allows doctors to quickly and securely access medical images from central hospital servers and manipulate them to assist in making an accurate diagnosis. Of note, our friends at iMedicalApps have a review of ResolutionMD, and anyone can download the app for free from the iTunes Store.

Article from the University of Calgary: Stroke diagnosis using iPhone app extremely accurate study finds…

Journal article: A Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke

Product page: ResolutionMD Mobile…

How To Take Back Control Of Your Google Searches

2011-08-09T00:07:00.000-07:00

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Eli Pariser talks at TED about how wea??re losing the internet to algorithmic gatekeepers at Google, Yahoo, Facebook and even our news sites, which tailor search results to what they think we want to see. Which is why I often start exploring my search results on page 10 instead of page 1. But what if some search results dona??t even make it onto my queue?

The side by side comparison of two different usersa?? internet search on the term a??Egypta?? during the crisis there is a stunning example of how computerized gatekeepers choose for us what we see (and dona??t see) when we log on.

You cana??t have a functioning democracy if citizens dona??t have a free flow of information.

I encourage you to watch the entire video, and hope the big mahoffs??of the internet sitting in the TED audience heard Pariser when he told them this ??-

We really need for you to make sure that these algorthms have encoded into them a sense of the public life, a sense of civic responsibility. We need you to make sure that theya??re transparent enough that we can see what the rules are that determines what gets through our filters. And we need you to give us some controls so that we can decide what gets through and what doesna??t.

Because I think we really need the internet to be that thing that brings us all together. We need it to introduce us to new things, and new ideas, new people and different perspectives.

And ita??s not going to do that if it leaves us all isolated in a web of one.

In the meantime, Pariser tells us ten things you can do now to get back onto the internet you fell in love with. ??Here is his list of what to do a?? head to his site to learn how.

1. Burn your cookies.

2. Erase your web history.

3. Tell Facebook to keep your data private.

4. Ita??s your birthday, and you can hide it if you want to.

5. Turn off targeted ads, and tell the stalking sneakers to buzz off.

6. Go incognito.

7. Or better yet, go anonymous.

8. Depersonalize your browser.

9. Tell Google and Facebook to make it easier to see and control your filters.

10. Tell Congress you care.

How To Avoid Dog Bites

2011-08-09T00:06:00.000-07:00

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Last year I didna??t write about dog bite prevention until the first week of June even though I know National Dog Bite Prevention Week is always the third full of week of May.

The numbers shared by the American Veterinary Medical Association (AVMA) havena??t changed:???? 4.7 million people are bitten by dogs each year in the US with 800,000 of them requiring medical attention.

If you have read this blog for very long, you know I dearly love my dogs — deceased ones (Columbo, Ladybug (photo), and Girlfriend) and the living one, Rusty.?? Still, I have no illusions that dogs bite and given the right provocation, I think mine would though most of the time they are totally harmless and would just invite you in to rob me.

Sadly, children are by far the most common victims of dog bites, occurring most often in children 5-9 years of age.?? Senior citizens are the second most common dog bite victims.

Children are also more likely to be severely injured and represent half of the dog-bite victims requiring medical attention every year.?? Almost two thirds of injuries among children 4 yrs or younger are to the head or neck region.

The family pet is often to blame, so it is important for parents to teach their children how to treat dogs. It is also important to train the family dog in obedience.

Dog bites are a largely preventable public health problem.?? There are a number of things that you can do to avoid dog bites.

Take care in selecting a family pet.?? Obedience training and socializing the pet beginning at a young age will insure the dog feels at ease around people and other animals.?? Keep the dog healthy.

Don’t put your dog in a position where it feels threatened or teased.?? Teach your children not to tease the family dog or any other dog.?? Neutered dogs are less likely to bite.

NEVER leave a baby or small child alone with a dog.

Basic safety around dogs

a?￠ Do not approach an unfamiliar dog.

a?￠ Do not run from a dog and scream.

a?￠ Remain motionless (a??be still like a treea??) when approached by an unfamiliar dog.

a?￠ If knocked over by a dog, roll into a ball and lie still (a??be still like a loga??).

a?￠ A child should not play with a dog unless supervised by an adult.

a?￠ A child should immediately report stray dogs or dogs displaying unusual behavior to an adult.

a?￠ Avoid direct eye contact with a dog.

a?￠ Do not disturb a dog who is sleeping, eating, or caring for puppies.

a?￠ Do not a pet a dog without asking permission from its owner first.

a?￠ Do not pet a dog without allowing it to see and sniff you first.

Source

American Veterinary Medical Association (AVMA)

American Kennel Club

United States Postal Service

Stop Watches May Be Better Than CT Scans At Predicting Heart Disease

2011-08-09T00:05:00.001-07:00

It is hardly news to say that we need better means to predict who will die of heart disease. No matter how much you may hear about medical errors, hospital acquired infections, or even distracted driving, ita??s still heart disease that kills the most of us.

The inflammation that begins narrowing our arteries starts when we are young. It percolates quietly, stealth-like for years. The young usually skate by unscathed. But all the cookies, beers, chips, inactivity and work stress adds up. The tension of life squeezes our arteries, daring them to crack or fissure. This cataclysm is one of the ways that middle age may introduce herself.

A friend, or colleague, or sibling dies suddenly of heart problems. Those of us that our a??masters-ageda?? have likely felt these sensations of sadness, and then the reality that they may be next.

a??I should probably come in and get a check-up,a?? is something I hear frequently in the doctora??s lounge after such a tragedy.

I agree. When you are old enough to use reading glasses it is time to think about what lurks inside your hearta??s blood vessels.

But herein lies the catch.

Whata??s the best way to evaluate people without?? symptoms?

Is it with simple tests or complex imaging procedures?

If we find partial blockages, should they be treated with medicines, or a procedure?

Anda?|does treating non-symptomatic blockages make any difference in outcomes?

These are the tough questions that keep preventive cardiologists coming to work.

As an illustration of how tough it is to predict heart disease, let me briefly mention two recent studies that highlight opposite spectrums of complexity. One study looked at using complex imaging of the heart with modern CT scanners, and the other used a stop-watch and a treadmill.

Leta??s start with the fancy new test. You have all heard about coronary CT angiography. The notion behind CT-Angio is that a CT-scan of the chest (often with the IV injection of contrast) can detect coronary artery disease. At a minimum, CT-scanners can detect calcium deposits in the heart, and at a maximum, these same machines can create beautiful 3D-images of the arteries surrounding the heart. They are indeed stunning images.

In this recent study published in the Archives of Internal Medicine, (summarized nicely here at Cardiobrief), researchers looked at the impact of using CT-scans for screening low-risk individuals. They compared 1000 South Korean patients that got a CT scan to a 1000 who did not.

There were interesting findings.

CT scans found more than 200 (of 1000) patients with heart blockages.

Many more patients in the CT scan group were treated with aspirin and statins.

More patients in the CT group underwent other heart tests or procedures.

All this sounds good, right? CT scans enhanced detection of disease, and more patients got treated.

But their final, and most telling finding was that none of this mattered.

At 18 months follow-up, there was one heart-related event in each group. In other words, the enhanced detection of CT-angiography had no impact on real outcomes!

(Nowa?|I know it was a small study with short term follow-up. Larger trials are needed to be more conclusive. Plus, these were low-risk patients; the results may have been different in moderate-risk patients.)

The point is that detecting heart disease, starting medicines, and even doing procedures, in patients without symptoms, may not make much difference in real outcomes.

So are their any other tests that could be done to better predict heart outcomes?

You beta?|check this out:

In a recent study published in the Journal of the American College of Cardiology, researchers studied the long-term predictive value of a single measurement of fitness at age 45, 55 and 65. Their metric did not involve radiating the patient, nor did it require injecting any potentially kidney-damaging dye. Rather they simply measured how long it would take a person to run a mile. They used a Timex.

The Cooper Institute in Dallas followed 11,000 patients for 23 years. They found that differences in fitness (as measured by mile times) were associated with marked differences in the chance for heart-related death. Listen to these numbers: A 55 year-old man who measured to be low fitness (>15 min/mile) had a 34% lifetime risk, while a high fitness (<10min/mile) 55 year-old had only a 15% risk.

They also found one other striking result

a??the combination of high fitness with a high traditional risk factor burden was associated with a lifetime risk for CVD death that was comparable to that of a person with low risk burden.a??

At least in their cohort, being fit counterbalanced having many of the traditional risk factors. Thata??s a strong statement.

Folks, I am still suffering a little withdrawal symptoms from Europe. All that pragmatism and mastery of the obvious was very infectious. But even so, I still love telling you about simple, inexpensive tests that speak strongly to our cardiovascular risk.

A simple measurement like the time it takes one to run a mile cannot make beautiful images of?? the hearta??s blood vessels. It just tell us about the end resulta??it measures function. And how things function arena??t always predicted by how they look.

When will it be that the message of fitness gets broadcasted as loud as the next new drug, bio-absorbable stent, or million dollar x-ray machine?

Taking care of the heart isna??t always complicated.

If it were, Ia??d only be a blogger, not a doctor.

FDA-Approved Drugs Are Not Always Effective: The Benefits Of Alternative Medicine

2011-08-09T00:04:00.001-07:00

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On Saturday, while thousands of Boston Bruins fans gathered at Government Center to celebrate the teama??s recent Stanley Cup victory, a hundred or so true die-hards met a few blocks away at a Massachusetts General Hospital conference to talk about complementary and alternative medicine for psychiatric disorders. While I hated to miss the Bruins parade, Ia??m glad I attended the MGH conference.

Ia??ve always been a bit of a skeptic about so-called natural therapies for one simple reason: they dona??t have to go through the same rigorous testing in clinical trials that medications do. At the same time, I realize that FDA-approved drugs dona??t work for everyone. One in three adults with major depression, for example, cana??t completely improve their mood and other symptoms even after trying multiple antidepressants.

Clearly, we need better options for treating mental health disorders. The MGH conference convinced me that some types of complementary and alternative medicinea??or CAM, for shorta??might be worth trying. The presenters, all psychiatrists who treat patients at MGH, backed up their recommendations with scientific evidence. Several of them also contributed to the American Psychiatric Associationa??s recent report on CAM therapies.

Wea??ll be doing a story on CAM therapies for psychiatric disorders in an upcoming issue of the Harvard Mental Health Letter. For now, here are some things I learned on Saturday:

Omega-3 fats, natural fats found in large quantities in cold-water Fish-in-Water-Belt-Buckle-246.html' target='_blank'>fish such as salmon, can boost the effectiveness of an antidepressant in some people with depression. Omega-3 supplements are now being studied as an alternative to antidepressants during pregnancy.

St. Johna??s wort is an herbal remedy that can help people with mild-to-moderate symptoms of depression, but doesna??t seem to work as well for severe depression. St. Johna??s wort can cause problems when taken with some antidepressants and other medications, so talk with your doctor before trying it.

Maca root, a relative of the potato that is used in some cultures to enhance sexual response, may help counter erectile dysfunction, reduced libido, and other sexual side effects of antidepressants.

Valerian, derived from the root of a pink flower, can alleviate anxiety and help improve sleep just as well as some sedatives. It may be a good alternative to consider for children and the elderlya??two groups especially sensitive to the side effects of medications. One downside: it takes a while to a??kick in,a?? so if you need fast relief, look elsewhere.

Words to the wise. Just because these remedies come from plants and animals doesna??t automatically mean they are safe. Herbal remedies have unwanted side effects and can interact with medications just like antidepressants and other drugs do. Talk with your doctor before trying any alternative approach, especially if you take any medications.

One more caveat: the fact that these products arena??t under FDA oversight means the amount of active ingredients can vary from one product to the nexta??and even within the same brand. Choose products that bear the U.S. Pharmacopeia Dietary Supplement Verification Program (USP-DSVP) mark. Or check ConsumerLab.com, which ranks herbs and supplements based on quality and content.

Why You Should Quit Smoking Before Surgery

2011-08-07T01:42:00.001-07:00

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Physicians and surgeons all agree on the link between smoking and postoperative complications.?? We dona??t agree (or know) how much time is required between cessation of smoking and surgery for optimal risk reduction.

Dr.Thomas Fiala wrote a nice blog post, Smoking Cessation and surgical complications, recently?? discussing the 3rd reference article below.

Smokers that quit smoking before surgery had 41% fewer complications. The researchers found that each week of cessation increases the effect by 19%.

Trials of at least 4 weeks’ smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).

Smokers that quit had lower rates of total complications, fewer wound healing complications, and fewer pulmonary complications.

The first two articles referenced below were evaluated in an article written by Michael Smith for MedPage Today:?? Smokers Who Quit Preop Seem to Do Okay Postop.?? Those two articles looked at pulmonary complications not wound healing complications.

There was also no significant benefit or harm when the analysis was restricted to the three studies with biochemical validation of quitting, the researchers reported. The relative risk was 0.57, with a 95% confidence interval from 0.16 to 2.01.

As noted by Clara and Chow (2nd reference, review of 1st reference article) (bold emphasis is mine):

While the review performed by Myers et al provides valuable information, it does not definitively answer the question raisea?|a?|

Physicians should ideally try to get their patients to stop smoking several months prior to their surgery. The appropriate advice regarding the optimal timing of smoking cessation for patients seen close to their scheduled surgery awaits further research.

I tend to agree with Dr. Fiala who writes, a??There is no safe minimum number of cigarettes that you can sneak before surgery. Even a couple can do you in.a??

New Drug Warnings For Breastfeeding Mothers

2011-08-07T01:41:00.001-07:00

Periodically, the FDA publishes drug warnings that should be shared with the public, especially if it affects pregnant women. Each year, over 4 million babies are born in the US and 43% will continue to be breast fed at 6 months. All of these moms will invariably use meds at some point after birth, so which meds are helpful and which are potentially harmful? These questions may now be answered by the Infant Risk Center, at the Texas Tech University Health Center, in Amarillo, Texas. This center provides up-to-date information regarding the safety of medications that are taken both during pregnancy and after birth.

Most drugs enter breast milk immediately after birth and during the first 4 to 10 days of life at a fairly fast rate based on the physiology of breast cells. New moms must therefore be careful of pain medications that are prescribed during the post partum period. Hydrocodone aka Vicodin is a potentially addictive opiate that is given for pain management. When it is processed by the body, it breaks down into a component called hydromorphone that is even more potent. The University of California at San Diego Medical Center performed a small study to determine how much of the drug is secreted into breast milk and what percentage is absorbed by newborns. 3 to 4% of hydromorphone was found in breast milk which is considered safe. As a rule of thumb, nonopioid medication should be prescribed first during the post partum period for pain relief. If the pain persists, no more than 6 Vicodin (hydrocodone) tablets or 30 mg should be prescribed in one day. Dosages greater than 40 mg should be avoided and the newborn should be monitored carefully for depressed behavior or inadequate breastfeeding.

Recently the FDA sent a drug warning to healthcare providers regarding the risks associated with the entire class of antipsychotic medications such as Haldol, Risperdal??, Risperdal?? Consta??, Invega?? and Invega??Sustenna, Clozaril, Zyprexa, Seroquel, Abilify, and Geodon. These medications are used to treat schizophrenia and bipolar disorders but are associated with abnormal muscle movements and withdrawal symptoms of newborns whose mothers took these medications during the third trimester. However it is recommended that patients should not abruptly stop taking these medications without speaking with their healthcare professional first. For further information, readers may go to the FDA website http://www.fda.gov/Drugs/Drug Safety/ucm243903.htm.

Remember, a healthy pregnancy doesna??t just happen. It takes a smart mother who knows what to do.

Announcing A Health Journalist Toolkit – To Help Get The Facts Straight

2011-08-07T01:40:00.001-07:00

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Beyond just evaluation and constructive criticism of news stories, we want to reach out to help journalists.

We know they often struggle with reporting on the costs of treatments, tests, products and procedures. It’s reflected in the facts: after 5 years and nearly 1,500 stories reviewed, we don’t like to report that more than 70 percent of stories fail to adequately address the costs of the stuff they’re covering.

So we talked with journalists and others to assemble our first stab (and that’s all it is – a first stab) at an online list of resources to help journalists explore the costs of health care products and approaches.

There are some links to websites, names, email addresses and phone numbers.

This is just one of many primers and resources offered on our site. Here’s a screen shot of the listing of primers available in the Toolkit.

We also point journalists to “Covering Medical Research: A Guide for Reporting on Studies,” a guide I wrote for members of the Association of Health Care Journalists.

We were pleased to see that the National Association of Science Writers also pointed its members to our Journalist Toolkit in a web posting this week.

Why We Women Can’t Win: Liposuction And Fat Redistribution

2011-08-07T01:39:00.001-07:00

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Herea??s the tweet I posted Sunday evening:

I’ve told pts this for years now>>> Liposuction Study Finds That Lost Fat Returns – http://nyti.ms/kheltN

The New York Times article reports on a liposuction study published in the April issue of the journal Obesity (full reference below).???? The NY Times article uses this photo as graphic illustration

and a quote from a plastic surgeon who says he is surprised.

Dr. Felmont Eaves III, a plastic surgeon in Charlotte, N.C., and president of the American Society for Aesthetic Plastic Surgery, said the study was a??very well done,a?? and the results were surprising. He said he would mention it to his patients in the context of other information on liposuction.

I have told my patients for years to consider the fat cells in their body as drawers or storage bins.?? If I take away some of the drawers and they continue to take in a??fata?? that needs to be stored, the body will put it somewhere.?? If there are now fewer drawer options in the saddlebag or abdominal region, then where will it go??? Most likely the upper body, etc.

This article does more definitively define the answer to where it will be placed.

The study enrolled 32 healthy women (mean age 36) with disproportionate fat depots (lower abdomen, hips, or thighs) were enrolled and then randomly placed into either a small-volume liposuction group (n = 14, mean BMI: 24 ?± 2 kg/m2) or control (n=18, mean BMI: 25 ?± 2).?? Participants agreed not to make lifestyle changes while enrolled.

Baseline body composition measurements included dual-energy X-ray absorptiometry (DXA) (a priori primary outcome), abdominal/limb circumferences, subcutaneous skinfold thickness, and magnetic resonance imaging (MRI) (torso/thighs).

The surgery group had their liposuction within 2-4 weeks of the baseline measurement.?? Identical measurements were repeated at 6 weeks, 6 months, and 1 year later.

After 6 weeks, percent body fat (%BF) by DXA was decreased by 2.1% in the lipectomy group and by 0.28% in the control group (adjusted difference (AD): a??1.82%; 95% confidence interval (CI): a??2.79% to a??0.85%; P = 0.0002).

This difference was smaller at 6 months, and by 1 year was no longer significant (0.59% (control) vs. a??0.41% (lipectomy); AD: a??1.00%; CI: a??2.65 to 0.64; P = 0.23).

The fat (adipose tissue) reaccumulated differently across various sites.

After 1 year the thigh region remained reduced, but fat (adipose tissue) reaccumulated in the abdominal region.???? Following suction lipectomy, BF was restored and redistributed from the thigh to the abdomen.

a?|..

I do not find this surprising.?? Once the drawer is removed, it can not store items any longer.

If you only liposuction the lower abdomen (area below the umbilicus), those patients are likely to return with increased fat in the upper abdomen.?? It needs to be keep in proportion.

REFERENCE

Fat Redistribution Following Suction Lipectomy: Defense of Body Fat and Patterns of Restoration; Hernandez TL, Kittelson JM, Law CK, Ketch LL, Stob NR, Lindstrom RC, Scherzinger A, Stamm ER,?? Eckel RH; Obesity, (7 April 2011); doi:10.1038/oby.2011.64

Calcium Supplements: Good For Your Bones But Bad For Your Heart?

2011-08-07T01:38:00.001-07:00

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Calcium is good for us, right? Milk products are great sources of calcium, and wea??re told to emphasize milk products in our diets. Dona??t (or cana??t) eat enough dairy? Calcium supplements are very popular, especially among women seeking to minimize their risk of osteoporosis. Osteoporosis prevention and treatment guidelines recommend calcium and vitamin D as an important measure in preserving bone density and reducing the risk of fractures. For those who dona??t like dairy products, even products like orange juice and Vitamin Water are fortified with calcium. The general perception seemed to be that calcium consumption was a good thing a?? the more, the better. Until recently.

In a pattern similar to that I described with folic acid, therea??s new safety signals from trials with calcium supplements that are raising concerns. Two studies published in the past two years suggest that calcium supplements are associated with a significantly increased risk of heart attacks. Could the risks of calcium supplements outweigh any benefits they offer?

Why Calcium? Osteoporosis

Osteoporosis is a progressive bone condition of reduced bone mass and deterioration of bone tissue, and a correlating increase in fracture risk. 80% of those diagnosed are women. Hips and spines are the most common fracture locations, but they can appear in any bone, and osteoporosis makes fractures more likely. In postmenopausal women over the age of 50, the lifetime risk of a vertebral fracture is about one in three, and one in five for a hip fracture. Because they are so common, hip and vertebral fractures cause considerable aggregate and individual morbidity and mortality. So prevention and treatment are major health issues.

The initial strategy to preventing and managing osteoporosis is ensuring adequate calcium and vitamin D dietary intake, as both influence bone density. Calcium intake influences overall calcium balance: adequate vitamin D and calcium ensure calcium balance is positive. This occurs at about 1000mg per day in premenopausal women, and 1500mg per day in postmenopausal women not taking estrogen. The North American Menopause Societya??s (NAMS) 2006 osteoporosis guidelines recommends [PDF] adequate calcium and vitamin D for all postmenopausal women, regardless of osteoporosis risk factors. The guidelines note that requirements increase with age owing to reduced absorption, and recommending adequate intake (preferably via diet) as the preferred sources. The 2010 Canadian guidelines [PDF] are similar, recommending 1200mg of calcium (diet and supplements) and vitamin D for all individuals over the age of 50. The Institute of Medicine recently updated its calcium and vitamin D guidelines (pdf) as well. It concluded with the caution that the consumption of levels beyond those recommended have not been shown to offer additional health benefits, and may in fact be linked to other health problems.

The effectiveness of calcium and vitamin D for the prevention and treatment of osteoporosis has been studied in both observational and prospective clinical trials. Wile there are data to demonstrate that calcium and vitamin D can prevent bone loss, the data on fracture prevention are much less convincing, with some trials showing no effect. Beyond density effects, calcium is also associated with generally positive effects on muscle strength, balance, and the risk of falls. So for most men and women with (or at risk of) osteoporosis, calcium and vitamin D are standard treatments. Given dietary intake in those at greater risk of osteoporosis may be below recommended levels, supplements are often used to meet recommended amounts.

The Safety Signals

Prior studies of calcium supplements have pointed to a possible relationship between calcium supplementation and cardiovascular events. Bolland et al specifically examined the relationship of calcium with the risk of heart attacks and cardiovascular events in a 2010 BMJ meta-analysis. It included all RCTs of calcium supplements (a?￥500 mg/day), with a study size of 100 or more participants, an average age over 40, and a duration of more than one year. Trials that included vitamin D as an intervention were excluded. 15 trials were identified: some with patient-level data, and some with trial level data. Analyses of both sets of data identified a significant increase in heart attacks in those randomized to calcium supplements. The trial-level analysis show a hazard ratio (pdf) of 1.27 with a 95% confidence interval of 1.01 to 1.59 (p=0.038). The patient level analysis revealed a similar hazard ratio for myocardial infarction of 1.31 (95% confidence interval 1.02 to 1.67, p=0.035). Overall, the analysis suggests that calcium supplements increase the relative risk of myocardial infarction by about 30%. Reassuringly, there were no statistically significant increases in the risk of stroke, death, or the composite endpoint of MI+stroke+death in either analysis. Based on the patient-level data, the authors estimated that treating 69 people with calcium for five years will cause one additional heart attack. The authors suggested that in light of calciuma??s unimpressive efficacy against fractures, that calciuma??s role in osteoporosis prevention and treatment should be reevaluated.

Time to stop the calcium? As noted above, the data to support the use of calcium supplements alone to prevent fractures are, on balance, unimpressive. And there are possible models for how calcium could be causing these harms: vascular calcification is a potential (though not proven) consequence that might be more likely in the elderly patients. However, given calcification can take years, and harms appear shortly after dosing starts, it could be a due to effects on carotid plaque thickness, leading to aortic calcificiation, and subsequent cardiovascular events. (Reid describes potential mechanisms for these harms in a2010 paper in Clinical Endocrinology.)

What happened after this paper was released? There were criticisms of the endpoints, and the fact the composite endpoint was not significant. Concerns were also raised that the trials included were not designed with cardiovascular endpoints a?? a valid criticism. And many pointed to the fact the studies excluded vitamin D, contrary to treatment guidelines and common use. Now the same group has done a new analysis, incorporating vitamin D. Bolland and associates followed up their calcium-only therapy with a study of calcium + vitamin D. They used the Womena??s Health Initiative (WHI) dataset to answer the vitamin D question, added in some other studies, and redid their meta-analysis.

The WHI was a massive 15-year trial of over 161,000 women that sought to answer a number of questions about womena??s health. The most well known components were the hormone therapy trials which changed our understanding of the risks and benefits of hormone treatments. The calcium and vitamin D study was a component of the WHI which randomized 36,282 postmenopausal women aged 50-79 into two groups. One group received 1,000 mg of calcium carbonate and 400 UI of vitamin D once daily, the other, placebos. Interesting in the design was that 54% of women were already taking calcium, and 47% were already taking vitamin D, and they were allowed to continue with their therapy, even after randomization. This meant that actual calcium and vitamin D doses women consumed varied from zero to substantially more than the intervention dose. The clinical question the study sought to answer was to understand the effects on fracture risk and the prevention of colorectal cancer a?? and the results were disappointing: no effects on colorectal cancer, and insignificant effects on fractures (though in a subgroup analysis of compliant patients, significant reductions in hip fractures were noted.)

Bolland sought to analyze the WHI data for cardiovascular effects, and then add these data into the previous meta-analysis. In the over 16,000 women not taking their own calcium and vitamin D, there was a significant increase (hazard ratio 1.22) in myocardial infarction noted in the group randomized to calcium and vitamin D (p=0.04, 95% CI 1.00 to 1.50). Similarly, significant effects were also noted in other composite endpoints. In contrast, women taking their own calcium and vitamin D didna??t show any changes in their cardiovascular risk when randomized to calcium and vitamin D. In addition, no relationship was found between calcium dose and risk of cardiovascular events.

The authors then pooled their own WHI analysis with two other studies of calcium and vitamin D where trial-level data for cardiovascular events were available: In total, over 20,000 participants could be studied. In this pooled analysis, calcium and vitamin D were associated with a significant increases in myocardial infarction (relative risk 1.21), stroke (RR 1.20) and a composite endpoint of both (RR 1.16).

Finally the authors combined the trial level data from their calcium-only meta-analysis with their trial level calcium plus vitamin D data:, resulting in a pool of over 28,000 patients across nine trials. In this analysis, there was risk increase of 1.24 (95% confidence interval 1.07-1.45, P=0.004) for myocardial infarction and 1.15 for the combined endpoint (1.03-1.27, P=0.009).

Difficult to interpret? Yep. The lack of effect of a??personala?? use of calcium on endpoints, and the lack of dose response, means this isna??t case closed for the clinical question. But the persistent and significant correlation between randomization to calcium, with or without vitamin D, and myocardial infarction, does concern me. There are a number of additional criticisms outlined in the editorial that accompanied the Bolland WHI analysis, and the keen reader is referred there for more.

Evaluation

Is it possible that calcium supplements can be causing harms that could outweigh their benefits? Yes, but the evidence isna??t clear enough to give an definitive answer. These data need to be factored into individual evaluations of diet as well as risk factors for cardiovascular disease and osteoporosis. Ia??d like to see these findings validated by other groups, as both meta-analyses came from the same group of researchers. The meta-analysis can be a very useful tool, but ita??s not without its own limitations, as is often pointed out by the contributors to this blog. Interestingly, a 2010 meta-analysis, from a different group of authors, and using a different methodology, has come to a different evaluation of calcium. So the question remains an open one. More data may help refine our estimates of number needed to treat, and number needed to harm, to inform treatment decisions. And it should help guide advice for younger, premenopausal women, as well as men. So until more data emerges, my tentative recommendations to consumers are as follows:

Calcium supplementation has been associated with increased risks of cardiovascular events like heart attacks. Until there is more evidence to confirm or refute this association, ita??s prudent to be cautious when taking calcium supplements.

No harms have been shown from calcium consumption via dietary sources. Efforts should be made to first meet dietary requirements through food products, before considering supplements.

Routine supplementation, in the absence of a dietary deficiency, is not necessary or advisable.

Calcium supplements may still be advisable for those with low dietary intakes, or those at risk of or being treated for osteoporosis. The risk-benefit assessment for calcium supplements needs to consider risk factors for both osteoporosis and for cardiovascular disease.

Vitamin D supplements are advisable for most people, and are recommended for the prevention and treatment of osteoporosis. The suggested doses of calcium and vitamin D may vary based on diet, medical conditions, and other considerations. Sources for target doses could include the IOM or recent osteoporosis guidelines (Canada) (USA).

Conclusion

The emerging safety data on calcium may yet become another cautionary tale about the unexpected and undesirable outcomes of targeted supplements. Until more evidence emerges, the safety of calcium supplements will continue to be questioned and debated. But thata??s science-based practice: Data can be conflicting, messy, and difficult to interpret. There is always the possibility of unintended consequences when we make therapeutic decisions, and only by rigorously evaluating what wea??re doing can we continue to improve the way we prevent and treat disease.

References

Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, & Reid IR (2010). Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ (Clinical research ed.), 341 PMID: 20671013

Bolland, M., Grey, A., Avenell, A., Gamble, G., & Reid, I. (2011). Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Womena??s Health Initiative limited access dataset and meta-analysis BMJ, 342 (apr19 1) DOI: 10.1136/bmj.d2040

Why Do Patients Stop Taking Their Medications?

2011-08-07T01:37:00.001-07:00

Lots of smart people over the years have been trying to figure out why people stop taking their medications within the first 12 months.?? Within the first 12-months of starting a new prescription, patient compliance rates drop to less than 50%.?? This rate is even lower for people with multiple chronic conditions taking one or more prescription medications.

If these medications are so important to patients, why do they just stop taking them? It defies common sense. Sure issues like medication cost, forgetfulness, lack of symptoms, and psychosocial issues like depression play a role in patient non-compliance. But there also something else going ona?|or in this case not going on.

The problem is that doctors and patients simply dona??t talk much about new medications once prescribed. Herea??s what I mean.?? Leta??s say that at a routine check-up a physician tells a patient that he/she wants to put them on a medication to help them control their cholesterol.?? The doctor spends about 50 seconds telling the patient about the medication.?? The patient nods their head takes the prescription and booma?|the visit is over.

Leta??s say the patient actually gets the prescription filled.?? For some people that is a leap of faith considering the likely chain of events up to that moment:

The physician didna??t really make a good case for why they needed the medication (if the doctor wanted me to take it he/she should have been emphatic about it as in a??I recommend you take thisa?? a?? not simple a??I want to try somethinga??), what it would do or what would happen if the patient didna??t take it.

The doctor didna??t mention how the new medication would interact with the 2 other pills I am already taking.

Consequentially the patient may not believe they really need the medication.

Fast forward 12 months. The patient has been back to see the same doctor twice for problem unrelated to cholesterol. At neither of these appointments did the doctor mentioned or ask how the patient was doing with the new medication. The doctor did mention the need for a blood test to check for liver issues and that they should recheck the cholesterol levels at the next visit.

So at this point the patient concludes the following about the new medication:

The doctor never talks about cholesterol or brings up the subject of the medication. I assume I am taking it correctly.

If the doctor doesna??t mention it (the medication) it must not be important.

I havena??t notice any difference in my health a?? I guess I dona??t need the medication.

Sure the patient should have asked their doctor if they had any questions about the new medication. But patients seldom ask their doctor questions. Sure they could ask the pharmacista?|but the pharmacist would tell them to just ask their doctor.

It so much easier for the patient to just not refill the prescription.

We have all heard the expression that whatever doesna??t get measured doesna??t get done.?? Well the same thing is true for when it comes to physician-patient communications.?? Whatever issues doctors dona??t talk with patients about will not get done over the long haul either.?? In this case patienta??s simply stop taking prescribed medications.

As primary care slowly shifts from episodic, acute care to continuous care with the aid of EMRs and the focus of patient-centered care things should get better with respect to patient compliance. It needs to. Give the current focus on episodic acute care too many chronic health issues simply are not being addressed for one visit to the next.

Thata??s what I think. Whata??s your opinion?

Burning Mouth Syndrome May Be Cured With Magnesium Supplements

2011-08-07T01:36:00.001-07:00

Patients with burning mouth syndrome (BMS) have two major findings: one, burning sensations in their mouth and two, no anatomical changes present in their mouth to relate to this burning.

Dr. Henkin and colleagues at the Center for Molecular Nutrition and Sensory Disorders have clinically distinguished two major groups of patients with BMS. One group has burning limited only to their tongue a?? called GLOSSOPYROSIS. The other group has burning in their entire mouth, including their tongue, lips, palette, gums and pharynx a?? called OROPYROSIS. They have recently been able to distinguish these two patient groups biochemically.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their red blood cells (erythrocytes) than do patients with OROPYROSIS or normal subjects.

Patients with GLOSSOPYROSIS have lower levels of magnesium in their parotid saliva than do patients with OROPYROSIS or normal subjects.

However, serum levels of magnesium and serum erythrocyte and saliva levels of calcium are similar in patients with GLOSSOPYROSIS, OROPYROSIS or in normal subjects.

These results suggest that patients with GLOSSOPYROSIS are magnesium deficient.

These findings does suggest magnesium supplementation to reverse the magnesium deficiency may be of benefit in patients with GLOSSOPYROSIS.

Courtesy of Dr. Robert Henkin of the Center for Molecular Nutrition and Sensory Disorders.

Reference:

Biochemical differences in parotid saliva distinguish patients with glossopyrosis from those with oropyrosis: Are there also neurochemical differences? The FASEB Journal. 2011;25:857.4

Raw Milk: Tipping The Odds In Favor Of Bacteria

2011-08-07T01:34:00.000-07:00

" alt="Science-Based Medicine" />

It is hard to get infected. The immune system is robust and has a multitude of interlinking defenses that are extremely efficient in beating off most pathogens. Most of the time.

Fortunately, it is a minority of microbes that have evolved to be virulent in humans. Bacteremia is common with our own microbiome. When you brush or floss, bacteria leak into the blood stream:

We identified oral bacterial species in blood cultures following single-tooth extraction and tooth brushing. Sequence analysis of 16S rRNA genes identified 98 different bacterial species recovered from 151 bacteremic subjects. Of interest, 48 of the isolates represented 19 novel species of Prevotella, Fusobacterium, Streptococcus, Actinomyces, Capnocytophaga, Selenomonas, and Veillonella.

but with a good immune system, low virulence bacteria and no place to go, unfortunately the bacteria rarely cause infections.

Even heroin users rarely get infection. Heroin is a rich melange of bacteria and, on occasion, yeasts (I hate to say contaminated, since avoiding microbes is hardly a worry of heroin manufacturers), and the water used for injection is rarely sterile, yet infections are relatively rare despite the filth in which many heroin users exist.

I used to be somewhat fatalistic about hospital acquired infections. However, as the institutions in which I have worked have proven, almost all infections in the hospital are preventable if the institutions aggressively pursue high standards of care.

There are many systems in place in society to prevent infections: flush toilets, good nutrition, public health, vaccines, antibiotics, good hygiene, and an understanding of disease epidemiology, and I suspect people forget there are bugs out there that are pathogenic, just waiting to sicken and kill us. At least a couple of times a year I see patients come into the hospital, previously healthy, who rapidly die of acute infections.?? But for most people, most of the time,?? it takes a lot of effort to get an infection.

From my perspective we are Charlie Chaplain on skates , mostly unaware of the infections that awaits us if we do something silly,or even when we act with the best intentions to avoid illness. The odds are small we will get a life threatening or serious infection in the US, just as the odds are small we will drown or be killed in a car accident. The germs are there, waiting, and in the end, no matter what we do, we will be consumed by the microbial world.

It is that perspective that leads to a lack of understanding as to why some people seem to love tipping the odds in favor of the bacteria. Avoiding vaccines is perhaps the most popular method for getting infections that could otherwise be avoided, but dietary habits are an curious way to acquire preventable infections.

Humans and cows have a long history of sharing infectious diseases. Measles is either a variant of rinderpest, a cattle illness, or they share a common ancestor. On the beneficial side of the relationship was cowpox, which lead to the small pox vaccination.

While I am a bit of a foodie (for example, while I do not remember by first kiss, I remember the epiphany of my first gourmet restaurant meal), I cannot grok (see how old I am) people who either think a specific food is to be avoided at all costs or is the panacea for preventing illness. Like cows milk.

There is school of thought that cows milk should be never be consumed: it is filled with pus, blood, hormones, foreign protein and antibiotics.?? And not only does milk not build strong bones, it leads to cancer. And if you cana??t trust a kinesologist, who can you trust?

Ita??s not natural for humans to drink cowa??s milk. Humans milk is for humans. Cowa??s milk is for calves.

Sounds like a metaphorical argument for cannibalism to me.

And, as the anti-cows milk proponents note,?? milk has infectious diseases swimming in the white murk. A cesspool of bovine feces and bacteria that should be avoided, although how you can eat a homemade chocolate chip cookie without it, I cannot imagine.

So milk is one of the bad foods and should be avoided. Except when you shouldna??t. Newtons Law states that for every SCAM, there is an equal and opposite SCAM. Milk is dangerous, except when it is a panacea, when the milk should be raw milk, fresh from the organic, happy, contented cow.

Why raw milk? Pasteurization and homogenization rids the milk of the beneficial components: white cells, proteins, lactoferrin, immunoglobulins, fats, cholesterol and bacteria, curiously all the substances that the anti-milk faction says are the root of milky evil. I suppose that, for a raw milk aficionado, there would be no greater dietary sin than a warm glass of milk at bed time or a cup of hot chocolate after skiing.

The truth? I do not doubt that flash heating (usually to 165 degrees for 15 seconds) is going to have some nutritional effects on the milk and, if my diet consisted entirely of milk, it would be a concern. However, what small decrements in nutritional value occur would, and should, be made up with a varied diet. Milk is not, unless turned into Baskin Robbins Chocolate Chip ice cream, a miracle food. I also have no reason to doubt that there is a subset of people who have allergic issues with cows milk. Not everyone can drink bovine proteins with impunity.

Taste, of course, is a personal matter, and I cannot gainsay those who say raw milk tastes better. In my family everyone is picky about their milk; it cannot come in plastic and has to be a specific brand, Dairygold. My wife insists Oregon milk is inferior in flavor to Minnesota milk. French milk tasted weird, and I though everything else tasted better in France. Pasteurization has mild effects on the nutritional components of milk, and perhaps the taste.

But what raw milk is, above all,?? a source for infection. There have been outbreaks with Campylobacter, Salmonella, E. coli associated with raw milk and other organisms can be found in raw milk, some not common in the US, including?? Brucella, Listeria, Mycobacterium bovis (a cause of tuberculosis), Salmonella, Shigella, Yersinia, Giardia, and norovirus. Some are found in cows milk, and some, such as Brucella, more common from goata??s milk. These outbreaks have lead to hospitalizations and a few deaths.

Warm liquid filled with protein, fat and sugars. A good growth media for a bacteria, if they can gain access to the milk. Impossible. Proponents of raw milk point to the clean cows and clean environments that produce raw milk, but you cannot deny both microbiology and gravity. The colons of cows are frequently colonized with the aforementioned potential pathogens and the udder sits below, waiting to be splashed with cow pie. MMMMmmmmmm. Milk and pie. Seriously. Would you lick any cow udder, no matter how clean?

Still, people want their raw milk for the taste and health benefits. Some obtain raw milk illegally at milk speakeasies where I bet the password is Swordfish. You can time share a cow and get the milk straight from the source, although you have to see a presentation on time sharing cows to get the free weekend on the farm. This is good news for me. Since we have instituted aggressive infection control at my hospitals nosocomial infections have plummeted. Once upon a time milk was associated with 25% of infection outbreaks; in part due to pasteurization those rates fell to 1%. Thanks to the raw milk advocates, infections are looking up. The sad thing is parents will feed their children milk supplemented with cow poo. Adults have the right to be stupid; it is what makes America great. But it is a shame that children should suffer as a result of their parents goofy id??e fixe.

There is a tendency for humans to have the oddest dietary obsessions, both for and against.

God told Moses certain animals were a??cleana?? to eat a?? those with cloven hoofs which chewed the cud such as cattle, goats, sheep, deer, and so forth. All Fish-in-Water-Belt-Buckle-246.html' target='_blank'>fish with fins and scales, and insects of the locust family were also a??clean.a?? The pig and the camel, however, were a??uncleana?? and were not to be eaten. All carnivorous birds, sea creatures without fins and scales, most insects, rodents, reptiles, and so forth were a??unclean.

Milk is not on the list. Milk can be an enjoyable part of a diverse diet for most people, but like most foods it should not be filled with live organisms. Pasteurization is a good thing. Except for Hefeweizen. Give me my raw beer.

The Benefits Of Participating In Clinical Trials

2011-08-07T01:33:00.000-07:00

" alt="Harvard Health Blog" />

For several years Ia??ve been preaching in the pages of the Harvard Heart Letter about the importance of taking part in clinical trials. Why? Because I believe they improve medical care, telling us what works and what doesna??t. Figuring it was time to put up or shut up, I volunteered for a clinical trial. Ia??m glad I dida??I learned a lot, received excellent care, and saw first-hand the effort it takes.

The trial was called Targeting Inflammation Using Salsalate in Type 2 Diabetes, or TINSAL-T2D for short. It was being conducted at 16 centers, including the Joslin Diabetes Center in Boston, a short walk from my office. Its aim was to see if an old drug called salsalate (a cousin of aspirin) could arrest low-grade inflammation that maya??emphasis on maya??make muscles resistant to the effects of insulin and eventually tip the body into type 2 diabetes.

I responded to an ad for TINSAL-T2D and, after undergoing a few preliminary tests, was accepted to take part in it. I was given a bottle of blue pills and asked to take several of them every day. No onea??not lead investigator Dr. Allison Goldfine, not study nurse Kathleen Foster, and certainly not mea??knew if the pills were the real thing or a placebo. I was also asked to check my blood sugar every morning, and to show up monthly for blood tests and questions galore.

I just finished my year-long stint, still not knowing whether I was taking salsalate or a placebo. I really dona??t care, though Ia??m keen to know if salsalate worked as hoped, something Ia??ll learn when the results are published.

Why bother?

For people with cancer or other potentially deadly conditions, joining a clinical trial might give them access to new drugs or procedures that may work better than existing ones. For the rest of us, taking part in a clinical trial may have more subtle benefits:

the possibility of better medical care and monitoring than you currently receive

learning more about your condition and how to manage it

feeling good that you are improving care for others by helping answer important medical or scientific questions

There are downsides, too. You dona??t get to choose whether you get the a??new thinga?? or the placebo, which can be difficult for folks who dona??t like uncertainty. ??The new drug or procedure may have unwanted or unexpected side effects. And volunteering for a clinical trials takes timea??over the course of a year I spent about 20 hours at the Joslin, and twice wore a portable blood pressure monitor for 24 hours.

Still, Ia??d do it again. And I hope you will think about taking part in a clinical trial. I had such a good experience with the TINSAL staff that Ia??d like to plug a second trial they are running, called TINSAL-CVD, thata??s looking for volunteers. (You can check it out on Facebook.) It is testing whether salsalate lowers the risk of heart disease which, like diabetes, may be an inflammation-related condition. To see the wealth of clinical trials that are currently looking for volunteers, explore ClinicalTrials.gov, the National Institutes of Healtha??s up-to-date listing of the 18,000 clinical trials now underway in the U.S.

Many Women Remain Unaware Of A Non-Surgical Treatment For Uterine Fibroids

2011-08-07T01:32:00.000-07:00

" alt="Health in 30" />

[image:?? iStockphoto]

Ladies imagine planning your daily events based around the timing of you menstrual cycle.

Some women suffering from uterine fibroids have a menstrual flow so heavy that it can impede their life.

a??Everything must be planned around their menstrual, and it can be very draining physically (from the anemia of blood loss), as well as, mentally from the resulting stress this creates,a?? says Dr. John Lipman, Director of Interventional Radiology & Center For Image-Guided Medicine, Emory-Adventist Hospital, Atlanta, Georgia.?? a??This can imprison women such that their entire life is tied to the menstrual cycle. They may not work or even be able to leave the house for several days each month. Even if they can work, the frequent interruptions throughout the day often makes this time very unproductive,a?? he adds.

a??Uterine fibroids are the most common non-cancerous tumors in women of childbearing age. Fibroids are made of muscle cells and other tissues that grow in and around the wall of the uterus, or womb. The cause of fibroids is unknown. Risk factors include being African-American or being overweight.a??

According to The National Womena??s Health Information Center a?? U.S. Department of Health and Human Services Office on Womena??s Health, about 20 percent to 80 percent of women develop fibroids by the time they reach age 50.

Dr. Lipman writes:

Teresa Edwards, the most decorated player in the history of USA basketball, underwent treatment for uterine fibroids recently at Emory-Adventist Hospital in Atlanta.

Ms. Edwards who is scheduled to be inducted into the Professional Basketball Hall of Fame in August, and is currently the Director of Player Personnel for the WNBA Tulsa Shock, had no time in her busy schedule for surgery. She chose instead a non-surgical treatment option called Uterine Fibroid Embolization (UFE).

The UFE procedure was performed in less than 1 hour. Ms. Edwards had an uneventful recovery and was discharged home that same day. a??I feel great,a?? she stated.

She was back to work within a week and is already resuming her workouts in the gym. a??I couldna??t afford the long recovery from surgery, and what was even more appealing to me is the fact that I can keep all of my parts. I know a number of women who have had new problems surface after hysterectomy.a??

Most medical experts agree that while the traditional treatment for symptomatic uterine fibroids in women who have completed childbearing has been hysterectomy, this is now unnecessary with non-surgical options like UFE.?? UFE patients go home the same day with a band-aid and avoid the surgical complications and other issues associated with losing your uterus.

The uterus is very important to heart health and bone health. Women who lose their uterus have a significantly higher cardiovascular risk (i.e increased risk of heart attack, stroke) and risk of osteoporosis and bone fracture. A number of women suffer psychologically after hysterectomy (from losing their womb) like a man being castrated. They also can have sexual dysfunction (exs. loss of libido, loss of orgasm) or urinary incontinence.

The lack of awareness of UFE despite its long track record of safety and efficacy surprised Ms. Edwards. This was highlighted in a Wall Street Journal article from 2004 entitled, a??Silent Treatment: Hysterectomy Alternative Goes Unmentioned to Many Women. Gynecologists Often Dona??t Cite Less-Invasive Procedure To Treat Fibroid Tumors. Bailiwick of Other Specialists.a?????? Even an edict from the American College of Obstetricians & Gynecologists from 2008 which stated that based on long- and short-term outcomes, UFE is a safe and effective option for women with fibroids who wanted an alternative to hysterectomy, has not significantly changed treatment patterns. Many patients like Ms. Edwards were initially unaware of any other options besides surgery.

This need for education of treatment options has spawned a grassroots movement entitled, Wear White Pants (WWP). Women suffering with uterine fibroids cannot typically wear white any time of year due to the heavy menstrual flow and fear of subsequent accidents that they often cause. This can imprison women such that their entire life is tied to the menstrual cycle.

UFE gives women their freedom and their life back. It is one of medicinea??s most significant breakthroughs yet over 1 million women in the US currently suffer with fibroids; many of whom are completely unaware of UFE.

The goal of WWP movement is to empower women with the information that are alternatives to hysterectomy that allow one suffering with fibroids to avoid surgery, keep their uterus, and get the symptom relief they long for.

As the newest spokesperson for the WWP movement, Ms. Edwards hopes she can help educate women on UFE and bring an end to suffering for the over one million women in the US who currently suffer with fibroids in silence.

Ms. Edwards summarized the WWP movement by stating, a??There is a lot of work to be done, but I hope through efforts in Atlanta and elsewhere we will get our message heard.a??

Bottom line

Smart and savvy patients ask questions

a??Fibroids are benign tumors, and yet every working day 3,000 women lose their uterus to hysterectomy because doctors are reluctant to talk about other treatment options,a?? says Dr. Lipman.?? Additionally, there are over 1 million women who are the a??silent sufferersa??: sitting on the sidelines and suffering with the bleeding etc. not knowing that they dona??t have to suffer like that (or get a hysterectomy either), he added.?? Many of these women could also be spared with the knowledge of this alternative to surgery.

How many women know that there other non-surgical treatment options besides a hysterectomy for uterine fibroids?

If your doctor tells you that you have uterine fibroids and you need a hysterectomy, are you going to question it??? You will if you know there are other treatment options.

Dona??t be intimidated by your doctor or any other health care provider.?? Ita??s important that you ask questions.

Todaya??s modern medicine is about the patient.?? Partnering with your doctor is critical, and you need to educate yourself first to be aware of alternative treatment options.

Ladies if you are told by your doctor that you have fibroids and that the only option is a hysterectomy, that is a red flag.?? You need to seek another opinion.

Be proactive and take charge of your health and be aware that there are different treatment options to treat fibroids.

An original email to Dr. Lipman from a patient who suffered with uterine fibroids.

Dr. Lipman,

I could not think of anyone else to email at this late houra?|after starting my menstrual cycle today.?? It is still amazing how my mind and body is on auto-pilot to wake up at this hour to change the towel on my mattress as well as my diaper because of the heavy blood flow I would normally receive.?? I just returned from the bathroom and the minipad that Ia??m wearing has only a few drops in it.?? I ABSOLUTELY CANNOT BELEIVE THIS!!!

Not sure you remember me, but you performed the UFE procedure on me on 4 Nov 09. Before I heard about the UFE procedure, I was close to deciding on a historectomy.?? My health and my life was a mess.?? I was severely anemica?|hemoglobin down to 8.1 and dropping, thyroid level all over the place, suffering from urine incontenence because fibroids were resting on my bladder and strapped up like a gangster with pads and tampons! I had pads everywhere, in the car, in my office, in my bible, in every purse, in my childrena??s luggage, in my bootsa?|etc.?? At times, I thought I would literally bleed to death with periods lasting 3 weeks every single month.?? My blood clots were painful and scary!?? The clots would drop into the toilet like little Angry Airborne Aliens!?? Sometimes I would stand up and blood would explode into my panties and run down my leg into my shoes.?? I cried many nights because I felt helpless and embarrassed.?? I couldna??t enjoy many of the activities I enjoyed because my periods kept me prisoner.

Not anymore!?? I have my life back and my family has me back. My hemoglobin level is already up to 10.3, my thyroid (TSH) is normal and I no longer suffer from?? urine incontenence. I just started training for a marathon.?? I plan to spend lots of time at the beach this summera?|in a swimsuit!?? This summer I can wear the cute, short sun dresses and can fall asleep on my girlfriends couch if I need to.?? Thanks so much for performing this amazing procedure.?? I cannot express how grateful I am to you and your staff.

a?|I just checked again.?? Still only a few drops.?? God is good!?? Going to bed, not planning to get up until ita??s time for work.

Thank you Dr. Lipman!!!!!

Goodnight!

N

Your turn

We would love to hear your thoughtful comments.?? Are you a woman suffering with fibroids??? Have you been treated for them??? Whata??s your story??? Can you wear white pants?

As always, thank you for your time.

Useful resources for you

U.S. Department of Health and Human Services Office on Womena??s Health

Sharecare a?? John C. Lipman, MD

Medline Plus

The Journal of the American Medical Association a?? Patient Page

MedlinePlus

Empowered Patient | Patient Engagement

Doctor-Patient Relationship: How Patients Can Help Enhance Communication

Empowered Patient: Bring a Family Member or Friend with you to Your Doctora??s Appointment

The Patient, the Most Important Part of the Medical Team

Rules of Patient Engagement: How to Deeply Connect with Empathy

About John C. Lipman, MD

Dr. Lipman is a nationally recognized fibroid expert, and has given over 150 invited lectures nationwide on uterine fibroids, including Harvard, Stanford, Vanderbilt, and Yale Medical Centers, and is the Director of Interventional Radiology & Center For Image-Guided Medicine, Emory-Adventist Hospital, Atlanta.?? Dr. Lipman is an Editorial Advisory Board Member and Womena??s Health Expert for Sharecare.com (Healthcare information website created by Dr. Oz & Jeff Arnold, creator of WebMD).?? He is Adjunct Clinical Assistant Professor, Department of Obstetrics & Gynecology, Morehouse School of Medicine, Atlanta, GA. He has appeared live on CNN with Wolf Blitzer and has been interviewed for USA Today, The Wall Street Journal, CNBC, Jet, Newsweek, The Health Network, Family Circle, and WebMD.

Travelera??s Diarrhea: The Basics

2011-08-05T01:14:00.000-07:00

" alt="Healthline Health Expert Paul S. Auerbach - Medicine for the Outdoors" />

This is a guest post by Dr. Erik McLaughlin.

**********

Traveler’s Diarrhea: The Basics

Known around the world by many names including a??Montezumaa??s revenge,a?? a??Delhi bellya?? and a??mummy tummy,a?? travelera??s diarrhea (TD) is the most common illness faced by travelers. Nothing can slow down a fun trip as easily as TD — and it can also have serious health implications. TD typically lasts four to six days, and 90 percent of cases occur within the first two weeks of travel.

Anatomy You Need to Know

The gastrointestinal tract starts at the mouth and ends at the anus. After food enters the mouth, it passes through the esophagus to the stomach, where it sits for approximately 45 minutes. After being broken down by gastric secretions, food matter enters the small intestine (duodenum, jejunum, and ileum in order). The small intestine is the site where most nutrients are absorbed by the body. From the small intestine, food matter begins to look more like feces as it progresses to the large intestine or colon. The colon absorbs water from the food material before the material passes through the anus and exits the body as feces.

Symptoms

Recognizing the warning signs of TD, such as blood in the stool, fever, or abdominal cramping, can help a savvy traveler know when to seek medical help.

TD has many definitions; the presence of three or more loose-formed stools in one day is a good one. Abdominal cramping, nausea, vomiting and fever may also occur. The presence of blood in the stool can indicate that infection has directly damaged the intestinal wall and should be taken seriously.

Clinical Diagnosis??and??Complications

Diagnosis of TD is largely based on symptoms. The presence of blood in the stool may indicate that there is an invasive process damaging the intestinal lining. As previously mentioned, this should be taken seriously. Diarrhea that is accompanied by fevers and severe abdominal cramping may also signal a more serious form of illness and should prompt the afflicted individual to seek medical care.

Typical travelera??s diarrhea is loose and watery. Some doctors advise a a??let it flowa?? approach with the reasoning that diarrhea is the bodya??s way of excreting the infectious agent that causes the symptoms. While this can be an inconvenient way to deal with diarrhea, it can also be a good approach, providing there are no warning signs indicating a serious debilitating infection, fluid losses are not excessive (such as with cholera), and the person continues to drink large amounts of fluids sufficient to keep pace with fluid losses and to avoid dehydration.

Warning signs of a serious diarrheal infection include fever, blood in the stool, massive fluid loss, and/or severe abdominal cramping. The most serious of these signs are blood in the stool or massive fluid loss. Bloody diarrhea indicates that the lining of the intestines is being damaged or penetrated by the causative agent, and massive fluid losses suggest cholera. Any time the intestinal lining is compromised, the possibility exists for a systemic infection. Should a traveler suffer from bloody diarrhea, a visit to a health care provider is advised if possible. This type of diarrhea typically requires treatment with an antibiotic, and may require tests to determine the exact cause.

Causes

The most common cause of travelera??s diarrhea is the gram negative bacterium enterotoxic Escherichia coli (E. coli or ETEC — seen pictured above). This bacterium has been implicated in up to 70 percent of the cases of travelera??s diarrhea worldwide. Campylobacter species, specifically C. jejuni, are considered the second most common cause (30 percent). This organism appears to have seasonal peaks. For example, in the U.S., C. jejuni infections peak during summer months, while in northern Africa, the peak occurs during drier winter months.

Other less common bacterial causes of travelera??s diarrhea include Salmonella, Shigella, Vibrio species (e.g., V. cholera and V. parahemolyticus), and Yersinia enterocolitica. These bacteria occur in up to 15 percent of cases.

Viral infections are estimated to cause 20 percent of TD cases in adults, with the Norwalk virus being a common agent, especially on cruise ships. Rotavirus and hepatitis A and E can also cause diarrhea in travelers. Rotavirus infection is more often seen in children than in adults.

Parasitic infections can also be causes of travelera??s diarrhea. Of these, infections with protozoans are considered most common. Giardia lamblia, Cryptosporidium, Cyclospora, Entamoeba and Isospora species are implicated in roughly five percent of TD cases. Less common causes of travelera??s diarrhea can include helminthic infections, food poisoning, and seafood toxidromes.

Care and Treatment

The most important treatment for travelera??s diarrhea is to ensure adequate hydration. Dehydration is very common in persons who suffer from TD due to the large amounts of water that are lost via loose stools. Oral rehydration with sports drinks and clean, disinfected water should be started the moment that diarrhea strikes. Depending on the causes of the diarrhea, antibiotics may be required to kill bacteria or parasites. Using anti-diarrheal medications to prevent frequent trips to the toilet has a role, but should be done with caution. Preventing the infectious diarrhea from leaving onea??s body may retain the bacteria or parasites in the intestines, allowing them more time to do damage. It is important to have a reasonable degree of certainty about the type of diarrhea before starting antibiotic therapy.

Diarrhea Evaluation in the Returned Traveler

Further studies into the cause of the travelera??s diarrhea start with a thorough travel history, focusing on destinations and eating habits/history. The majority of classical TD cases occur within the first two weeks of travel and last four to six days. Thus, a typical traveler with complaints of diarrhea upon return home will likely be suffering from recurrent or prolonged diarrhea. Only five to 10 percent of travelers have TD symptoms lasting longer than two weeks.

Initial laboratory investigations into diarrhea in a traveler by health care providers may include electrolyte determinations and stool studies looking for the presence of fecal red blood cells, white blood cells, ova and parasite studies, and bacterial culture.

Anatomy and Diet

Knowledge of intestinal anatomy and physiology is important in understanding proper dietary modifications and treatment for those affected by travelera??s diarrhea. The inner lining of the wall of the small intestine is lined with a a??brush bordera?? that contains enzymes to assist in food digestion. When someone suffers from diarrhea, this brush border is frequently damaged and excreted with the diarrhea.

Lactase, which is the enzyme that breaks down lactose (found in dairy products), is one of the enzymes in the brush border, and it can be particularly fragile. When the brush border is damaged, the victim can no longer digest lactose as effectively as before the diarrheal illness.

Thus, food containing lactose in their intestines goes undigested and can act as an osmotic attractant to water. Basically, the undigested bits of dairy food (cheese, milk, etc.) draw more water than normal into the intestine, causing increased diarrhea and water loss. Avoidance of dairy products during diarrheal illnesses should be considered. After a few days to one week of no symptoms, the brush border typically re-grows to the level it was at prior to the diarrheal illness.

**********

Erik McLaughlin, MD, MPH is a medical doctor who specializes in travel and expedition medicine. Erik is the Medical Director of the Adventure Doc Clinic based in Tucson, Arizona.

Before going to medical school, Erik was a professional outdoor athlete, competing in adventure races and multi-sport endurance events around the world. His interest in medicine came from taking care of his teammates during these remote events. In addition to his qualifications as a medical doctor, Erik has completed a Masters in Public Health in International Health and the Diploma Course in Travel and Tropical Medicine.

Erik works part time as a rural emergency physician in southern Arizona as well as acting as a travel and expedition medicine consultant. He also provides educational modules on remote and expeditionary medicine. He is an active member of the Wilderness Medical Society, The International Society of Travel Medicine, The Australian Society of Ruraland Remote Medicine, and a Fellow of the Royal Society of Tropical Medicine and Hygiene.

This post, Travelera??s Diarrhea: The Basics, was originally published on
Healthine.com by Paul Auerbach, M.D..

A Surprising Discovery And The Value Of The Physical Exam

2011-08-05T01:13:00.000-07:00

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I’ve remarked in the past how rarely I ever learn anything useful from physical exam. It’s one of those irritating things about medicine — we spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing’s sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don’t do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don’t often learn much from it. But I always do it.

The other day, for example, I saw this elderly lady who was sent in for altered mental status. There wasn’t much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn’t clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. “Uh-oh. She don’t look so good,” I commented to a nurse. As an aside, this “she don’t look so good” is maybe 90% of my job — the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed “sick” to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash.

Sigh. Probably another case of urosepsis. Sorry, I mean UTI with sepsis. Boring, and unsatisfying. Let’s scan her and cath her and lab her and see what shows up. Let me just take a look at her legs and make sure there’s no cellulitis or anything there. Nope, but boy she really groaned when I moved that leg, didn’t she? Weird. Seems that left hip hurts her when I push on it. Did she fall out of bed? Maybe she’s got a broken hip. Is there a bump on her head? That would explain the altered mental status. Nope. So I flip up her gown to look at the hip better, and I was surprised to see a bright red rash all around her leg and pannus (she was quite large). Huh. Here we go — she has a rip-roaring cellulitis. That would explain the altered mental status quite nicely. Good. I’d better take a look at her backside, though. She might have a pressure sore there that could be the source, and we have to document that it was present on admission. The nurses glared at me a bit, but we got a team together and rolled her on her side so I could examine her sacrum. No pressure ulcer, and I was about to let them roll her back, when I noticed something — “Hey, what’s that?”

It was a little dark area, like a bruise, just the size of a quarter, on the back of her thigh. ??But it wasn’t quite like a bruise — it was too sharply demarcated, and too dark, almost black. I poked at it, but she didn’t groan, and the skin was intact. ??Weird. It was involved in the cellulitic area, though.

I didn’t like it. So as I put in the orders I decided to add on a CT scan. Shortly afterwards, the labs started to come back, and it was clear this was looking serious. White count of 22,000. Glucose 950. Creatinine 3.5. ??All bad. Then the call from the radiologist**. I pulled up the images:

Uploaded with Skitch!

There was extensive air all through the soft tissues of the thigh, tracking to the perineum and the abdominal wall. Aha! Now this made perfect sense. She had necrotizing fasciitis, commonly known as the “flesh eating bacteria!” This is a true surgical emergency, and indeed she got a very big surgery. The whole area involved simply had to be excised, and in such a sick patient, that’s a huge operation, with a very high mortality. When the famliy eventually showed up, I prepared them with the “she may very well not survive” talk. (And, yes, it turned out this was a dramatic change from her baseline level of function.) To everyone’s great surprise, she did pull through the surgery (and the repeat surgeries), and last I saw was getting prepped for discharge to rehab.

The take home point here, really, was that the physical exam, while a rote and generally unrevealing exercise, simply cannot be skipped. This lady had no crepitance — the crackling underneath the skin that is classically the hallmark of subcutaneous gas. I think she was just too fat, and the thigh too tense, and maybe the air too widely disseminated. If I had not taken the time to look at her backside, I would never have seen the black spot that clued me into the fact that this was more than a routine cellulitis. Had I sent her to the floor on antibiotics, she would have died. This is not at all to be taken as a recantation of my original thesis: in 99% of cases, I learn little to nothing from the exam. She just happened to be in the 1% that actually had a critical finding, which proves the corollary to my thesis, that despite the seeming pointlessness of exam, you still have to do it.

* pro tip for Emergency Medicine interns: respect tachycardia.

* pro tip #2: the radiologist never calls to discuss the fortunes of your local sports team, or a pleasant surprise he experienced in the market. It’s always Somethign Bad when the radiologst deigns to speak directly to the emergency physician.

Physical Activity Versus Physical Fitness: It Could Mean The Difference Between Life And Death

2011-08-05T01:12:00.000-07:00

My neighbor Ed was a thin man all his life. He maintained an ideal body weight by combining regular physical activity with a modest intake of calories. He was a a??younga?? seventy year-old who looked the picture of heart health.

Ed regularly read the newspaper while walking on his treadmill, he hit a golf ball straighter and longer than his peers, and he wore the same size jeans now than he did in college 50 years ago. Whata??s more, he bragged about his low blood pressure, normal cholesterol level and perfect blood chemistries. He took no pills. I think he went to his primary care doctor each year just to show off his health.

The morning he woke with crushing chest pressure and shortness of air stunned him. a??This couldna??t be a heart attack?a?? he thought. An hour later, minutes after his urgent heart catheterization showed severe blockages in all three of the main coronary arteries, a sternal saw provided a heart surgeon access to his dying heart.

Ed did well. The story had a happy ending. He still looks the picture of health, but now therea??s a scar on his chest and a few pill bottles in his medicine cabinet.

How can a human who exudes heart health go to bed well and wake up with severe heart disease? Whata??s missing? What could Ed have done differently? Could his doctors have measured anythinga??over and above the traditional risk measuresa??that might have suggested his obviously higher cardiac risk?

Regular readers of Cycling Wednesday might think Ia??m heading down the inflammation road here. Was Ed a hot-headed bike racer? Was he divorced, alone, or, did he stay up all night ruminating about the stagnant stock market?

No. I have never heard Ed holler; hea??s married, and goes to bed every night before the local Fox news comes on. He even has a dog.

So what gives?

It turns out that Ed was physically active, but he wasna??t physically fit. Therea??s a big difference. Ed strolled easily on the treadmill, he played golf, and he kept busy in the yard with regular duties. All this activity burned enough calories to help him maintain a size 34a?3 waist and good blood chemistries. But Ed never pushed his exercise to a level that produced adaptations of the heart, lungs and blood vessels. He never jacked ita??as we bike racers say.

On an objective measure of exercise capacity, one that requires a sustained high heart rate and consistent oxygen uptake from the working muscles, Ed would have looked pedestrian. He could stroll at a ten-minute mile pace for miles, but ask him to run 1 mile at an eight-minute per mile pace and he would have come apart.

Competitive cyclists, runners and swimmers can tell you about the notion of physical fitness. You get fast by going fast for cycles. These jabs of exertion produce adaptations that increase the hearta??s ability to pump nutrients and the musclesa?? ability to burn the delivered fuel. Thata??s called fitness. And it doesna??t come by reading on a treadmill or a recumbent bike.

Improving your fitness isna??t just good for getting a shout out at the towna??s criterium bike race, or a mention in the local papera??s 5k race results. Though under appreciated by many medical people, how long one can drill it on a treadmill translates as a major predictor of heart health.

This week, in a a??published online before printa?? version of Circulation, a 66,000 patient-strong study from the well known mecca of exercise science, the Cooper Clinic (Dallas, TX), suggested that exercise capacity improved the classification of heart risk, over and above the traditional risk factors (smoking, age, BP, blood sugar and cholesterol). The researchers measured how long each person could sustain exercise on a standard treadmill protocol. (This time correlates well with the standard measure of fitness, the VO2 max.) They then followed these subjects for the next 25 years. Surprisingly, the capacity to exercise resulted in a significant re-classification of some subjects from low to high heart risk. This study appeals to me for four reasons:

Exercise capacity was easy to measure. All one needs is a stopwatch and a treadmill.

The time on a treadmill bested the predictive value of other more sexy tests, like the CRP level, for instance.

Unlike coronary calcium CT-scans, measuring exercise capacity is radiation free and much less expensive.

Exercise capacity as a metric for predicting heart disease risk is consistent with prior scientific studies: Take this NEJM study which revealed peak exercise capacity to be a stronger predictor of mortality than smoking, diabetes, high blood pressure or an abnormal ECG.

I realize that speaking negatively about regular physical activity while our society is overcome with languidness seems heretical.

Being thin, maintaining a normal blood pressure, and having favorable blood tests, as Ed did, would clearly be an improvement for most citizens of North America. What would be better though, is to exercise vigorously enough to improve your exercise capacitya??to become fit.

This means sweating (not reading) on a treadmill or an exercise bike. It means getting out of your comfort zone for periods of time. Sure, it may sound nit-picky, but exercise is like anything else: there are good kinds, better kinds and really dumb (Ironman) kinds.

Anda?|you bet I believe that exercise is something that should not be multi-tasked. Dona??t expect me to tweet on the bike.

Go fast. Rest. Be Fit.

JMM

P.S. Herea??s link to the Balke Test: The treadmill protocol that the Cooper Clinic researchers used to to estimate physical fitness. After an adequate warm-up and clearance from your doctor, you could use this as a simple measure of your exercise progress.

Oops: Pre-Term Labor Drug Does More Harm Than Good To Pregnant Moms

2011-08-05T01:11:00.000-07:00

The Federal Drug Administration (FDA) recently issued a new warning about a medication that has been used for years and it has sent shock waves throughout my specialty. Terbutaline is an FDA approved medication that is used for asthmatic patients or patients who have significant narrowing of the airways. However for years it has been used as an a??off-labela?? medication to treat preterm labor but now thata??s about to change. An off-label drug means it hasna??t been approved for that specific use by the FDA.

According to the FDA, the injectable form of Terbutaline should only be used for a maximum of 24 to 72 hours because the drugs association with heart problems and death.?? The FDA goes on to say that the oral version (pills) should not be prescribed to treat preterm labor because ita??s ineffective and can cause similar problems. As an obstetrician, I feel utterly betrayed. The medication clearly had side effects that included shortness of breath and a racing heart. As resident physicians we were taught that the benefit outweighed the risks of having a premature baby and the patients should try to adjust to the medication.

We now learn that there have been 16 maternal deaths from 1976 until 2009 that have been associated from the use of Terbutaline. In 1997 the FDA issued a warning about its prolonged use but the prescribing patterns by physicians did not appear to change. There have also been 12 reported cases of mothers with serious heart conditions that were also associated with the use of Terbutaline; hence, the need for a repeat warning.

There are maternal fetal medicine specialists that think Terbutaline should not be abandoned completely and cite clinical conditions such as an over stimulated uterus, the need for a relaxed uterus ??and transporting a patient from one institution to another while in preterm labor as a reason for the short-term use of Terbutaline.

In view of the FDA warnings, it is important for all pregnant women to be aware of the medications they are receiving, especially if they develop preterm contractions. Terbutaline should only be given in a hospital for a maximum of three days and never taken at home.

Remember, a healthy pregnancy doesna??t just happen. It takes a smart mother who knows what to do.

Tips For Physicians On Handling Their Online Persona

2011-08-05T01:09:00.001-07:00

Like everybody else, physicians are expanding their online personal identities. At the same time, they are trying to comply with codes of conduct that help consumers trust them and their profession.

Therea??s no problem so long as the personal online activities of physicians dona??t jeopardize their obligations as professionals, which means that??there is a problem, unfortunately.

In a recent study for example, 17% of all blogs authored by health professionals were found to include personally identifiable information about patients. Scores of physicians have been reprimanded for posting similar information on Twitter and Facebook, posting lewd pictures of themselves online, tweeting about late night escapades which ended hours before they performed surgery, and other unsavory behaviors.

As I mentioned Monday, medical students and younger physicians who grew up with the Internet have to be particularly careful, since they had established personal online??identities before accepting the professional responsibilities that came with their medical degree.

Medical schools, residency programs and teaching hospitals can help young professionals manage their dual lives online. Some have implemented curricula and policies that foster appropriate use of social media, but surprisingly these programs are not widespread. In a recent study of medical schools that had experienced at least one incident in which a student used social media inappropriately, only 38% had adopted formal policies to handle future incidents. An additional 11% reported they were developing such policies. We can do better than this.

Non-teaching hospitals, CME providers and professional organizations like the American Medical Association can also help providers navigate the online world. The AMAa??s recent guide to Professionalism in the Use of Social Media provides helpful guidance in this regard.

What You Can Do Now

Frankly, this is not something that can wait. If you havena??t already done so,??you should immediately take steps to assure your personal online identity doesna??t threaten your professional identity, your patientsa?? rights to privacy, and other responsibilities you have as a physician. Here are some tips for getting started.

1-Look Before You Leap. If you are just starting to expand your online personal identity (say, by registering for a Twitter account), dona??t feel compelled to lay yourself out there right away. Therea??s nothing about Twitter or Facebook that requires you to do anything after you register (nor for that matter, is anyone compelling you to generate searchable events like comments??on??newspaper articles, donating to political campaigns and so on).??A quiet listening period up front allows you to get a feel for things before taking part. After a few days of following the tweets and posts of others, particularly other physicians, youa??ll get a sense for etiquette and social boundaries.

Remember that if you see content posted by a colleague that you think is unprofessional, you should inform him or her. After that, ita??s up to them to remove it or take other appropriate actions.

2-Review and Maintain your Online Profile. This advice appears in the AMA guidelines and is the centerpiece of a recent article on the subject by Arash Mostaghimi and Bradley Crotty.

The recommendation amounts to??carrying-out an electronic self-audit of your online identity and taking action to create a a??dual online citizenshipa?? to the extent possible. Often, a simple search of your name on Google or Bing is sufficient for the audit. If the audit reveals a relatively sparse professional footprint online, you can beef it up by creating a web page for your office, posting your CV online, posting information about yourself on Google Profiles, starting a professional blog, and so on. You may also need to address personal issues that show up during the audit as well. Finding these issues is a key reason for doing the audit in the first place.

3-Go Ahead! Answer General Questions from Patients Online.?? Ita??s safe and reasonable for you to answer general questions like a??What is heart failure?a?? and a??When is the right age to get a mammogram?a??, so long as you do not include individually-identifiable information about a patient. Just remember that existing and prospective patients read this stuff, so make it good!

4-Think Twice before Using Social Networking Sites to Communicate with Patients. Companies like Facebook and Twitter control the information posted on their sites. The same goes for search engine companies, who are having a field-day with your online search behavior as we speak. These companiesa???? privacy and security policies have been criticized as flimsy and capricious. Once you post something, it can be nearly impossible to delete it completely.

That said, social networking sites are great platforms for your general announcements like the addition of a staff member, flu shot availability and matters of public health.

Pregnant Moms: Beware Of Shift Changes In The Hospital

2011-08-05T01:08:00.001-07:00

business " src="http://drlindagalloway.files.wordpress.com/2011/05/1031747_hospital.jpg?w=300&h=197" alt="" width="300" height="197" />At one time, a hospital would be called a 24-hour institution but now ita??s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists.?? In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, a??no.a??

Sign-outs, handoffs, shift changes, nursesa?? report. These are the multiple names for the process where a departing?? provider is responsible for letting the arriving provider know whata??s going on with the patient.?? According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mothera??s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change.

a??While in labor, there will most likely be a change of shift and a transfer of information should occur. However, it is not always successful. Information is sometimes lost, incomplete, misunderstood or inaccurate. ??Your doula or a family member should make a list of all tests that have been ordered since your admission. He or she should also know your most recent vital signs, including your blood pressure and whether your babya??s fetal tracing was reassuring. Other important include:

The length of time since your membranes ruptured: the longer your membranes have been ruptured, the greater your chances of developing an infection in the amniotic sac around the baby called Chorioamnionitis

A positive group B strep that must be treated with antibiotics to prevent your baby from contracting the infection

The length of time you have been receiving Pitocin. The status of your fetl tracing should be noted to make certain that the baby can tolerate the contractions caused by Pitocin.

Any other significant clinical issue that might have been discussed that could adversely affect your labor

Before the end of a shift, your family member or doula might ask the departing nurse or provider to review his or her notes regarding your care and ask a??Is this correct?a?? When the new shift takes over, your doula or family member would show them the notes and ask whether they received the same information that was verified by the previous shift.

The path to a successful delivery becomes much straighter when everyone marches in the same direction. Remember, a healthy pregnancy doesna??t just happen. It takes a smart mother who knows what to do.

SCUBA Diving With A Disability

2011-08-05T01:05:00.000-07:00

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Outdoor recreation is intended for everyone, and can be enormously beneficial for persons with disabilities. I am in awe of disabled skiers, climbers, divers, and others who have learned to coordinate their bodies and take great enjoyment and a sense of accomplishment from their wilderness activities.

It behooves everyone in the healthcare profession to be aware of certain special medical concerns for persons who are disabled physically or emotionally. Additionally, family members and friends are often well aware of what they can do to help in providing a joint effort to support the disabled.

At the 2010 Wilderness Medical Society annual meeting in Snowmass, Colorado, JenFu Cheng, MD (a pediatric rehabilitation specialist from NJ), gave a wonderful presentation on the medical aspects of (scuba) diving with a disability. He pointed out that there may be up to nine million certified recreational scuba divers in the United States alone. His presentation, rather than focusing on persons who are fully capable physically and emotionally, examined the lesser-known benefits of being in the water for individuals in need of additional support. For instance, aqua therapy (largely enacted in swimming pools) takes advantage of the buoyancy of water to allow a range of mobility that is not possible on land. For example, aquatic exercise has been shown to improve lung capacity and mobility skills in children with cerebral palsy.

Scuba (self-contained underwater breathing apparatus) diving takes aqua therapy to another level. Imagine being a person previously restricted to a wheelchair, who can now freely explore the undersea environment! Although there are few guidelines for selection and training of disabled persons when scuba diving, there are unwritten rules, like advising against diving beyond a??no decompression limits.a?? As Dr. Cheng remarked, John Williams (a professional diver and author of a number of diving guides) observed in 1984 that progress in all aspects of selection of disabled persons for diving, their training, and any applicable a??rulesa?? will come from the combined experience of people who are trained in rehabilitation, psychology, and diving medicine. Of course, progress also relies on the divers themselves and their instructors.

The literature, both medical and non-medical, supports the psychosocial aspects of scuba diving for persons with disabilities. Benefits include:

ability to explore a new environment

abandoning a mindset of disability

realizing new physical freedoms

being equal to others in their achievements

enjoying a spectacular marine environment

socializing and relaxing

gaining confidence, even to the point of assisting others in distress

Assistance and certain adaptations may be necessary. These include webbed gloves (for greater propulsion or to substitute for amputations), motorized underwater scooters, low-platform dive boats or boats with lift (for easier entry into and exit from the water), different diving techniques that emphasize overcoming physical limitations, and so forth. The Handicapped SCUBA Association includes a certification structure for disabled divers and facilitation of dive buddies.

Special medical concerns for disabled divers include many aspects of diving. Examples are decompression illness in persons with spinal cord dysfunction (such as spina bifida (myelominingocele), where it is important to have the participanta??s pre-dive neurologic status available for comparison if there is any question later of decompression illness. Autonomic dysreflexia is a significant problem for spinal cord-injured persons, when there is a complete injury above the sixth thoracic vertebral bone. In this situation, a noxious stimulus below the level of the spinal cord lesion may trigger and maintain a dangerous increase in blood pressure, low heart rate, headache, sweating, and anxiety. Is this a contraindication for diving? Authorities differ on their recommendations. What if someone has a seizure disorder? Some dive certification agencies allow diving if the diver has been seizure-free without medications for at least five years. But what if someone is seizure-free on appropriate anticonvulsant medications? Again, opinion is divided. Other medical situations related to disabilities that should be taken into consideration include ventriculoperitoneal shunts (placed in individuals with elevated intracranial pressure), inner ear (cochlear) implants, implanted pain medication pumps, and gastrostomy tubes. Individuals who must be catheterized in order to empty their bladders should not dehydrate themselves to avoid this necessity. Indeed, they must emphasize hydration to avoid becoming dehydrated, and may therefore need to enjoy shorter duration dives.

Custom-fit wetsuits are available to accommodate deformities and absent limbs. Depending on balance underwater, additional weights may need to be placed to achieve proper neutral buoyancy.

One particular concern is for stasis of blood flow in the veins in limbs that are immobile or have poor vascular tone for many different reasons. This could lead to blood clot formation. If the skin is fragile or in poor condition due to a disability, it should be specially padded and protected from rough handling. Latex allergy appears to be more prevalent in persons with spina bifida, so it should be avoided in dive equipment and the seals in dry suits.

With regard to the heart, exercise testing can be performed to determine if a person meets reasonable requirements to sustain exertion underwater and dive safely. Any lung disorder that creates a residual situation of air trapping that could lead to an overpressurization accident and acute air embolism clearly excludes the afflicted from diving.

This post, SCUBA Diving With A Disability, was originally published on
Healthine.com by Paul Auerbach, M.D..

Behavior Vs. Disease: A New Way To Look At Health

2011-07-30T17:38:00.000-07:00

What is the leading cause of death in the United States? Heart disease? Cancer? No, it’s smoking. Smoking? Yes, depending on how you ask the question.

In the early 90s, McGinnis and Foege turned the age-old question of what people die of on its head by asking not what diseases people die??of but rather what the causes of these are. Instead of chalking up the death of an older man??to say lung cancer, they sought to understand the proximate cause of death, which in the case of lung cancer is largely smoking. Using published data, the researchers performed a simple but profound calculation — they multiplied the mortality rates of leading diseases by the cause-attributable fraction, that proportion of a disease that can be attributed to a particular cause (for example, in lung cancer 90 percent of deaths in men and 80 percent of deaths in women are attributable to smoking). Published in JAMA in 1993, their landmark study became a call to action for the public health community.

When??looked at??the conventional way, using data from the 2004 update of the original study, heart disease, cancer, and stroke??are the leading causes of death, respectively. This accounting may help us understand the nationa??s burden of illness, but does little to tell us how to prevent these diseases and improve health. Through the lens of McGinnis and Foege we get the??actual causes of??death (e.g., the major external modifiable factors that contribute to death). This analysis shows that the number??one cause of death in??America is tobacco use, followed closely by poor diet and lack of physical activity, and then alcohol consumption.

For those??who are??passionate about preventive health, we take heart that fully??six of the 10 leading actual causes of death are controllable behaviors — all except microbial agents, toxic agents, motor vehicle, and firearms (though handwashing and seatbelts can make a huge difference!) a?? and that??four of the 10 are addressed by U.S. Preventive Services Task Force recommended clinical preventive services.

You may wonder why am I presenting the results of a seven-year-old study that is itself an update of a paper published 18 years ago.??Two weeks ago, I attended the American College of Preventive Medicine’s annual scientific session. Along with hundreds of my peers, I went to the conference??excited to hear about the latest and greatest in preventive medicine. At??highly anticipated??keynote address, the opening speaker Dr. David Katz??presented the??first of what would be hundreds of slides of data shown throughout the three-day conference. And what did he kick off the conference with???The graphs above showing the top 10 actual causes of death in America.

Often when it comes to health it is hard to separate the signal from the noise. We get so many messages through the media, our social networks, and even our doctors: a??Heart disease is the number??one killer,a?? a??Eat more omega-3,a?? a??Dona??t forget to check your breasts.a?? There are only so many hours in the day and so many competing agendas, it is hard to know what to make a priority. Sometimes to sort it all out it helps to just step back and let the data speak for itself.

So the question is:??What does the data say to you?

- Shantanu Nundy, M.D.

The Seven Golden Rules For Kidneys

2011-07-30T17:37:00.000-07:00

In the better-late-than-never category comes my shout out for World Kidney Day, which was March 10th.

I love their slogan: a??Protect your Kidneys, Save your Heart.a??

As an organ, the kidneys are a lot like offensive lineman in football; they do all the hard work but remain mostly anonymous. They sit motionless in the back of the body,quietly and humbly filtering salt, water and toxins from our bodies. Though some may think that pee smells bad, or is gross, not having a??healthya?? pee is a real problem.?? No one ever thinks of their kidneys until they malfunction.

Though the inner workings of the kidneya??with all its convoluted loops, capsules and ion exchangersa??are more complicated to understand than the heart, keeping your kidneys healthy is simple: just make heart-healthy choices.

Only kidney peeps give their rules a far more creative namea?|

The Seven Golden Rules:

Stay fit and active.

Keep your blood sugar under control.

Monitor your blood pressure.

Eat well and stay thin.

Do not smoke.

Do not take over-the-counter pills on a regular basis. (NSAIDsa??Non-steroidal anti-inflammatory drugs are even harder on the kidneys than they are on the heart.)

Check your kidney function if you have any of these risk factors. (Note: Unlike Echos and ECGs, a kidney function test is objective; the level of creatinine comes with an easy to read a??Ha?? or a??La??.)

Thata??s it, I have to goa?|

JMM

Your Dog May Be Your Best Personal Trainer

2011-07-30T17:36:00.001-07:00

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Earlier this week there was an article in the NY Times by Tara Parker-Pope?? –Forget the Treadmill. Get a Dog. — which states in a more elegant way what I have been saying for years now.

a?|a?|Several studies now show that dogs can be powerful motivators to get people moving. a?|..

Just last week, researchers from Michigan State University reported that among dog owners who took their pets for regular walks, 60 percent met federal criteria for regular moderate or vigorous exercise. a?|a?|.

A study of 41,500 California residents also looked at walking among dog and cat owners as well as those who didna??t have pets. Dog owners were about 60 percent more likely to walk for leisure than people who owned a cat or no pet at all. a?|a?|..

I have called my dog Rusty my personal trainer.?? He never lets me off the hook.?? We walk daily regardless of the weather (hot, cold, rain, snow).

I also use a pedometer to remind me to get up and move more.?? It it a nice device to motivate me to not sit (& blog, read, knit, quilt) too much.

Herea??s a replay of my tribute to Rusty, My Personal Trainer (January 2010):

a??Five more minutes,a?? I tell him as he nimbly places his paws on my knees, brown eyes imploring.

a??Okay, you win.a??

Orange ball cap on my head, gloved hands grab the leash.

We exit the gate, the January sun cold as we jog toward the neighbors woods.

Will there be ducks on the pond today?

Verification: The New Scam In Town

2011-07-30T17:35:00.001-07:00

Therea??s a new scam in town.

Company calls over and over again (claiming to be the phone company, actually) just wanting to a??verify your addressa??. Over and over again they get told we arena??t interested, leave us alone, dona??t call. Finally, my solitary staffer gets sick of fending them off and goes through their voice activated a??address verificationa??, during which a mechanical voice asks questions, followed by a command to a??Say Yes or No, then press the pound key.a??

So she goes through the innocuous questions, including her full name, the office address and phone number, plus several iterations of saying a??Yes or No, then press pound.a?? The calls stop; everyone is happy.

Until I get the phone bill six weeks later. Lo and behold, there is an extra $49.99 charge (plus tax) from a company I never heard of. Multiple phone calls reveal it to be a company providing a??Internet optimization, web services, and a toll free number,a?? stuff I neither need nor want.

I call to complain. I am told there exists a recording of Solitary Staffer authorizing said services. Ia??ve actually heard this line before. a??Let me hear it,a?? I demand. What usually happens is that said recording a??cannot be found,a?? the services end up canceled, the account credited.

This time, though, they produce a recording of what is clearly SSa??s voice saying her full name, the office address and phone number, plus the word a??yesa?? several times. However the mechanical voice is saying things like, a??Do you agree that you are authorized to incur charges at this number,a?? which SS clearly is not, knows she is not, and to which she never ever would have responded a??Yesa?? and pressed the pound key.

Obviously they have taken clips of her voice and spliced them into whatever they wanted.

A nice touch is the a??30 day free trial perioda?? during which I could have stopped the service for free, the catch being that I received no notification until the phone bill six weeks later.

I yell, scream, moan politely demand that they discontinue the service and credit my account immediately. Although the first person I get on the line claims not to have the authority to do so, she puts me on hold for a while, then comes back and agrees to credit me $99.98 for the two billing cycles. Now I have to decide if ita??s worth calling the phone company to get the $6.00 credit for the damn tax.

Take home lesson: be very leery of calls for a??verification,a?? a word whose root comes from the Latin for a??trutha??, that now seems to portend naught but lies.

iPad Cover Used In Kitchens Could Also Be Used In Hospitals

2011-07-30T17:34:00.001-07:00

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Apple iPads are taking the clinical world by storm, but they’re not exactly built for a busy environment full of liquids, dirty hands, and pathogens. The Chef Sleeve is a plastic wrapping originally designed to help cooks prevent their iPads from getting hit by a splash of this and a dash of that. The plastic is compatible with the touch screen, provides basic protection, and won’t require you to sterilize it before bringing it home from the hospital. At $20 for 25 sleeves, your new baby can get the basic protection it deserves.

Product page: Chef Sleeve…

Technophobic Physician Discovers iPhone, Recommends Apps

2011-07-30T17:33:00.001-07:00

Your humble Luddite Whistleblower has leapt across the??sea to reach the Isle of Technology. I now own and operate an iPhone, which identifies me as groovy, hip and cool, three adjectives that none of our 5 kids ever use to describe their technophobic father. Ia??m told that my text messages are too long and too frequent. I am admonished that it is not necessary for me to photograph moments of high drama, such as a kid eating breakfast, and then to disseminate the image to my contact list. I am reminded often that I am slow to grasp the mechanical intricacies of the device, such as switching from ring to vibration mode.

You may wonder how it was possible that I, who consider using an ATM to be a high level computer operation, could make the iPhone, my phone. I knew I couldna??t fail, despite my trepidation of all things cyber. I had a secret weapon, a a??Plan Ba??. Actually, I had Plan Z, the most powerful asset that anyone in my situation could hope for. Z stands for Zachy. One sentence will explain all and may provoke screams of envy from those who have no available similar resource.

Zachy is our 14-yr-old kid!

Zachy is our youngest son and lives and dreams in the cyberworld. Like his contemporaries, he relies on computers to communicate and interact with the world. He is excited to devise new mousetraps that seem unnecessarily complex. When he receives a phone call, he can reroute the call so that it the callera??s voice will emerge out of a speaker from another techno-contraption in his room. Is this cool? Yes. Is it easier than simply answering the phone? You decide.

Of course, the real appeal of the iPhone is the Apps. Since App to me means appendectomy, I assumed that the iPhone was a well-designed physiciana??s tool. Relax readers, I have since become educated and have increased my Apptitude. I can now spend time I dona??t have searching for cool Apps that will solve problems I dona??t have.

Some Apps I Have

Dragon a?? This is a must-have App and is well worth the price. Ita??s free. It permits you to dictate directly into the contraption and then transforms your voice into text with reasonable accuracy. This is great for TWD, or texting while driving, an act that no responsible physician has ever committed.

Epocrates a?? Another gratis App, although the company hopes you will upgrade to one of their premium products. Ia??ve used Epocrates for years, and consult it nearly every day. Ita??s a quick and easy resource for all medications, including dosage, adverse reactions, drug interactions, contraindications and cost. How many medications do we really need to take care of patients? Probably, 2 dozen or so.

Liver Calc a?? My partner is always showing off when he rounds on liver patients and calculates the MELD score in his progress notes. Who can remember this stuff? It reminds me of the Ranson criteria for pancreatitis that we medical students were forced to memorize. (I remember Dr. Ranson from my medical school days. He was warm & fuzzy a?? NOT). Do these liver scores help actual patients or merely provide grist for board examinations? With this App, I can now calculate on the spot a variety of scores for liver patients, most of which this board certified gastroenterologist has never heard of. Anyone out there heard of the RUCAM criteria?

Medscape a?? This is a very comprehensive site, but seems to cruise more horizontally across the medical landscape than vertically. Will I ever use it? Not sure. The goal, I am learning, is not to use Apps, but just to collect a??em.

Epocrates Disease Game a?? This is a cool way to spend time in the airport when your flight is delayed and the smiling airline personnel will not divulge the updated departure time regardless of threat or bribery. Tap the App and a medical image appears in stages, until the entire screen shows the finding. Choose the correct diagnosis among the 3 given choices. For those who were born during the Eisenhower era, this game reminds me of solving the rebus in the classic TV game show Concentration.

Apps I Want

Colon Cleanse App a?? This is a double plug in App. You plug in the device into the headphone jack of the iPhone and plug the larger end into the rectum. Attach the accessory funneled cleansing tube to a standard faucet, and watch the toxins disappear.

Medical Coding App a?? This turns your iPhone into a high voltage device, similar to the Invisible Fences that are used to restrain pets to a given area. Tap the App and then place the iPhone in your front pocket. After seeing a patient, if you code higher than you should on your EMR, you will get a light shock. The intensity will increase until you have expressed remorse, atoned and coded properly. I expect that Medicare will provide incentives for using this technology in the coming years.

Formulary App a?? This will be fun for the entire office. When the physician guesses the drug that is on the patienta??s formulary, carnival music starts blaring from the iPhone. Since this occurs rarely, do not worry that this App will be disruptive to your office routine.

Am I getting just a bit slAPP hAPPy? Probably, so. The APPendix may be a vestigial structure, but the iPhone Apps are like the oxygen drive. You can try holding your breath, but how long can you hold out?

Medical Meeting Vendors Don’t Know How To Use Twitter Appropriately

2011-07-30T17:31:00.000-07:00

Ia??ve been to several major medical meetings recently and Twitter is beginning to see traction.?? Slowly but surely Twitter hashtag use among doctors at meetings is growing.?? The vendors are there, too. I attended AGA/Digestive Disease Week this week and I have been unimpressed with the attempts of vendors to participate in the back channel. ??Those trying seem inept at real dialog.

Remember that a meetinga??s Twitter feed is a communication channel, not an opportunity for spam. ??Go ahead and remind us about your booth but only after contributing in a way that serves everyone in a non-promotional way (one pitch tweet for 10-20 informational tweets).

What works is sharing, not selling.????Take interest in the attendees.????Watch the feed.????Listen.????Re-tweet the interesting stuff. ??Share some breaking medical information. ??Reach out to attendees in a genuine, respectful way. ??And fear is no excuse a?? because the most memorable dialog will not involve your drug or medical device.

Start there and Twitter will work for not only for you but everyone.

Inflammatory Bowel Disease Puts Patients At Risk For Some Skin Cancers

2011-07-30T17:30:00.000-07:00

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I stumbled across this review article (first full reference below) earlier this week.

Skin cancer is the most common form of cancer in the United States.?? Most skin cancers form in older people on parts of the body exposed to the sun or in people who have weakened immune systems (such as inflammatory bowel disease patients on immunosuppressive therapy).

According to the National Cancer Institute (NCI), in there were more than one million new cases of nonmelanoma skin cancers (NMSC) in the United States in 2010.?? There were less than 1,000 NMSC deaths during the same time.

NMSC includes?? squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).???? Both occur more frequently on sunlight-exposed areas such as the head and neck. BCC is far more common than SCC and accounts for approximately 75% of all NMSC.

The causes of NMSC in the general public are multifactorial, including both environmental and host factors. Known environmental risk factors for NMSC include sun exposure (ultraviolet [UV] light), ionizing radiation, cigarette smoking, and certain chemical exposures such as arsenic. Host risk factors include human papilloma virus infection, genetic susceptibilities, skin type, and immunosuppression.

That last risk factor mentioned a?? immunosuppressiona??is one IBD patients have in common with solid organ transplant patients (kidneys, livers, lungs, face, hands).?? Note the third reference below.?? The results summary of that article

Two hundred patients developed a first NMSC after a median follow-up of 6.8 years after transplantation. The 3-year risk of the primary NMSC was 2.1%. Of the 200 patients with a primary NMSC, 91 (45.5%) had a second NMSC after a median follow-up after the first NMSC of 1.4 years (range, 3 months to 10 years). The 3-year risk of a second NMSC was 32.2%, and it was 49 times higher than that in patients with no previous NMSC. In a Cox proportional hazards regression model, age older than 50 years at the time of transplantation and male sex were significantly related to the first NMSC. Occurrence of the subsequent NMSC was not related to any risk factor considered, including sex, age at transplantation, type of transplanted organ, type of immunosuppressive therapy, histologic type of the first NMSC, and time since diagnosis of the first NMSC. Histologic type of the first NMSC strongly predicted the type of the subsequent NMSC

Attention is now being paid to other patients (ie IBD, rheumatoid arthritis) on immunosuppression and their increased risk of NMSC.

Millie D. Long, MD and colleagues (first reference) note that?? no IBD-specific, evidence-based guidelines for NMSC prevention exist.?? The current recommendations for prevention of skin cancer for the general population include sun avoidance and sun protection strategies include protective clothing, hats, sunglasses, and sunscreens.???? Sun avoidance should include tanning bed avoidance.

Any skin lesion suspicious for malignancy in a patient with IBD on immunosuppression should be evaluated by a trained dermatologist.?? Among solid-organ transplant recipients, annual skin examination is recommended by various transplant organizations.

Long and colleagues note a??There are no guidelines for skin cancer screening in patients with IBD, as it is unclear whether the riska??benefit ratio of skin cancer screening in IBD patients correlates with that of the general population, or more closely with that of the solid-organ transplant population. Consideration could be given in the future to skin cancer screening programs for patients with IBD on immunosuppression.a??

REFERENCE

1.?? Nonmelanoma skin cancer in inflammatory bowel disease: A review; Millie D. Long, Michael D. Kappelman and Clare A. Pipkin; Inflammatory Bowel Diseases Volume 17, Issue 6, pages 1423a??1427, June 2011; Article first published online: 25 OCT 2010 | DOI: 10.1002/ibd.21484

2.?? National Cancer Institute; Skin Cancer

3.?? Incidence and Clinical Predictors of a Subsequent Nonmelanoma Skin Cancer in Solid Organ Transplant Recipients With a First Nonmelanoma Skin Cancer: A Multicenter Cohort Study; Gianpaolo Tessari; Luigi Naldi; Luigino Boschiero; Francesco Nacchia; Francesca Fior; Alberto Forni; Carlo Rugiu; Giuseppe Faggian; Fabrizia Sassi; Eliana Gotti; Roberto Fiocchi; Giorgio Talamini; Giampiero Girolomoni; Arch Dermatol. 2010;146(3):294-299

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When Less Is More: How To Improve The Quality Of Primary Care

2011-07-30T17:29:00.000-07:00

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On the NPR Shots blog, Scott Hensley writes, “Quality Prescription For Primary Care Doctors: Do Less,” about an article in the Archives of Internal Medicine. Excerpt:

“A group of docs who want to improve the quality and cost-effectiveness of primary care tinkered with some Top 5 lists for of dos and don’ts for pediatricians, family doctors and internists.

After testing them a bit, they published online by the Archives of Internal Medicine. Most of the advice falls in the category of less is more.

So what should family doctors not be doing? The Top 5 list for them goes like this:

1. No MRI or other imaging tests for low back pain, unless it has persisted longer than six weeks or there are red flags, such as neurological problems.

2. No antibiotics for mild to moderate sinusitis, unless it has lasted a week or longer. Or the condition worsens after first getting better.

3. No annual electrocardiograms for low-risk patients without cardiac symptoms.

4. No Pap tests in patients under 21, or women who’ve had hysterectomies for non-malignant disease.

5. No bone scans for women under 65 or men under 70, unless they have specific risk factors.”

Statins Reduce Heart Disease Risk, But Probably Not Because They Lower Cholesterol

2011-07-30T17:28:00.000-07:00

When cyclists find out that I am a heart doctor, they most frequently ask about cholesterol numbers.

a??a?|My cholesterol is thisa?|What do you think?a??

a??a?|My doctor wants me to take a statina?|But I read that these drugs might lower my functional threshold power 2.014 watts/40km.a??

All this focus on numbers saddens me. Remember, I am a forest guy, not a tree guy. Whata??s more, as a doctor that revels in the adrenaline rush of ablating rogue circuits with technology that would impress even a twenty-something, I find questions about biochemistry drearya??like eating quinoa.

I wish folks would ask me about how to terminate AF with a catheter, or how an (evidenced-based) ICD saved a moma??s life, or perhaps even this: a??Do you do heart surgery?a??

But more often than not people want to know about cholesterol.

Okay. It just so happens that this week brought some very interesting news concerning the treatment of abnormal cholesterol lab values. News that big-picture docs have to like.

Here goes:

The AIM-HIGH trial, a large NIH-sponsored study which tested the addition of the HDL-raising drug Niaspan to a statin drug in patients at high risk of heart disease, was terminated early due to lack of benefit. The trial included patients with low levels of?? HDL (a??gooda?? cholesterol) and well-controlled LDL levels (a??bada?? cholesterol). Most of the patients enrolled already had manifest heart disease, or they had a cluster of other risk factors, like obesity, diabetes and high blood pressure. These were truly high risk patientsa??a group that would be likely to benefit from higher levels of HDL.

Niaspan worked as intended: it did indeed raise levels of HDL. But the striking finding was that there was not any reduction in heart-related adverse events. The drug simply did not reduce a??harda?? endpoints, like heart attack, stroke and death.?? (In fact, there was a small increase in the number of strokes in the Niaspan group.)

How is this possible?

This finding seems counter-intuitive. We know that low HDL levels are associated with a higher risk for heart disease; therefore it would seem logical that raising the level of the molecule would confer benefit. But such is not the case with drugs that increase HDL. (A 2006 study called ILLUMINATE revealed that another potent HDL-raising drug, Torcetrapib, actually increased the risk of heart events.)

I see three important lessens in this trial:

(1) Though low HDL levels are associated with a higher risk of heart events, it is clear that raising HDL levels with drugs is not helpful. Heart health doesna??t come from swallowing pills!

(2) The best way to increase HDL levels is through regular and vigorous exercise.

(3) The over-attention to levels of chemicals (medical people call them biomarkers) is problematic. When looking at a study which claims benefits, a reader should ask whether there were actual differences in outcomes. Changing the level of something (like cholesterol, blood sugar, or bone density) may not correspond to actual benefit. Always ask about outcomes.

Let me conclude with a comment about statin drugs. I strongly believe that statins lower the risk of heart-related events through actions on the blood vessel wall. They mitigate inflammation in the blood vessel. We cana??t measure this anti-inflammatory effect, so we measure cholesterol levels. But statins are different than other cholesterol-lowering drugs because they have favorable outcome data. Numerous trials have shown that patients at high heart risk of heart disease that take statins have fewer heart attacks and strokes.

Thata??s enough biochemistry quinoa.

References:

Here is the NIH press release for AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health)

More complete and academically rigorous accounts can be viewed on Cardiobrief and TheHeart.org.

Thyroid Cancer: A Hazard From Radioactive Iodine Emitted By Japana??s Failing Nuclear Power Plants

2011-07-26T20:11:00.000-07:00

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One of the most abundant substances in the cloud of radioactive steam released by a failing nuclear power plant is iodine-131 — a radioactive form of the element iodine that is found throughout nature. Iodine-131 poses a special health risk because of its cancer-causing effect on the thyroid gland.

The small, butterfly-shaped thyroid sits just below the voice box. From this perch, it controls how fast every cell in the body changes food into energy. The glanda??s main product, thyroid hormone, governs the function of the digestive tract, brain, heart, nerves, muscles, bones, skin, and more.

Iodine is a key ingredient that goes into making thyroid hormone. We get this element from ocean-caught or ocean-farmed Fish-in-Water-Belt-Buckle-246.html' target='_blank'>fish and shellfish, milk, cheese, yogurt, eggs, and fruits and vegetables grown in iodine-rich soil.

The human body is surprisingly good at absorbing iodine and storing it in the thyroid gland. Thata??s a problem when iodine-131 is released into the atmosphere. The thyroid stores it as readily as natural, non-radioactive iodine. As iodine-131 builds up in the thyroid gland, it emits bursts of radiation that can damage DNA and other genetic material. Such damage can remove the normal limits to cell growth and division. Unchecked growth of thyroid tissue is thyroid cancer.

Iodine-131 gets into the body several ways. A person can breathe in radioactive steam released by a nuclear power plant. Fallout — radioactive particles that fall out of the atmosphere and settle onto plants, soil, and water — further adds to the burden when a person eats iodine-131 enriched fruits and vegetables or drinks water containing the isotope. Milk is another vehicle — cows that eat grass sprinkled with iodine-131 make milk that contains it.

Following the explosion and meltdown of the nuclear reactor at Chernobyl in 1986, follow-up health studies showed a significant increase in thyroid cancer in the area around Chernobyl, especially among children who were under 10 years old at the time of the explosion and those in utero. Youths may be most affected by iodine-131 because their thyroid glands are still growing and developing. Fortunately, as cancers go, thyroid cancer is one of the least deadly. In the United States, only about 5 percent??of people who develop thyroid cancer die of the disease. (Researchers arena??t yet sure if this applies to radiation-induced thyroid cancer.)

As my colleague Peter Wehrwein describes in a??related post, taking potassium iodide pills can help keep iodine-131 from taking up residence in the thyroid gland. The seafood-rich Japanese diet provides an abundance of iodine. Because the thyroid glands of those affected by fallout from the failing nuclear power plants may be a??fulla?? of natural iodine, iodine-131 may not be able to get into the gland, giving them natural protection against radiation-induced thyroid cancer.

- P.J. Skerrett, Editor, Harvard Heart Letter

The Psychological Price Of Surviving Cancer

2011-07-26T20:10:00.000-07:00

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One of my closest friends is a two-time breast cancer survivor. Terry (as Ia??ll call her) has been cancer free for eight yearsa??long enough to be considered cured (generally defined as being in remission at least five years). But in no way is she a??freea?? of cancer. Every abnormal blood test, every callback for another mammogram terrifies her so badly she cana??t sleep until doctors rule out a recurrence. In some ways, the ongoing psychological and emotional challenges she faces have been worse than the physical treatments she endured.

I thought about Terry when I read the latest government statistics on the number of cancer survivors in this country. Nearly 12 million Americansa??4% of the populationa??are still alive after a cancer diagnosis.

In many respects this is terrific news, and a testament to improved diagnosis and treatment options. But survivorship comes at a psychological price. We discussed these challenges at length in the?? Harvard Mental Health Letter, but herea??s a quick look at some of the major issues.

a??Damocles syndrome.a?? According to Greek legend, once Damocles realized that a sword was dangling precariously over his head, he could no longer enjoy the banquet spread in front of him. In the same way, the specter of cancer hangs over some cancer survivors. They can become emotionally paralyzed and have a hard time deciding to get married, change jobs, or make other major decisions.

Fear of recurrence. Given cancera??s potential to lay dormant for a while and then spread (metastasize), cancer survivors often experience ongoing fear of recurrence. Follow-up medical visits, unexplained pain, or even sights and sounds they associate with treatment can trigger bouts of anxiety and fear that are as debilitating as those that occurred during cancer treatment.

Survivor guilt. Although happy to be alive, cancer survivors may feel guilty that they survived while fellow patients they became friendly with during treatment or as part of a support group did not. (Early after a diagnosis of cancer, people first ask, a??Why me?a?? When survivors think about those who have died, they tend to ask, a??Why not me?a??)

Recognizing these challenges, the Institute of Medicinea??s Committee on Cancer Survivorship explored ways to help people rebuild their lives after treatment ends. You can read the report, a??From Cancer Patient to Cancer Survivor: Lost In Transition,a?? for free online or buy it from the National Academies Press.

Given that one in three Americans will face a cancer diagnosis at some point in their lives, living with cancer is a topic that touches all of us. If you are a survivor, or know someone who is, these Web sites may be useful.

American Cancer Society Cancer Survivors Network

National Coalition for Cancer Survivorship

National Cancer Institute: Cancer Survivorship Research

If you have suggestions for dealing with the challenges of cancer survivorship, please let us know in the comment section.

Positive Message Of The Day

2011-07-26T20:09:00.000-07:00

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Source: thatshappy.blogspot.com via Dawn on Pinterest

Food And Migraine Headaches: Triggers Are Hard To Predict

2011-07-26T20:07:00.000-07:00

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At a Harvard Medical School talk on migraine and food, a nutritionist from Harvard-affiliated Beth Israel Deaconess Medical Center delivered a message that people in the audience probably didna??t want to hear: a??There are no specific dietary recommendations for migraine sufferers,a?? said Sandra Allonen. But she did have some advice to offera??and she emphasized that the connection between food and migraine is a very individual one.

Several foods have been associated with triggering migraine. None of them has been scientifically proven to cause migraines, explained Allonen, but many people report a link between eating these foods and getting a migraine. Possible migraine triggers include:

Aspartame (Equal, NutraSweet)

Caffeine (Caffeine can help stop a migraine when it starts, but if you dona??t drink the same amount every day, caffeine withdrawal can trigger a migraine.)

Chocolate

Cultured dairy products, such as yogurt

Broad beans, such as fava beans

Nuts and nut butters

Nitrates and nitrites, which are found in processed meats such as bacon and cold cuts

Sulfites, which are found in wine

Tyramine, which is found in aged cheeses and meats, and fermented beverages

Yellow Dye Number 6, which is used in Doritos, Mountain Dew, and Peeps

Preventing migraines

Can you eat to prevent a migraine? Sadly, there arena??t any magical foods. But Allonen did say that keeping blood sugar steady throughout the day can be important. To do that, follow these tips. (Happily, they will help you keep your heart healthy as well.)

Eat small, frequent meals

Choose whole grains over processed grains (whole wheat bread vs. white bread, for example)

Eat lean protein at every meal

Keep hydrated

The most important prevention tactic may be keeping a daily headache diary, in which you write down everything you eat and drink, the activities you do, your stress level, and even the weather, along with how your head feels. It is a tedious activity, but a worthwhile one, especially when you start to see patterns emerge. For example, one person in the audience noted that she found she only got migraines when she ate pizza and chocolate at the same meal.

Allonen attributed the dearth of research into connections between migraine and food to finance: a??Therea??s no money in studying diet and migraine,a?? she said. With so little research being done in this area, you have to be your own personal researcher. And in reality, youa??ll probably learn the most this way, since it seems migraine triggers vary from person to person. After all, you dona??t want to cut chocolate out of your diet unless you truly have to.