Tuesday, December 17, 2013

The Microbiome

I am fascinated by the new research and information on the gut microbiome.  These microorganisms (germs, bacteria, microbes) live harmoniously in every part of our body and especially in our gastrointestinal system.  It wasn't even really discovered until the late 1990s and we now know that these microbial communities affect our health in ways we never dreamed.  The human microbiome may play a role in obesity, immune response, diabetes, irritable bowel syndrome, and maybe even anxiety, depression and autism.

Anything that is this new has many possibilities the science is just starting, but there is clearly something very important here.   The Human Microbiome Project  is a NIH initiative with the goal of identifying and characterizing the microorganisms which are found in association with both healthy and diseased humans.  They intend to test how changes in the human microbiome are associated with human health or disease.

A new study published in Nature this week showed that adaptation to the gut microbiome can change in a day.  This is important because dietary changes can have a huge immediate effect on disease.  The researchers showed how immediate changes occur, depending upon subjects eating a plant based or animal based diet.  They fed the volunteers either plant (grains, legumes, fruits and vegies) or animal (meats, cheese, eggs) diets for 5 consecutive days.  They tracked food in the digestive tract, how the subjects felt and bowel movements.

The researchers analyzed 16S ribosomal RNAs to identify microbiome components in fecal samples, which were collected for several days before the dietary changes and each day during the study.
The animal-based diet clearly had a greater effect on the microbiome than the plant-based diet. Even after 1 day, the microbiome of those eating the animal-based diet differed significantly from baseline analyses.

The researchers found fecal bile acid changes in the animal based diet that are associated with liver cancer and Irritable bowel disease. These bile acids change the bile tolerant bacterium that is associated with IBD.

There is no cause-effect found here and the study size was too small to know what is actually occurring.  But the fact that changes could be found in the gut microbiome in such a short amount of time is compelling.  It is simply another potential explanation why diet is so important to health.  And changing our diet can have an immediate effect on our health.


Saturday, December 14, 2013

Answer to Medical Challenge



OK, the answer to yesterday's Image Challenge was #3, Squamous cell carcinoma.

Ninety percent of all mouth cancers are squamous cell cancer.  Factors that increase your risk of mouth cancer are:
  • tobacco use of any type (including smoking, chewing, cigars and pipes)
  • heavy alcohol use
  • Human Papillomavirus (HPV)  (think of Michael Douglas)
Usually surgery is needed to treat squamous cell carcinoma in the oropharynx, along with radiation therapy to eradicate all of the cells.

Wednesday, December 11, 2013

Image Challenge

Back by popular demand is this weeks medical challenge where you get to make the diagnosis. (click on the image for a close up view)

The patient opens his mouth, says "ahhh" and this is what you see.  Is it:

1. Aphthous stomatitis
2.  Pyogenic granuloma
3.  Squamous-cell carcinoma
4.  Syphillis
5.  Traumatic fibroma

Make your diagnosis in the comments section and check back tomorrow for the answer.

Sunday, December 8, 2013

Things Doctors Do (That Normal People don't)


I have been too swamped to blog recently on EverythingHealth, spending lots of time with my physician colleagues (as well as patients).  I realized that doctors are really not normal when it comes to a few things.  Here is a list of things doctors do that normal people don't.  You may have more to add!
  1. Eat standing up, while walking or while charting on patients
  2. Take expired medication (we know that expiration date is phony)
  3. Work hard-core, even when sick
  4. Don't get regular check-ups
  5. Cannot watch doctor TV shows (House is especially intolerable)
  6. Freely discuss body functions at dinner.  Nothing is off limits
  7. Silently diagnose medical conditions on strangers.  No lump or rash goes unnoticed.
  8. Combine vacations with work
  9. When we shake hands, think "Oh, that's a nice vein"
  10. When our child is hemorrhaging, we can fix anything with steri-strips
  11. Seldom use antibiotics on ourselves or family
  12. Listen to lectures and medical information while commuting
  13. Take suitcases full of journals to catch up on when on vacation
  14. Carry stethoscope, and full medical supplies in our trunk because "you never know"
  15. Seldom take vitamins or supplements
I'm sure I'll hear from my nurse and doctor readers, or spouses of medical people if I got something wrong. 

Sunday, October 6, 2013

Oral Melanoma


The answer to yesterday's image challenge was #4- Melanoma.  Many of you diagnosed correctly.

Oral malignant melanomas are uncommon and like other melanomas of the skin they arise from melanocyte cells.  Unlike cutaneous (skin) melanoma which are linked to sun exposure, the risk factors for oral melanoma is unknown.  We think they arise de novo (from no cause).

Oral melanomas are more common in Japanese race and occur in men more than women (2:1)  It is rare in people under 20 and more common in men over 40 years.

Good oral exams by the dentist are always important to identify mouth lesions.  Most are benign and many other less serious conditions can cause pigmentation.

Wednesday, October 2, 2013

You Be the Doctor


This 42 year old man came to the doctor with these changes in his gums.  What is the diagnosis?

1.  Chewing tobacco
2.  Implantation of amalgam
3.  Lead Poisoning
4.  Melanoma
5.  Peutz-Jegher's syndrome

Make your diagnosis in the comment's section and check back Friday for the answer.  Can you be the doctor that gets it right?

Tuesday, October 1, 2013

Ignore these 15 Obamacare Myths


I've pulled my head up from frantic medical work just in time to give faithful readers 15 Myths that are being spread about Obamacare.  I have been first to admit that the government has done a lousy job of explaining the plan and it is no wonder the Tea Party has had a field day with mis-information.  But now that sign-ups for the Exchanges are open to the uninsured and under-insured population, these are the lies you should avoid:
  1. Congress is "Exempt" from the Affordable Care Act  
  2. Premium prices will increase due to Health Care Law
  3. The Affordable Care Act includes death panels
  4. Shutting down Government over Obamacare funding will stop the Health Care Law
  5. The ACA is "socialized medicine" and a "government takeover"
  6. People will be able to commit subsidy fraud on the Exchanges
  7. Obamacare "Narrow Networks" will constrain health choices
  8. The Affordable Care Act is bad for women
  9. The Affordable Care Act covers abortions
  10. The Affordable Care Act is a job killer
  11. With full access to medical records, the IRS will discriminate against conservatives
  12. Navigators will abuse private information
  13. Obamacare mandates doctors to ask patients about sexual history
  14. The Medicaid expansion will force doctors to turn away patients
  15. Obamacare is to blame for a projected 30 million people who will remain uninsured.
There is plenty to be mad at the government about.  The fact that the Tea Party has literally shut down government is atrocious and bad for mankind and bad for business.  Obamacare isn't the problem.  it isn't a perfect law but it is the same act the GOP came up with during the Bush years and it is a (minor) step in the right direction.

If you want to learn more...go here.

Aren't you glad I'm back with facts and the truth? 


Thursday, August 15, 2013

New Hep C Screening for Baby Boomers

If baby boomers weren't special enough,  now the U.S. Preventive Services Task Force has singled them out as a special group to be screened for Hepatitis C virus (HCV).  Individuals born between 1945 and 1965 are recommended to undergo this one-time blood test screening because they are at high risk for the virus.

What is it about this age group that gets special notice?  According to the Centers for Disease Control, baby boomers account for three out of four people with HCV.   Many of them contracted hepatitis C from blood transfusions or needle procedures before we had a screening test for the virus.  Others may have caught it from high risk behaviors like injecting drugs, HIV or piercing or tattoos in unclean environments.  It is less common to contract it through sexual relations but it can happen.

We have had a test that could screen for Hepatitis C antigen for many years but only recently are we able to treat chronic Hepatitis C with anti-viral medications.  There is an increased incidence of hepatocellular carcinoma (liver cancer) in people who acquired HCV two to four decades earlier and many people have no idea that they are carrying the virus.  It is hoped that by screening patients in this age group, patients can be identified at earlier stages of disease and receive treatment before developing complications from liver damage.

HCV infection is the leading cause of complications from chronic liver disease.   More than 30% of U.S. adults that receive liver transplants have HCV.

Baby boomers just need to undergo screening once.

Thursday, August 1, 2013

Some Doctors Set Their Own Pay

The Centers for Medicare and Medicaid (CMS) sets the rates all physicians get paid and insurance companies base their rates on the same formula.  So who creates the formula?  Well, it's the doctors, silly!  Or at least some of the doctors.  Here's how it works:

A 31 member committee formed by the American Medical Association is made of of representatives from the various specialty societies.   This Relative Value Update (RVU) Committee meets in private and decides how much value each unit of medical work represents.  That unit of work is then assigned a dollar amount and that creates the pay scale.   The catch is that primary care (Internal Medicine, Family Medicine, Pediatrics) is very poorly represented on the committee.  The surgical specialties; anesthesia, radiology and even tiny surgical specialties (like urology or ENT) are equally represented and as a group they get to decide how to value a doctors time and expertise.   This is why primary care has been "undervalued" and underpaid all of these years.  Somehow something done with a scope or a tube or a scalpel is considered many times more valuable than thinking and diagnosing and treating.

This RVU Committee has been criticized for years but no other system has been designed to replace it.  The value that some specialties like ophthalmology and orthopedics are paid has created situations where doctors are paid the equivalent of 12 hours of procedures in a single day.  The panel estimated 75 minutes for each colonoscopy and, according to The Washington Post, one doctor was able to bill for 26 hours of paid work in a single day.  A colonoscopy rarely takes more than 20-30 minutes and most of the work is done by the nurse setting up the procedure.

I have been writing about the fact that fewer and fewer of our brightest physicians are choosing primary care specialties.  This decline has persisted for years and now we have truly reached a crisis point, especially when ObamaCare goes into effect and more people will be seeking care.  It is no wonder that young graduating doctors with $150,000 in school debt would pick a specialty like anesthesia where they could work 8 hours, never be on call, have no practice expense (except a billing and accounting service) and make 4-5 times what an Internist makes.  Thanks to the RVU for the lopsided value they place on medical care. 

Medicare spending is capped.  There is no way to raise the rates for needed physicians (like primary care) unless the value of other services is ratcheted down.  The current RVU Committee is seriously flawed and the time and relative work estimates some of the specialties have come up with is just wrong. Furthermore, this payment method shows no consideration for quality outcomes or value to society. 

The Unites States is the only country where these wide ranges of specialist physician pay is seen.  The Relative Value, as it is done now,  needs to change.




Saturday, July 20, 2013

Answer to Challenge

Harlequin Color Change
The answer to yesterdays Medical Challenge is...drumroll....

#4:  Harlequin color change

Harlequin color change is a dramatic but benign phenomenon in which the color on 1/2  (downward) of an infant turns deep red, while the upper half is pale.  Usually this color change is abrupt and lasts between 30 seconds and 20 minutes, then it resolves.  Up to 19% of infants undergo this color change which occurs between the 2nd and 5th day of life.  It is attributed to a temporary imbalance in autonomic regulation and it is more common among low-birth-weight infants.

The fact that the baby did not have IV lines or oxygen or evidence of being in an ICU pointed to a less serious cause and was the "hint".

The other conditions would indicate a life-threatening condition.
Collodion baby
Collodion baby is a genetic condition that causes the skin surface to crack and completely peel.  It also includes the mucous membranes, eyes and mouth.  It has the same genetic abnormalities as Bullous ichthyosiform erythroderma. Harlequin Ichthyosis is often called collodion baby so there is some confusion but it is quite different from Harlequin color change.

Cutis Marmorata
Cutis marmorata is an extremely rare congenital vascular disorder that affects the blood vessels of the skin and looks like a reticular pattern on the skin.











Wednesday, July 17, 2013

Medical Challenge


 I couldn't resist this challenge from the New England Journal of Medicine.  Make your best guess in the comment section and answer will be posted tomorrow.  One hint:  The newborn baby doesn't have any IV's or tubes inserted. (click on the image for a close up). 

Any neonatal specialists out there?

1. Bullous ichthyosiform erythroderma
2. Collodion baby
3. Cutis Marmorata
4. Harlequin color change
5. Staphylococcal pyoderma

Thursday, July 11, 2013

Delay Cord Cutting in Newborns

A new study has shown that delaying cutting the cord in a newborn baby is associated with better health for the baby because more blood (hemoglobin) passes from the mother to the baby as the cord is still attached.  Prior studies have also shown this advantage but there was a concern of hemorrhage in the mother if the cord cutting was delayed.  Doctors often rush to cut the umbilical cord as soon as the baby is delivered.  This study, published in The Cochrane Database of Systematic Reviews, shows there is no increased danger of hemorrhage  to the mom and the benefit is for the neonate.

The researchers found that babies who had later cord cutting (after one minute) had higher hemoglobin levels 24-48 hours post-partum and they were less likely to have iron deficiency at 6 months, compared to the early cutting babies.

This is especially important in developing countries where anemia is common.  The World Health Organization (WHO) has long recommended waiting 2-3 minutes to cut the umbilical cord to improve the status of the infant.  In the United States, where low iron is not as much of a problem, the American College of Obstetrics and Gynecology (ACOG) has not recommended the early cut practice.  Concerns about jaundice and the longstanding practice of early cutting caused ACOG to say there is insufficient evidence.

Changes in medical practice to not come easily.  It took over 200 years for sailors and seafaring merchants to accept the fact that deadly scurvy could be prevented in sailors by just taking citrus fruit on board long voyages.  Dr. Ignaz Semmelweis proved that hand disinfectant could prevent child bed fever (with a maternal mortality up to 35%) but his ideas were rejected by the medical community and he ended up dying in an insane asylum.  Despite his publishing of a book that showed the death rate falling to under 1% if physicians would just wash, it was decades before his theories were adopted.

We shall see if delayed cord clamping becomes adopted practice in the United States.  In nature, the mother animal (including humans without medical assist) have to severe the cord naturally and that certainly takes a bit of time.  Maybe there is some selection advantage to that delay in the health of the baby.

Saturday, June 22, 2013

Poem - Do Not Resuscitate



Do Not Resuscitate

I can say
your father is dying.
I can say
wishing will not make it so,
belief doesn't change a thing.

I can say
love does not conquer all,
miracles are pretty stories told in church,
the movies you saw as a child are lies,
blind hope is not a recipe for success,
underdogs usually lose,
death is not the worst thing, it is just
the last thing.
But for you that is not true.

I can say
we have to pretend
that we can bring him wheezing
back to you like an old accordion,
chest pleating in and out,
singing his customary songs,
oxygen bumping its hurdy-gurdy way again
through his ancient heart.

But how can I tell you how
someone will shout down the hallway, kneel
frantic on the bed,
lean his fists against that old breastbone, sharp, frail,
one onethousand, two onethousand, and count it out.

I can say
we should not do this.
He will never be the same.
I can say
if it were my father.

I can say
do not confuse resuscitation
with resurrection, although
neither works particularly well.

You look like you are drowning,
pallid and slow in the waiting room's
underwater light.

So. Tell me.
Tell me again.
Tell me about your father.

Brenda Butka, MD


(From Jama, October 24/31, 2012- Vol 308, No. 16)

Tuesday, June 11, 2013

Morning After Pill Now Available Without Prescription

The U.S. Justice Department has dropped its appeal to block a ruling by a New York Federal Judge to allow easy access, over-the -counter purchase of the "Morning After" pill for birth control. The emergency contraceptive, named for women who either got caught without a contraceptive, or the condom broke, is called  Plan B One-Step.  (I guess that is when plan A fails.)  Plan B is a one dose pill of 1.5mg levonorgestrel that reduces the possibility of pregnancy.  It is to be taken within 24 hours of unprotected sex and the drug’s principal effect is to prevent ovulation, but it may also make the lining of the uterus less hospitable to a fertilized egg.

The controversy about Plan B began when HHS Secretary, Kathleen Sebelius, invoked her authority over the FDA, who had approved the drug for purchase from a pharmacy without a prescription.  Ms. Sebelius, in an unprecedented move, stated that prescription dispensing requirements should not be removed for women of all ages.  She believed younger teens should not have access to the pill without a prescription.  Many lawmakers were surprised by this reaction and criticized the Obama administration of placing politics ahead of science.

Margaret Hamburg, FDA commissioner said "There is adequate and reasonable, well-supported, and science-based evidence that Plan B One-Step is safe and effective and should be approved for nonprescription use for all females of child-bearing potential".

The go-ahead for Plan B will be welcomed by medical groups such as the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists and the Society for Adolescent Health.  They had denounced HHS' decision and said, "As physicians who care for our nation's children, it is our responsibility to protect the health of our teenage patients, and an unintended pregnancy can have significant implications for adolescents' physical and emotional health."

Women who have unprotected intercourse have about one chance in 20 of becoming pregnant. Those who take Plan B within three days cut that risk to about one in 40.  According to the New York Times, as of now, half of all pregnancies are unplanned, more than 40 percent of children are born to unwed mothers, and 1.2 million abortions are performed every year involving one in every 50 women of reproductive age.

Margaret Sanger would be happy.

Sunday, June 9, 2013

Answer to Image Challenge



The answer to the image challenge this week is #1 - Atherosclerosis.  Most of you got the right answer because you obviously know that the diagonal crease seen in the earlobe is known as "Frank's sign".  The sign was originally described as a marker for coronary artery disease, with a moderate sensitivity ( approximately 48%) and specificity ( approximately 88%).  Frank's sign has been associated with other cardiovascular risk factors like atherosclerosis.

Good job, readers!  How many of you have looked in the mirror at your own earlobe?

Thursday, June 6, 2013

Komen Suffers For Its Blunder

How do you wreck a beloved brand?  Just look at Susan G. Komen Foundation For the Cure (Breast Cancer) and remember what a well-known brand they had.  From pink ribbons to breast cancer walks and gala events, corporate and individual sponsors were happy to give to such a worthy cause.  The "Race for the Cure" was catchy and easy to promote.

 Fast forward to January 2012 when Komen foolishly bowed to social conservatives and announced they would "defund" Planned Parenthood because of the highly political abortion issue during the last Presidential race.  The Breast Cancer Foundation decided not to pay for screening mammograms for poor women through Planned Parenthood.

The backlash was rapid, strong and widespread on Facebook, Twitter and other social media.  The Komen board of directors reversed their decision within a few days.  Two top executives at Komen Foundation resigned and apologies were rendered.  But that wasn't enough to keep the brand that women loved from becoming an ugly testament to politics and money.

Now Komen has canceled charity walks in seven cities in 2013 and 2014 that failed to meet fundraising goals.  These were previously top revenue sources for the breast cancer charity and drew the most dedicated supporters, many who also support Planned Parenthood.

Many are asking why CEO Nancy Brinker is still at the top of this organization.  Months after the controversy,  Brinker's handling of the situation became a case study in how not to manage a crisis. A press release said that Brinker "plans to move to a new management role focusing on revenue creation, strategy and global growth...when the search for a new senior executive has been completed."  (What doublespeak!  I thought that was the role of the CEO,  but never mind)

That was 10 months ago.  Oh and by the way...she got a 64% pay raise this year.

So maybe it's the economy and financial uncertainty that is affecting Susan G. Komen Foundation.  Of course, the fact that Avon's Breast Cancer walks are proceeding would suggest that the Planned Parenthood debacle is still haunting the organization.  This should be a warning to politicians and organizations everywhere that women will rise up and defend what they believe in.  Social networking brings a new awareness and bonding to the Community of Women.  (my caps!)




Wednesday, June 5, 2013

Medical Challenge

This weeks Challenge from the New England Journal of Medicine is a good one.  Check out the photo (click on it to see closer) and make your best guess as to the diagnosis.  The answer will be posted tomorrow so put your answer in the comment section and check back to see if you are a good diagnostician!

What condition would cause this ear abnormality?

1.  Atherosclerosis
2.  Fabry's disease
3.  Gout
4.  Hashimoto thyroiditis
5.  Ulcerative colitis

Monday, May 27, 2013

Ovarian Cancer Screening

Here is a real case study from American Family Physician with the correct "answers" that may surprise women (and men).  It is a common case in my practice too as more and more women are health conscious and want to do everything possible to detect early cancer.

CASE STUDY

A 35 year old woman presents for a routine well-woman exam.  She is worried about ovarian cancer because one of her friends was recently diagnosed.  She has no family history of breast, ovarian or colon cancer.  What do you do?

Answer:  Based on U.S. Preventive Services Task Force recommendation on screening for ovarian cancer, you advise against screening tests because they do not have good sensitivity for cancer and there are too many false-positive results.  The screening tests like Ca125 and transvaginal ultrasound have not been shown to reduce the number of ovarian cancer deaths.

Keep in mind that these recommendations do not apply to the following women.  Studies show these woman would benefit from those screening tests:
  • A woman with a confirmed BRCA1 genetic mutation
  • A woman with multiple family members who have had colon cancer (Lynch Syndrome)
  • A woman whose mother, sister or grandmother had ovarian cancer and breast cancer also in the close family
  • An Ashkenazi Jewish woman with close family members with breast or ovarian cancer.
I know being advised NOT to undergo a screening test is hard to understand.  Most patients believe if there is a test that could remotely pick up an early cancer, they want to have it.  Unfortunately we just don't have good tests for ovarian cancer.  False positive tests usually lead to removal of an ovary and the harm outweighs the good.   Perhaps in the future we will have genetic biomarkers that will help detect cancer.  Right now we don't.


Monday, May 20, 2013

Blame Bunions on your Genes

Thanks to KM for sending a pic of her bunions (yes, genetic)
There is good news for women who love high heels and pointy toe shoes.  Contrary to what we've been told, they don't cause bunions.  A new study published in Arthritis Care & Research shows that bunions, hammer toes and other toe deformities can be blamed on your parents.  Yes, like so many disorders, it's all in the genes.

The medical name for bunion is hallux valgus and up to 60% of people get foot disorders and foot deformities in later life.  By using heritability software that performs genetic analysis of familial data, the researchers found out that these conditions are genetically passed down.

Before you throw away those Birkenstock sandals, however, remember there is always an interplay between genetics and environmental factors that affect our bodies.  One look at the feet of dancers shows that constant trauma or strange positioning of the foot structures can cause permanent change.

My advice to women who love heels is to walk barefoot in the sand as much as possible and give your feet a good rest.

Thursday, May 2, 2013

Few Americans Understand Basics of New Health Care Law


I wrote last week about the massive confusion about ObamaCare ( the Affordable Care Act) but it seems that it is much worse than I thought.  The Kaiser Family Foundation came out with a poll that shows 42% of Americans don't even know that ObamaCare is the law.  Seven percent of people think the Supreme Court struck it down and 12% think Congress repealed it. 

I understand that there is confusion about the way it will work and who will be affected.  But my advice to Americans is TURN OFF THE DAMN TV.  Really, we are blessed to live in an age where information about any subject is available with the click of a mouse and  people seem to know more about the Kardashians than they do about a health care law that is as important as Social Security or Medicare legislation.

I'm not surprised, however that most Americans said they don't have enough information to understand how ObamaCare will affect them.  The Administration should have hired the same marketing firm that did the superbowl ads or even the clever ads for Dollar Shave Club.  Sure, I get that health care is more complex than a Pepsi ad, but at least doctors and hospitals should have some understanding of it by now.  This is a huge marketing FAIL so far.

According to the Washington Post, the Administration is waiting until the optimal time to roll-out the details.  A public awareness campaign is slated for this summer, as open enrollment will begin in October.  That seems way too late to me.  Helping 30 million Americans understand that they will be buying insurance, making sure there are networks to care for these people, understanding the subsidies that most will get and understanding the various plan options is a huge undertaking and it will be here in 5 months.  I would say ObamaCare is in a pot of boiling water right now.

It is the private insurers (Cigna, Well-Point, Blue Cross, United Healthcare, etc)  that will have the exchange products to sell.  Has anyone ever truly understood their coverage provisions when dealing with these insurance companies?  Now imagine 3 tiers of new insurance products to chose from, with varying co-pays and pricing.  Now imagine covering Americans who don't use computers or have never really dealt with the insurance system.  Now imagine different options being offered in each State.

I would say there is a lot of work to be done by Health and Human Services. 

 

Monday, April 29, 2013

Poison Oak

Photo from Consultant360.com
As the weather heats up and people are hiking and walking animals outdoors, we physicians start seeing the results of a contact dermatitis known as poison oak or poison ivy.  Some of the tell-tell signs for diagnosing this condition is the severe itching, patchy redness that is in certain skin areas only and also notice the linear streak on the top back area of her neck.  That is a classic rhus dermatitis (poison oak) appearance as are clusters of  fluid filled blisters.

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

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

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

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

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


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

Wednesday, April 24, 2013

Health Care Reform Confusion

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

Here are some basics that we do know:

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

Saturday, April 20, 2013

Answer to Image Challenge

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

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

Thanks for your guesses.  This was a hard one.

Wednesday, April 17, 2013

What is the Diagnosis?

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

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

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


Tuesday, April 16, 2013

Fake Drugs

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

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

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

Monday, April 8, 2013

Meat and Heart Disease

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

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

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

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

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

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

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

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

Friday, March 29, 2013

Unhappy Nurses

I am sad to read that a new survey reported in Forbes shows that nurses are the 4th most unhappy profession in the US.  The survey evaluated 10 factors of the workplace including  work environment, relationships with co-workers, compensation, and control over one's daily responsibilities.  They required at least 50 employee reviews to qualify in a category.


 Careerbliss  found out that associate attorneys are the most unhappy followed by customer service associates, clerks  and coming in 4th on the unhappy scale was the registered nurse.  Equally sad was that teaching came in 5th on the unhappiness scale.

What workers were most happy?  Number one was Real estate agent followed by Senior Quality Associate Engineer.  Sales Reps and Construction Superintendents were also happy in their jobs.

Overwork, lack of opportunity for advancement and poor workplace culture were the biggest factors in the dissatisfied categories.  Nurses were most unhappy with the workplace culture and the people they worked with. We can only guess that that means doctors, other nurses and administrators.  Teachers, on the other hand were happy with their work and the people they work with.  They were dissatisfied with rewards for their work,  lack of support and lack of growth opportunities.

Nurses are the unsung heroes of health care.  Not enough attention is paid to increasing their satisfaction and professionalism.  This small survey should ring some alarm bells, somewhere.

Thursday, March 28, 2013

Tuberculosis Made Easy

Tuberculosis (TB) is a contageous infection that is caused by a bacterium called Mycobacterium tuberculosis. One third of the world population has been infected with TB and it caused over 1.5 million deaths in 2010.  We don't hear as much about TB in the developed world but new infections in third world countries occur at a rate of about 1 per second.    Risk factors for TB are:
  • A weakened immune system such as diabetes or HIV
  • Working in health care or refugee camps
  • Traveling to countries where TB is endemic
  • Living in overcrowded situations or extreme poverty
 The disease usually affects the lungs and is spread when people cough or sneeze and spray moisture droplets.  In the old days, TB was called "consumption" and at the turn of the century it was treated by isolating patients in sanitariums for months to years and hoping they recovered. In the 19th Century, TB killed more people in New England than any other disease.


Active TB is when a person has symptoms (fever, cough, night sweats, fatigue, wasting) and has a positive ppd skin test.  These people can spread the bacteria.

Latent TB is when a person with no symptoms has a positive ppd skin test and the bacteria is in a dormant or inactive state.  These people are not contagious.  A chest XRay can distinguish between active and latent TB.

We treat patients who have active TB with antibiotics and treatment usually lasts for 6 months to get rid of the infection.  Persons with latent TB are also treated as a preventive for the infection flaring up again.  Multidrug-resistant TB is a form of active TB caused by bacteria that do not respond to the medications most commonly used to treat TB.

Health care workers, child care workers, home-care professionals and immigrants should all have regular ppd tests to make sure they have not been exposed to TB.  Once a ppd test is positive, it will always remain positive, even if the infection has been treated and resolved.

Sunday, March 24, 2013

Ten Sleep Facts That May Surprise You

I think we all know that sleep is not only beneficial for good health, but lack of sleep can lead to a number of serious disorders and diseases.   Here are ten sleep facts that may surprise you:

1.    When we are awake our brain cells produce adenosine as a byproduct. The build-up of adenosine in the brain is thought to be one factor that leads to our perception of being tired. (Incidentally, this feeling is counteracted by the use of caffeine which blocks the actions of adenosine in the brain and keeps us alert.)

2.    Older adults need about the same amount of sleep as younger adults (7-9 hours) but seniors go to bed earlier and wake up earlier than when they were younger.

3.     We dream only during REM (Rapid Eye Movement) sleep but get the deepest sleep during non-REM cycles.

4.     It is not only important to get sleep to learn, but it is also important to get good sleep after we learn something new to process and retain that knowledge.

5.     Insomnia is the most common sleep disorder after age 60.  People with insomnia have trouble falling asleep and staying asleep.

6.    Major restorative functions in the body like muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep.

7.    Hitting the snooze button makes getting out of bed more challenging than simply getting up with the first alarm, because a few more minutes of shuteye causes the brain to enter a deeper sleep cycle.

8.    Losing just a few hours of sleep a week - similar to the effects of jet lag or cramming for final exams - can lead to almost immediate weight gain.  The good news is getting extra sleep can cause those pounds to shed.

9.    Recent studies show that daylight savings time increases risk of getting into an accident by 11% and your risk of myocardial infarction by up to 10% in the three weeks after the change.  To get used to the change, experts recommend soaking in the sun in the evening with the later sunset,  getting some exercise and going to be earlier.

10.   Residents in the Southern U.S. states experience the most sleep disturbances and daytime sleepiness, according to a new "sleep map" that outlines how geography can influence sleep patterns.  Residents of the West Coast report better sleep.   Check out the sleep map here.

Here is something I just learned this week.  If you have an iPhone with Siri (4S or later) you can ask Siri to wake you in the morning at a specific time.  It is a great alarm.



Probiotics - What and When?

Probiotics contain microorganisms that are similar to the beneficial bacterial that occur naturally in our intestinal tract.  There is so...