Get Grandma a Computer

One of the best things you can do for your aging granny or grandpa is get them online. Ninety two percent of American ages 18-29 use the internet and email. But for folks older than 65, the rate falls to 42%.

Why is it important to get seniors on line? A recent study by the Phoenix Center for Advanced Legal and Economic Public Policy Studies (they need a better name), a non-profit Washington think tank, shows that seniors who are on the computer cut the incidence of depression by 20%.

Another recent study from UCLA showed that first time use of the internet by older people enhanced brain function and cognition. Even performing internet searches changed brain activity patterns and enhanced neuro function. They performed brain scans on participants after they were on line and found enhancement in the areas known to be important in working memory and decision-making.

So if you are wondering about that perfect gift for your grandparents...think about a computer with internet access. Soon they'll be twittering up a storm and maybe even posting their own blogs.

Should Doctors Wear Neckties?

Neckties worn by physicians may be contaminated with dangerous bacteria and viruses that are transported from patient to patient. The British Medical Association made a decision in 2006 that doctors should forgo wearing neckties because they carry germs and bacteria. The American Medical Association is looking at the same issue.

Stethoscopes are draped across ties, patients sneeze on them and neckties are worn repeatedly without being washed. A study from 2004 at New York Hospital Medical Center at Queens showed half of the neckties worn by the study doctors harbored bacteria, including MRSA.

If an article of clothing has no function and may be contaminated, I say why wear it? I doubt that given the choice of a dressed up doctor vs a clean doctor, patients would choose the necktie.

Personally, I think we should all be wearing scrubs in the hospital and in the office. They are comfortable, professional and clean. I would welcome saving $$ on clothes and dry cleaning. Or what about the old Dr. Kildare look?

What do you think? Is it time for men physicians to lose the tie?

Premature Ejaculation Spray

We have been talking about women's health for the past week. Now it is time to discuss men's health. The Sexual Medicine Society of North America met in San Diego and heard reports on a new spray to prevent premature ejaculation in men.

The drug maker Sciele Pharma, Inc, a division of Japan's Shinogi has been testing the new spray that contains the numbing agents lidocaine and prilocaine. The researchers from San Francisco tested 300 men who used the spray on their penis five minutes before intercourse. The men were able to last 2.6 minutes. (compared to less than a minute without the spray).

They did not address what happened to the woman, who probably experienced some of the topical spray anesthetic herself via contact! I don't mean to sound glib, but the new spray strikes me as a biochemical fail! It is hard for me to see how this would be considered a success.

Sciele Pharma plans to file for U.S. approval next year.

New Guidelines on Pap Smears for Women

Right in the middle of the national firestorm about Mammogram recommendations, the American College of Gynecologists (ACOG) has issued new guidelines for screening of cervical cancer. After 40 years of successfully convincing women to get pap smears annually, the new recommendations say women should not get their first pap test until age 21 and the intervals for testing can then be stretched out.

The new recommendations say that women should start pap screening at age 21 (not teens who are sexually active as previously recommended) and then every two years through age 29. Women age 30 and over with three negative pap smears can stretch it out for three years. Women over age 65 can stop getting pap tests if their previous tests have been negative. Women who have had a hysterectomy for non-cancer reasons never need a pap smear.

The study experts looked at pooled data from around the world. We now know that cervical cancer is caused by certain strains of Human Papillomavirus (HPV), however most women infected with HPV will not develop cervical abnormalities. Most women who contract HPV have an effective immune system that clears the virus. Paps that are done too frequently can show abnormalities that would, in the majority of cases, clear spontaneously.

The researchers also found that pap tests are difficult to interpret and there is inconsistency among cytologists reading the slide. Upon a second review, most results that were reported as showing abnormalities were downgraded to normal.

The study points out that abnormal pap tests lead to a sequence of further testing, biopsies and excisional procedures that can adversely affect a young woman's reproductive health.

In summary, the new guidelines recommend:

• Start pap smears at age 21 regardless of prior sexual activity (no need at all in virgins).
  
• Test every 2 years to age 30
• After age 30, test every 3 years if prior tests are normal
• Stop at age 65 if prior tests have been negative.
• No paps needed for women who have had hysterectomy if there was no cancer

It is ironic that we now have two significant changes for screening tests in women's health. According to the chair woman of the ACOG study group, Dr. Cheryl Iglesia, it was a bizarre coincidence that their guidelines hit right at the same time as the mammogram controversy.

The 12 page recommendations from ACOG can be found here.

Answer to the Medical Challenge

OK, you got it. The drug of abuse was cocaine which can cause perforation of the nasal septum and palate in serious abusers. Enough said!

My 2¢ on Mammogram Screening

As I predicted, the controversy and backlash against the recommendation to change mammogram screening to women over age 50 is huge. Special interest groups are coming out of the woodwork and every woman who found a breast cancer by mammogram has been interviewed by CNN and Fox news. Here is my 2¢.

We have thousands of tests we can perform on people. Why not perform these tests on everyone? Lung cancer is more prevalent than breast cancer and it shows up in young women with no risk factors. Why don't we get Chest X Rays on everyone every year? Why don't we get EKGs or thyroid scans on everyone every year to find silent heart attacks or thyroid nodules? Why not get CT scans annually? That way we could find early adrenal, kidney, brain or pancreatic cancer.

The decisions about screening exams for the population are made by scientific groups like the USPSTF. There is often confusion because other groups like the American Cancer Society and other specialty medical groups (Radiologists, Surgeons, Urologists, Cardiologists, Republicans and Democrats) also offer their own recommendations. Those groups are not impartial and can be influenced by politics or gain.

The impartial and independent physicians and scientists are crucial for making recommendations for the Nation.

The USPSTF studied over 500,000 women for more than a decade. They found that yearly Mammograms in women under 50 could possibly be detrimental to health. The effects of excessive radiation have been known for decades. They based their screening recommendation on the best and current science that is now available.

Mammograms do save lives by detecting early cancer. Other tests can also detect early cancer but determining where the benefit of the tests exceed the risk (in both $$ and health ) is the goal before we recommend mass screening. Some women have breast cancer in their 30's. Why not start screening at age 30? It is because we have determined that the risk exceeds the benefit. The new recommendations are saying the same thing for under age 50.

I will continue to prescribe mammograms to women younger than 50 if the woman wants it. I have never believed there is a magic age (40?, 41?) that made logical sense. We must keep in mind that detecting cancer is not the same as preventing cancer. We have not yet found a way to do that.

Medical Challenge

This weeks medical challenge should be pretty easy for readers of EverythingHealth. Which one of the following drugs of abuse causes the abnormality in the photo? (click on image for a better view). Show us how smart you are!

1. Ketamine
2. Heroin
3. Cocaine
4. PCP
5. Mescaline

The answer will be posted tomorrow.

Guidelines for Mammograms Changed

For years women have been advised to have an annual mammogram starting at age 40. The advice and insurance coverage for mammograms has been so effective that nearly 2/3 of women over age 40 had mammograms. Scratch that advice. The new guidelines, published in the Annals of Internal Medicine will spark a wave of controversy. Women are now advised NOT to have screening mammograms until age 50 and then to space them every other year. The United States Preventive Services Task Force, an independent panel of experts, says the new guidelines were based on new data and analysis and were aimed at reducing the harm of overscreening.

Why the switch? The report says the risk/benefit of mammogram just doesn't pan out for women age 40-49. The task force said that once cancer death is prevented for every 1,904 women who are screened for 10 years in the 40-49 age range. As a woman ages, her risk of cancer increases so one death is prevented for every 377 women screened at age 60-69.

Mammograms often detect abnormalities that are not serious. These false positives cause women to undergo more testing and biopsies that can cause harm. The Task Force recommends the way to get the most benefit and the least harm is to start screening at age 50 and have approximately 10 mammograms in a lifetime.

The new advice will undoubtedly change the insurance and Medicare coverage for mammograms. Already the group that "grades" health plans on quality, the NCQA, is changing the measure for mammograms to women over age 50, every two years.

We can expect an outcry from women who had an early mammogram and it "saved my life". People will say it is part of "Obamacare" and meant to save billions of dollars ( BTW, it will save $billions) but they would be wrong as the USPSTF is probably the most impartial scientific group around.

The new guidelines do not apply to women with genetic markers or family history of early breast cancer. Let the debates begin.

Insurance Poll

It was interesting to read the results of my little poll, "Do You Have Health Insurance". The readers of EverythingHealth that chose to participate don't exactly match the population at large.
40% have insurance through their employer
10% buy their own insurance coverage and another 10% have a high deductible so that means they most likely pay the full cost of claims too.
12% are covered by Medicare, Medicaid or the VA. (In the normal population it is about 50%).
22% have no coverage. That is about average for the U.S.
4% of readers have government coverage (probably foreign).

So, 42% of readers are paying their own health costs through buying insurance or paying out of pocket for medical costs. 52% of readers have government or employer based insurance. It doesn't quite add up to 100% but you get the drift.

Fertility Doc Uses Wrong Sperm

When patients see a medical license framed on a doctor's wall, they assume his credentials have been checked and that the state has done due diligence about his practice behavior. That wasn't the case for patients who saw Dr. Ben D. Ramaley in Greenwich, Conn. In 2002 he performed insemination on a woman patient, but he did not use the husbands sperm. Twins were born but the husband was black and the mom was white and the twins did not look bi-racial. The couple did a paternity test that proved the husband was not the father. The couple filed a lawsuit months later and charged the doctor with using HIS OWN SPERM. The lawsuit was settled in 2005 without the doctor ever undergoing a DNA test. He did admit to using "the wrong sperm" for the insemination.

In 2006, the Dept of Public Health launched an investigation into his care practices. They found numerous problems including other instances where the standard of care had been seriously violated. His record keeping was poor and there was no systems to verify and maintain identity of the sperm sample. No DNA analysis was done on him to confirm if he used his own sperm.

In 2008, Dr. Ramaley received a $10,000 fine from the state and was allowed to continue practicing medicine. He has a unrestricted license. He continues to practice in Southport, Conn. There would really be no way any of his patients would know about this case or assume he is anything but a wonderful fertility doctor.

I have no idea if Dr. Ramaley used his own sperm to inseminate a patient. We cannot know if the fact that the husband was black played any role in the "accidental" switch of sperm. What we do know is that a physician did not practice to the standards that are expected and the error was an "extreme and outrageous act".

Doctors rights to fair process are paramount in a democratic society. But patients have rights too and it is up to the State to protect the rights of patients to know that a doctor's license meets certain standards of care.

New Treatment for Dupuytrens

The FDA's Arthritis Advisory Committee has approved a new treatment for treating advanced Dupuytren's disease. If approved, this would be the first nonsurgical therapy for the disorder.

Dupuytren's disease (named for Guillaume Dupuytren, 1778, of course) is a formation of scar tissue under the skin of the palm of the hand. This scar tissue pulls the flexor tendon of the fingers and causes the fingers to slowly be pulled into a grip. Over time, the contracture progresses and the skin is pulled in a fixed flexed position. Dupuytren's disease is inherited and it occurs mainly in males.

When the Dupuytren contracture was bad enough, the only treatment previously was surgical release of the scar tissue. (see image above...yikes) Even after surgery, the disease can recur. The new treatment is an injectable biologic treatment that breaks down collagen. The bacterium Clostridium histolyticum, is injected into the cord at 4 week intervals for three injections. In double blind studies, patients treated with collagenase clostridium had almost a complete reduction in contractures compared with those who received placebo.

Ain't science wonderful?

Answer to Medical Challenge.

The readers of EverythingHealth are so darn smart! Most of you knew that the swollen finger joint with the yellowish white material under the skin was gout. Gout is a disease with elevated levels of uric acid in the bloodstream. The crystals of urate are deposited in joint cartilage and cause painful attacks of acute arthritis. Any joint can be affected but the large toe is the most common. Approximately 75% of first attacks are in the large toe.

Gout occurs more often in men than in women. There are probably some genetic causes of gout as well as excessive alcohol use and untreated hypertension, hyperlipidemia and certain medications.



I have blogged before about the association of high fructose corn syrup and gout attacks. There is also evidence that Vitamin C supplements can prevent gout.

New Medical Challenge

This weeks image challenge is a good one. Click on the photo for a better view. This 52 year old man has a painful index finger. What is the diagnosis?

1. Cellulitis
2. Gout
3. Osteoarthritis
4. Rheumatoid Arthritis
5. Septic Arthritis

Be brave and make your best diagnostic comment. Check back tomorrow for the answer.

Shameless Corporation of the Week Award

This weeks Shameless Health Care Corporation is United Healthcare. (For prior winners, scroll down the blog). I have many examples of the shameless and egregious behavior of United over the years, but this story sums up how they treat their policyholders. They treat their contracted physicians even worse.

Marlene is a single stepmom who is raising the two children of her deceased sister. They live in a cramped apartment and stretch a dollar as far as they can. She is extremely responsible about health care for herself and her stepkids. Since I don't contract with United Health Care, she pays me and sends the bill to United for them to reimburse her. Over the last two years, they have reimbursed her ZERO for health visits and illnesses for herself and the teenage kids.

Under the contract with United, they should pay a portion of "out of network" care. United has a pattern of delay and hassle that is repeated over and over. United sends me forms to fill out after each visit, even though they have the information in full on the bill I give her to submit. They want a complete duplicate of the information that they already have. When I resubmit the forms they stall and after 90 days they send a denial, stating they did not receive proper information and allowing me to "appeal" on the patient's behalf. When I send the appeal letter with copies of everything, nothing more happens. This cycle can take about a year to complete. There is no phone number to call on the letters and phone calls to United Health Care corporate puts you on a recording loop.

United Healthcare is truly a shameless corporation. Despite the fact that my patient has insurance that should cover her and her step-children, I provide heavily discounted care because I know she will never be paid a dime by United.

The CEO of United Health Group was paid $3,241,042 last year and has a retirement account of $10,703,229. The prior CEO of United was paid $342 million over 5 years. I don't know what his retirement is.

Shameless!

U.S. Should Focus on Primary Care

A new study conducted by the Commonwealth Fund was published by Health Affairs and it showed that the U.S. lagged behind other nations in some very important ways that affect health and access to quality health care. The study surveryed over 10,000 primary care physicians in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. The study found that:

• The vast majority (69 percent) of U.S. respondents report that their practices have no provisions for after-hours care, leaving their patients no choice but the emergency room. The U.S. was behind every other country surveyed on this finding.

• Fifty-eight percent of U.S. primary care physicians say their patients often have trouble paying for their medications and care, compared to 5- 37 percent in the other ten countries.

• While 99 percent of doctors in the Netherlands and 97 percent of doctors in New Zealand and Norway use electronic medical records (EMRs), only 46 percent of U.S. doctors report EMR use.

• One-third of U.S. physicians report receiving any financial incentives for the quality improvement measures tracked in the survey. By contrast, 89 percent of doctors in the U.K. and sizable majorities of their counterparts in the Netherlands, New Zealand, Italy, and Australia report financial incentives tied to quality.

Primary care forms the foundation of a quality health delivery system, coordinating care and holding down prices.

The authors conclude, "Overall, the survey highlights the lack of national policies focused on U.S. primary care. Unless primary care practices are part of more integrated care systems, they are on their own facing multiple payers with uncoordinated policies. In contrast, other countries with multiple payers seek coherent payment and coverage policies. As the United States looks to develop new primary care models that could work well for patients and physicians, policymakers can learn a great deal from diverse initiatives under way in other countries."

It's Post Secret Day

Check it out every Sunday.

When to Take Tamiflu

With the H1N1 flu season hitting most communities, the question of when to give patients Tamiflu comes up for physicians. Tamiflu is the antiviral medication that can shorten the severity of flu symptoms by...drumroll...one day. To be effective it should be given within the first 48 hours of symptoms.

There are no medical guidelines for who should take Tamiflu. If patients have symptoms severe enough for hospitalization or have a chronic condition or asthma, Tamiflu should definitely be prescribed. Pregnant women and young children are at more risk for severe flu so they should be given Tamiflu when symptoms present, but what about everyone else?

Is shortening the illness by one day worth the $100 Tamiflu costs? Some doctors are concerned about creating resistant strains of influenza if Tamiflu is overused. And giving Tamiflu to "prevent" flu is not recommended because people who live in a household with a flu victim have only a 15-27% chance of catching flu anyway. That said, if a person with high risk factors is exposed to the flu, giving Tamiflu is likely to prevent illness.

As with any medication, adverse events can occur. With Tamiflu adverse event reports were primarily related to unusual neurologic or psychiatric events such as delirium, hallucinations, confusion, abnormal behavior, convulsions, and encephalitis. Most of the reports come from Japan.

I am not prescribing Tamiflu routinely for people with flu symptoms. If they ask for it, and understand how it works and the small risks of taking it, I will write the prescription. Tamiflu is not a substitute for the flu shot.

Who Sues for Malpractice?

There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a lawsuit.

• Angry patients: A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians. What works in a medical error? An explanation of what went wrong and, if appropriate, an apology!

• Money Issues: Now that more patients are paying out of pocket costs, if they feel overcharged they become less tolerant of errors. If patients know the approximate costs up front, they aren't surprised and outraged when that big bill arrives. We all know, however, how hard it is to find out anything about costs in advance. Big problem!

• Doctors Dissing Others: So many lawsuits have been filed because of one doctor or nurse making disparaging remarks about another; "How did such a thing happen to you?" It's easy to be a Monday morning quarterback.

• Lousy Service: Bad service goes along with poor doctor-patient rapport. It is hard for someone to feel respected and cared for, if they get bad service or the rooms are dirty or the phone call isn't returned. If a mistake happens, the doctor must be available to discuss it. An absent doctor or poor service turns patients and family members into "angry patients" (see number 1).

Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record.

Big J&J Layoff

Johnson and Johnson has announced that they will lay off 7000 employees. That is about 7% of the employees at the company. How can the economy really be improving with such large job eliminations occurring?

J&J is one of the most admired and diversified health conglomerates with a consumer division, diagnostic/devise equipment, pharmaceutical drugs and R&D arm. Johnson and Johnson is present in 57 Countries around the world.

If a company like J&J is cutting back this much, it shows the economic recovery will be long and hard.

Unreal Health Care Costs

I took my son to the ER for a broken thumb. It was a minor injury but the thumb is the most important digit on the hand. The ER care was just fine...a quick look, an Xray and a small splint. We didn't have to wait long and everyone was courteous.

Imagine my surprise to receive the bill from the hospital. Yes, I have insurance. My out of pocket expense was minimal but here is what the insurance company was charged:

• Hospital Misc.- $56.00 (could this be the splint?)
• Diagnostic Xray - $342.00
• Emergency Care- $952.00
• Surgery - $570.00
  Total $1920.00

Take a look...surgery? There was so surgery, no procedure. There was no break in the skin. The doctor component of the visit was about 7 minutes (mainly because I knew the doc and we chatted about politics)

This bill is unreal and is comprised of unreal health care costs. The insurance paid a component of the bill. They have a cap on what they will pay for each element.

I am an informed consumer so I will be calling the hospital billing office to discuss the unreal charges. I doubt that most patients would do that if they had insurance. It would be "somebody else's problem". We need to bring the patient back into the loop to control costs. We all pay in the end anyway.

The Doctor and Radiologist bill will be separate.

A Weeks Worth of Food

Universoul Productions has compiled a fascinating look at what one family from different countries eats during one week. Take a good look at the family size and diet of each country. I found this amazing. Starting at the top:
#1 - Chad, cost $1.23 U.S.
#2- Bhutan, cost $5.03 U.S.
#3- Ecuador, cost $31.55 U.S.
#4- Egypt, cost $68.53 U.S.
#5- Poland, cost $151.27 U.S.
#6- Mexico, cost $189.09 U.S.
#7- United States $341.98 U.S.
#8- Germany, $500.07 U.S.
#9- Italy, $260.11 U.S.

I think the photos and the cost of food speak for themselves. Which country has the best diet?

Fake Hymens For Non-Virginal Women

As a physician, I see a lot of strange things and meet lots of interesting people. I guess I shouldn't be surprised when the oppression of women in many countries across the globe has created a market for fake hymens for non-virginal women. Since virginity is valued above all else in many religions, it was only a matter of time when the artificial hymen would be manufactured and sold. Now with the internet, fathers and mothers in Sudan and Egypt and anywhere else, can order online for their little bride.

For $15-$29.00, a family can obtain a Chinese-made artificial hymen that might (?) fool a groom or at least the groom's family. The "hymen" is a 5X7cm folded piece of albumen covered on one side by dark red ink. Place in the vagina before sex, the plastic hardens slightly and rips upon intercourse. Voila! A few drops of "blood" and everyone is happy.

Why would a product like this be in demand? In Muslim countries a girl who is not a virgin will have hell to play after the wedding. Her husband can divorce her or the family can keep the dowry and disown her. It is such hypocrisy that 50% of the population can be discriminated against. There is no such obsession with the man's virginity.

The whole issue of a woman's virginity is a carry over from ancient times and religious texts. "Then the wedding night sheets were hung over the balconies in the morning, to let the rest of the world know how virginal the bride was, altho rumours of sheep's blood and substitutions have been heard." A visitor to Rome in the mid-20th century remarked on how virginity could be faked.

The "fake hymen" is just a modern day version of ancient misogyny. It goes along with the horrendous practice of marrying off pubescent girls to older men who want "virgins". I guess there is more success in finding a 12 year old virgin. Sick, sick, sick.

Blog Plagiarizing

I was just alerted by a fellow blogger (thanks, Yesmeen) that another site is stealing my posts and posting them as if it is their content. The blogs are completely posted, titles, graphics and all, on this other site that has health advertising also. There is no contact info so I cannot contact the blog administrator.

Blogging is a passion and a hobby for me and I spend a great deal of time researching the information I post to make sure it is accurate and as clearly written as possible. I also try to think of topics that are of interest to a wide variety of readers.

With permission, I allow my material to be re-printed at other credible sites because my goal is to educate and reach even more readers. Those sites attribute my blogs to EverythingHealth.

If anyone knows how to top this practice, I would be grateful to have information.

SSRI Withdrawal Syndrome

Karen is a 38 year old new mother (baby girl 8 months) who came to me with unusual symptoms that were of concern. She began having "episodes" of a buzzing, electrical feeling in her head and neck. It felt like a "shock" in her head. At times she would feel so dizzy and off balance that she had to pull over in the car or sit down. There was no headache but she felt some numb patches on her arms and legs. There was a vague depersonalization that accompanied the spells. It would happen for several days, then disappear for weeks and then come back. The "spells" lasted a few minutes to hours but seemed to be increasing over the past week.

When patients present with strange symptoms like this, a doctor has to start at the beginning with a detailed history. Any new medications? Any over the counter medications? Any drugs or alcohol? Any visual changes or blurry vision? The answer to all of these questions was no.

The work up progressed with blood tests looking for Vit B 12 deficiency, thyroid dysfunction, infection. When these returned normal and the symptoms persisted, more testing was needed.

Unusual symptoms like this in a young woman could be a sign of an autoimmune disease that affects the myelin sheath around nerves, such as Multiple sclerosis. In MS the episodes can wax and wane, just like Karen's did. She felt worse when it was hot and MS episodes can be triggered by heat. I was quite concerned that it could be MS, but we were reassured when an MRI of the head and spine returned normal.

Luckily, the symptoms disappeared again. Imagine my surprise two months later when the mystery was solved. Karen had been prescribed Zoloft, a SSRI medication for post-partum depression. She started on a low dose and when that didn't work, her OB doctor told her to increase it. Instead of getting a new prescription, she just doubled the dose and ran out of the drug after two weeks. She would fill the prescription the next month and run out again and again. She was starting and stopping an SSRI medication, getting no good effect, but triggering classic SSRI withdrawal syndrome each time she stopped.

Zoloft is a short acting SSRI. That means they are cleared from the body quickly when discontinued. If the dose is abruptly discontinued there is a rebound that blocks the neurotransmitter, Acetylcholine. It can also cause an excitability in the brain that is not well understood.

When Karen was asked if she was taking any new medication she honestly said "no" because she had stopped the Zoloft and didn't realize the importance of her "on and off" regimen. That one key clue would have solved the mysterious diagnosis months earlier.

When she started taking the proper dose of Zoloft continually, her depression lifted, her "shock waves" and dizziness resolved and it was a good lesson for both doctor and patient.

What Medical Condition Costs the Most?

What medical condition costs the U.S. Health system the most in disability and overall costs? If you said heart disease or cancer or pulmonary disease you would be wrong! I would have said one of those myself.

The answer...slow drumroll....is musculoskeletal disease. Yes, 50% of the adult population reported having a disabling musculoskeletal condition in 2008. The expenditures for these problems include the costs of preventive care, the cost of direct care, the cost of care in hospitals, by physicians, therapists and other caregivers. It also includes the loss of productivity. In 2004 it was estimated that the cost of care for musculoskeletal problems was $840 billion. (Hey, isn't that about equal to the bank bailout?)

What are musculoskeletal conditions? They include that old nemesis: Low back and neck pain. Spine problems are among the most common problems that bring patients for medical care. That's why the chiropractic industry is booming.

Another leading cause of disability is osteoarthritis, which affects almost 22% of all adults. Osteoarthritis leads to millions of Advil and Tylenol doses and often culminates with total joint replacement (hips and knees). With the influx of baby boomers, the increase in total joints will ensure orthopedic surgeons decades of future employment.

Osteoporosis (bone loss) is another disease of aging that causes hip, spine and humerus fractures in people older than 65. All of those Sally Field commercials for Boniva are aimed at consumers and the expense to diagnose and prevent bone loss adds to the overall cost of treatment.

About 60% of all injuries involve the musculoskeletal system and falls are the most common cause. The emergency department, doctors offices and hospitals all deal with patients with bone and muscle injuries. Patients that are admitted to a hospital spend an average of 5 days in the hospital. Ching, ching!

Despite these facts, the NIH research budget for musculoskeletal conditions has been decreasing with time and they are not in the top 10 conditions that receive funding. In addition, the proportion of orthopedic surgeons to the aging population is not keeping pace. We aren't training enough orthopedic surgeons to keep up with demand and the projected need for 2020 is woefully short.

With declining Medicare payments and rising malpractice insurance costs, physicians are shying away from specialties that take care of "old" people. Rheumatology, geriatrics, primary care and orthopedic surgery are all specialties that are going to be needed, but we have done no workforce planning as a nation to ensure there will be enough to care for the population.

Need Surgery, Travel Abroad

Medical Tourism has been a growing phenomena since the cost of health care is increasing by double digits each year in the United States. The Journal of American Medical Association (JAMA) reports that up to 750,000 U.S. patients have traveled to other Countries for surgery. Patients in other countries like Canada and the U.K. travel even more for surgery and medical care. Some health insurance companies will even pay you to travel because they reap the value of lower cost procedures for the insured. How much value? A patient who needs a spinal fusion would pay $90,000 in the U.S. compared to just $7,000 in Thailand.

Medical centers in Thailand, India, Singapore, Argentina, Costa Rica, Brazil, Mexico, Hong Kong, the Czech Republic and Hungary are popular worldwide destinations. Need a new dental bridge? It would cost you $5,500 in the U.S. but only $500 in India. A full facelift can be obtained in South Africa for $1,200 compared to $20,000 here.

Many of the surgeons in these centers were trained in the United States (Harvard, Johns Hopkins) and the Medical Centers are spa-like. The hospitals are accredited by a relative of the Joint Commission, the accrediting agency in the U.S. The price may also cover travel and hotel expenses for the patient and a companion. Medical Tourism or Global Health Care has been called "first- world health care at emerging-market prices".

The American College of Surgeons has acknowledged the changing landscape that Surgical Tourism brings. The ACS has issued a statement that offers tips for patients to consider before booking international surgery. The three main concerns are the possibility that the "informed consent" is not up to par with the U.S., the communication with the health care team may not be like the U.S. and the devices used and the procedures may not be up to U.S. standards.

Cover those bases and the gastric bypass for $6,000 in Costa Rica might look more attractive than paying $28,000 in the U.S. With the out of pocket expense for patients who have insurance, these prices can look attractive. For the 46 million U.S. citizens that are uninsured, a vacation coupled with a hip replacement (USA-$43K, Thailand-$10K) might be appealing.

Victorian Health

In the Victorian Era, a doctor could have a carriage trade of just a few wealthy women invalids that he visited every day. It was a status symbol for a wealthy gentleman to have a personal physician come to the house to minister to his wife. Now we know what kind of treatment was being offered!

Shameless Corporation of the Week Award

This weeks Shameless Corporation Award is shared by Horizon Blue Cross Blue Shield of New Jersey and the company it contracts with to manage claims, Magellan Health Services. Magellan is notorious for denying benefits to the Blue Cross patients. In this case, a young woman who was a victim of date rape was unable to receive mental health benefits even though she was insured. Magellan stopped paying for her mental health visits with a psychologist for no reason. They just said "no"and appeals were met with further denial.

Lois Gorwitz is a psychologist who worked for Magellan for two years as a claims reviewer and she said the culture and pressure from supervisors was to deny claims. Gorwitz said the company denied claims because they are in the business to make money. She quit because she was uncomfortable with the pressure to deny valid claims. Magellan is expecting 2009 profits of $210 million, exceeding predictions.

Horizon Blue Cross Blue Shield is the states largest insurer and they posted $5.5 Billion in sales last year. To see more about EverythingHealth's Shameless award recipient, and the college student who was denied benefits, watch this Vid.

Nurses, Lawsuits and H1N1

Only in the United States could a virus like H1N1 bring out the worst in medical politics and greed. We are facing a "pandemic" that requires coordination, communication and the best of medical practice. But what are we getting? Strikes, lawsuits and anything BUT putting patients first!

The strong nursing union, California Nurse Association (CNA), is taking this opportunity to call a strike on three large Catholic hospital chains (including 34 hospitals) throughout California and Nevada. The union bosses say the chief concerns are a lack of protective gear, improper isolation techniques and staffing that requires nurses to work (oh horrors!) 12 hour shifts during the flu crisis.

Although the nurses seem to want to walk out during a pandemic to "protect patients", the nurses in New York and Washington also filed a lawsuit over the idea that they should be required to get the flu vaccine. You can't have it both ways, nurses! You either want protection or you don't.

This is such an obvious smokescreen for contract negotiations, not H1N1 preparedness. Coincidentally, the CNA is in negotiations now with Catholic Healthcare West. How convenient! Since nurses in California already earn more than many physicians, this type of unprofessional bargaining rhetoric is nursing at it's worst!

By the way, most nurses in California hospitals work part time and receive full benefits. At a time when unemployment is at an all time high, nurses are receiving up to 6% pay raises due to union bargaining.

I respect nurses and believe in true collaboration for patient care, but as we prepare for flu season, this type of unprofessional, opportunistic behavior needs to be called out for what it is!

Copperhead Snake Bite

Ever wonder what a copperhead snake bite will do? This patient was bit on his finger 4 days prior. The venom causes local tissue destruction and a secondary infection can set in. Copperhead snake bites are usually not fatal but, as you can see, the damage can be extensive.

(hat tip to copperhead-snake.com)

Too Tired to Blog

Good News for Proton Pump Inhibitors (PPI)

Proton Pump Inhibitor drugs (PPIs) have been used since the 1980s to reduce gastric acid secretion and to treat ulcers and reflux. They are now among the most widely prescribed drugs world wide and Prilosec and others can be obtained over- the- counter. Any time drugs are used long term, we should be re-evaluating their safety. The good news for PPIs, is that they are safe for chronic use.

PPIs do their work on the parietal cells of the stomach. They bind at the "proton pump" and prevent secretion of acid into the stomach. The effect is prolonged (24-48 hours) and the drug is cleared by the liver with very little effect on the kidneys.

The side effects are few so these medications (Prilosec, Aciphex, Prevacid, Protonics) are often prescribed to hospitalized patients and for patients with GERD, gastritis and ulcers. Patients take these medications for years and there have been numerous studies that looked at potential long-term effects of PPI use.

The studies have shown that PPIs are highly effective drugs and they have revolutionized the management of acid-related disorders during the last 2 decades. When was the last time you heard of someone getting surgery for "ulcers"? That was a common treatment just 30 years ago.

Studies that looked at PPIs and their effect on Vit B12 absorption, iron loss, colon cancer, gastric cancer and calcium deficiency found no definite link. There may be an association in hospitalized patients who are on PPIs and the incidence of Clostridium difficile infection. No association was seen in non-hospitalized patients.

As with all medications, PPIs should be used for appropriate indications only as long as needed. If you or a friend have been taking PPIs for a long time, you may wish to talk with your doctor about a "drug holiday" to see if it is still needed. I review chronic medications with my patients at least every year with the goal of eliminating any that are not absolutely needed.

The Water Giver

EverythingHealth strongly recommends a wonderful new book called "The Water Giver" and I predict you will not be able to put it down. Author Joan Ryan is a remarkable writer who takes the reader on a journey she lived when her son, Ryan, sustained a near -fatal severe head and brain injury on a skateboard. It is both a medical drama and a meditation on motherhood.

The book begins with Joan's description of her son's learning difficulties and years of psychological and developmental testing. Her style as a mother was to intellectualize, do research and try to fix what was "wrong" with her son. The years went by with family stress and teachers conferences and medical consultations but it wasn't until the day he fell, that Joan realized some things are too big to be studied and fixed.

The nightmare began when he was 16 and went skateboarding without a helmet. The fall on a hill near their home caused a huge brain bleed that obliterated much of his brain tissue. He remained in a coma for weeks and underwent multiple surgeries to relieve pressure. The book chronicles months of near death events in the Intensive Care Unit that nearly drove his parents insane with worry. I will let you read it to find out how it turns out.

"The Water Giver" is more than a medical story and more than an account of a child's medical crisis. Joan Ryan used this harrowing time to look deep within herself and understand, finally, what her relationship with this remarkable child was all about. It was a time of sadness, fear and anger, but also a time of self-reflection. It was a time for Joan to realize that sometimes, the best you can do for someone you love is to be the water giver and sooth their thirst. Through Ryan's accident, she discovered what was at her core.

This book is interesting on so many levels. The medical story is riveting and each page is turned to find out what will happen next. It is also terrifying because we know how close each of our children can be to an accident that could change their lives forever.

But the wonder of "The Water Giver" is the deep emotion it evokes as we read about the personal transformation that Joan Ryan underwent when she experienced the most terrifying time of her life. And it is a transformation we can identify with and be thankful that she was brave enough to put it down in writing.

All You Need To Know About Scabies

While playing tennis last weekend, one of my partners whispered, "Hey you should blog about scabies. There is an epidemic going around." I don't know about a scabies epidemic, but catching scabies is common and it can crop up just about anywhere. People don't like to talk about parasite infections, so here is all you need to know.

Scabies are tiny borrowing skin mites with a scientific name of Sarcoptes scabiei. The little female mite burrows just beneath the skin and deposits eggs that mature in about 10 days. New mites hatch and spread to other areas of skin or other people. Symptoms appear 4-6 weeks after infection unless a person has had scabies before. Then the symptoms appear right away.

Scabies are contagious and spread through close physical contact in families, schools or nursing homes. The victim has severe itching, usually worse at night and sometimes you can see little burrow tracks or tiny blisters on the skin. The itching is not caused by the mite but is the body's allergic reaction to the mite. Any part of the body can be infected but they like to go toward the folds of skin...around the waist, wrists, between fingers, breasts, buttocks.

Scabies can be diagnosed by the physician looking under a microscope at small scrapings. Prescription topical creams and lotions eliminate the infestation but the itching can continue for several weeks. (Since it is an allergic reaction). Usually close family contacts are also treated even if they are not showing symptoms.

To prevent re-infestation all clothes and linen need to be washed and dried with high heat. The scabies mite can also be starved by putting items that can't be washed in a sealed plastic bag for a couple of weeks. Mites die if they are starved for a week. Fumigation of the living area is not needed.

Scabies can be dangerous and hard to treat in people that are immune suppressed. For others, the prescription lotions will kill the infection readily.

Shameless Corporation of the Week Award

This weeks Shameless Health Insurer Award goes to American Community Mutual Company. The saga of 17 year old Brianna Rice starts in the summer of 2008. Her dad lost his job as a business consultant and also lost his group insurance. Continuing coverage with COBRA was too expensive so they took out a new policy with American Community Mutual in Illinois. Because the 17 year old was healthy, the monthly premium was only $130.00

In February, 2009, Brianna was diagnosed with celiac disease. On May 12 the insurance company rescinded her insurance and said it was a pre-existing condition and they would not cover any of the doctor or lab bills. Doctor visits from the distant past had mentioned dizziness, high cholesterol (a lab error), fatigue and a cough. They attributed those mentions to celiac disease and said they would not pay for treatment. A physical exam performed on July 2, 2008 showed no major health concerns.

Celiac disease is a digestive disorder and is treatable by eliminating wheat products from the diet. It does not cause cough, dizziness or high cholesterol. Some patients do experience fatigue.

If insurance companies can collect premiums and then cancel a policy when a patient gets sick, the insurance is virtually worthless. Brianna's father has called several other insurers in Illinois but they will not insure her based on the February diagnosis. She qualifies for the Illinois Comprehensive Health Insurance Plan (CHIP) which is designed to help people who cannot get insurance through the conventional market. The average premium is $7,666 to a high of $16,000.

Congratulations to American Community Mutual Insurance for winning this weeks "Shameless Corporation Award."