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Mail order pharmacy, part 1

By | May 11, 2013

I wrote this last year. It is still true this year. I have illustrated it with cute kittens, to reduce the stress caused by thinking about dealing with mail-order pharmacies.

< corporate name deleted > is a “pharmacy benefit manager” offering mail-order prescriptions. They are supposed to be convenient for patients.

Like all capitalist health enterprises, they mainly seek to limit and deny care in order to maximize their profits.

One important way for them to do this is by obliging me to call them personally to obtain permission for my patient to keep taking the same medication he has taken for the past ten years, which he has been ordering from < corporate name deleted > for the past several years.

Since I knew from past experience that I would be on the phone for a long time, I spent the time reading what others have said about < corporate name deleted > on the internets (links highlighted below).

2:50 pm, I entered the automated system.

The last three times I went through this process, on behalf of two other patients, I was repeatedly told that < corporate name deleted > had already sent me the fax, and would graciously send it again – but I never did receive it.

Meanwhile, I did a little research and discovered that the same medications were much cheaper at our local big-box stores, and those two patients simply transferred all their prescriptions from < corporate name deleted > to those pharmacies instead. Their insurance would only cover a 30-day supply at a time, but they didn’t mind, because they go to that store regularly anyway.

Some drugs are pricey no matter where you go – but in my own personal life I still steer clear of < corporate name deleted >, because they suck so much. For example, I don’t know what this drug costs from < corporate name deleted >, with insurance paying for most of it, but at one of the local big-box stores, paying out of pocket, it is $17.40/month (brand name version = $342.66, boo, hiss).

…Okay, the medicine is sumatriptan. (Brand name, Imitrex.)

I am saying that in some cases, it may cost less to pay out-of-pocket, than to have insurance “cover” the medication. Many patients tell me they paid a $10 co-pay for a medicine that is $4 per month, cash. This is not true for the very spendiest medicines, of course, but it is true for the vast majority of the drugs for which I personally write prescriptions.

I know it is very irritating to listen to doctors whinge about how annoying it is for them to deal with insurance companies of all varieties, including mail order pharmacies that are part of an insurance system.

But a large part of my own annoyance is how obvious, how terribly obvious it is, to those of us who are struggling to deliver the health care to you, the consumer, who already paid for it (through lower wages, since your employer pays through the nose for their part of the insurance, and through the premiums you pay, more and more each year, and through the sizable chunk your insurance declines to pay for and you must pay for yourself)… To us, at least, it is obvious that their main business is to limit and deny that care.

To you, it may appear that your doctor, or their helper, is an incompetent boob who can’t manage to get through a simple phone call without getting mad.

But to us, it’s obvious that we’re being made the fall guy for heartless capital, not to mention wasting hours every week, trying – often unsuccessfully – to get you what we want you to have, for your health and safety.

Down with < corporate name deleted >, I say! Down with them and all their friends!

…Okay, the corporate name is Medco.

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We will not all sleep, but we will all be changed

By | March 18, 2013

Natural burial is the interment of the body of a dead person in the soil in a manner that does not inhibit decomposition but allows the body to recycle naturally.

It’s 5:30 a.m. and my midwife daughter is getting ready to go to a birth, sipping a cup of coffee and checking her kit. We’re idly chatting about it, in that offhand midwife way. “How’s she doing?” “She went active about an hour ago – she sounds great.” “Did you pack your knitting?” I have a superstition that if a midwife doesn’t bring her knitting, she may be tempted to interfere, to speed things up. Knitting shows you’re settling in for the long haul.

She takes off in her car, and I start thinking about death.

No state or province in North America requires the routine embalming of bodies… The most common embalming fluid is composed of organic chemicals and contains 5–29% formaldehyde, ethanol and water… Formaldehyde is a suspected carcinogen and damages the health of workers exposed to it in high quantities.

There was something about encountering midwifery at 5:30 a.m. in the kitchen that made me ponder death – not in a scared or sorry way, but in that offhand midwife way: with gentle concern for those who might not have thought it all the way through, who will then be overwhelmed by all the structures and institutions (emergency room, intensive-care-unit, funeral home, church, cemetery) sweeping into their lives, alienating them from the process. Also, like a midwife, with awed respect for the transfiguration of bodies and lives taking place among those who are dying and those at their sides.

I remember, as a young mother, laboring through the quiet night, buoyed by the sudden awareness that everywhere, all over the world, there were many other women just like me, laboring in dark houses, a literal thousand points of light, little candles in windows all across the land, grappling individually with raw, powerful life, along with those at hand, at the bedside, all our helpers giving help. “Midwife means with-woman,” as the old bumper sticker used to say.

And I remember walking the quiet, dark hospital halls as a young doctor-trainee, proceeding from one nurse’s station to another, checking in, where the nurses all sit quietly in front of the monitors, with their pens and charts and cups of coffee, keeping watch through the night: midwives of the dying, often: watching with care, getting up to help when they’re called, demonstrating with calm and gentleness to the frightened, grief-stricken family that there is nothing to fear, and much to love. Whole hospitals full of quiet, watchful nurses, settled in for the long haul.

That might not have been your experience of death in the hospital, especially if you were there mainly in the daytime and evening. Corporate medicine is committed to making large profits, and one fundamental way they do it is by minimizing the number of nurses available to care, help, attend, and watch. In the daytime – and at night, too – nurses are assigned more patients than they can manage, and it is by design.

One outcome is the high incidence of chronic stress-related illness among nurses. Another is the feeling, among families, that nobody really understands, or cares, and some are permanently scarred by that perception. But if you walk around the sleeping hospital in the night, you learn different.

Organize your core group of helpers for the crossing; those who will help at the time just after death, and those who will help over the stay at home. If possible, meet with everyone to share your purpose around this event. It is important to feel comfortable with each other – you will be doing a great service together! …Allow all concerns to be voiced. The act of caring for our own at death is not difficult, but it does take a certain determination as well as occasional physical strength to make it happen. Most people who are hesitant will rise to the occasion as they experience the dignity and grace involved. –from the Crossings resource guide

When I was a young mother, many decades ago, we started staying home to have our babies, due to fear and loathing of the assembly-line medical management of childbirth, which does such damage to bodies and minds in the name of control, enforcing predictability, by means of intervention, in the face of a kind of chaos. We asserted that what seemed chaotic was actually natural and normal, not dangerous, though not easy – part of life.

So now we have midwife care teams, specialized in birth at home. They trust the process; they teach us to do so.

People want to stay home to die – I am talking about expected deaths, not sudden unexpected catastrophes. People have terminal cancer, people have “the failures” – kidney, heart, liver, etc.; people have “Old Timer’s disease” and “the dwindles.” They dreamed of staying home to die more or less peaceably and may have discussed it with loved ones; it is not a controversial concept.

Yet, somehow, people still end up in the hospital. Mom struggles to breathe, so of course you call 911. Dad starts throwing up blood, so of course you get to the Emergency Department as fast as you can. Even though they wanted to die at home.

That’s how it would be with birth, too – if you never had any helpers or midwives, when active labor set in, you’d also head for the car. Homebirth midwives stand by as guardians and guides of the normal, and they assume responsibility, and assist the transition to the hospital, if true need for medical intervention arises. They don’t gratuitously take someone to the hospital just because they feel a sense of urgency and don’t know what else to do.

When homebirth midwives are gauging the situation, determining how much or how little hovering they should do, much of the discussion is about “active labor.” Because it’s not until active labor that you really begin to require assistance, and only active labor keeps progressing, until birth is achieved. Early labor – “latent,” “prodromal” labor – is exciting and challenging, but it comes and goes, and its presence doesn’t signify how long it will be, before the going gets tough and completion is near.

This is also true of dying. Doctors and nurses try to assess “active dying”; it is where the final transition becomes clear, but because we don’t understand it well, it is not obvious. The body and spirit actively, visibly withdraw from the world, but we don’t want to misjudge what we are seeing. It may last for a long time, or or may go very quickly, but it only has one outcome.

We don’t have a word for “early dying” – latent dying? Prodromal dying?

My father recalls that his grandmother’s wake was a family affair, carried out at home. Her body was prepared (washed and dressed) by the women of the family, a casket was procured from a local woodworker, food was organized and provided by family and neighbors and his grandmother was ‘laid out’ or ‘waked’ in the parlor.

He’s always talked about ‘a plain pine box’ for himself, but we talked seriously about his own funeral arrangements last summer. He joked, at first, about wanting one of my burial shrouds but then made it clear to my brothers and I that we were to call the local funeral home and have them do “the same as they did for your mother.” The standard procedure. Embalming, limited viewing hours, a metal casket, a Catholic mass, and burial in the local veteran’s cemetery. I wanted to ask him ‘what happened to doing it all at home?’ But it seemed like too loaded a question. –Marian Spadone

“Early dying” is heart-wrenching and frightening and intense – think, for example, of finding out, explaining to the family, that the cancer is back, the surgery didn’t work, the damage is too great to ever be cured – but we, the ones at the bedside and the one in the bed, undergo a qualitative, quantitative change during active dying. Active dying is irreversible, but easily obscured and confused, messed up and rendered ugly and upsetting, by the huge amounts of medical intervention that usually swoop in at just this time. (That used to be true of active birthing, as well.)

Interestingly, there are vast armies of doctors and nurses staunchly against such interference in the process, unless it can literally save a person’s life. For example, I know a nurse who has “DNI” and “DNR” tattooed over her femoral veins, in each groin – “Do Not Intubate” and “Do Not Resuscitate,” right there where emergency teams normally insert large-bore IVs in advanced life-support. She says, if her condition is bad enough to need femoral IVs, then she only wants morphine and blankets. Did she discuss this with her family? You bet she did. Why? Because she is a critical-care nurse, and she has presided at many messy, terrifying, futile, medicalized deaths.

“I live in a part of the world where people are particularly aware of the opportunity that comes at the end of life. In Viroqua, my tiny southwestern Wisconsin town, we’re changing the way we honor the process of death… Death is one of life’s most important moments. We only get one shot at it… Someone will wash the body. Someone will dress the body. Someone will close the eyes for the final time. Someone will. At the critical moment of death, someone will perform these tasks for the person whom we have loved and cared for all our lives. Why would we give those meaningful rituals away to a stranger? …We need not let fear of the unknown keep us from what often turns out to be one of life’s richest moments.” –Anne O’Connor, Threshold Care Circle

My daughter, the homebirth midwife, says she promises to provide midwifery care, not just homebirth care. She brings all of her skill, experience, and education to care for the family throughout the childbearing cycle, including when/if it turns out that birthing in the hospital is medically necessary; her promise, her guardianship extends beyond the mere place of birth.

We need midwives and doulas for the dying cycle as well – midwives and doulas who can help the actively dying person and their loved ones determine whether medical intervention will actually save life, how “passing away” at home can be pain- and terror-free, and how to negotiate, how to navigate the crossing, including what is to be done with the body and spirit and all that is left behind.

With birth, everybody knows there are options: home, hospital, birth center; midwife, doctor, unassisted. Regardless of which options they personally find best, safest, most aesthetically pleasing, most meet and right, most practical, they are aware that options exist and are chosen by various kinds of folks very routinely. The same should be true of dying.

We have “childbirth education” classes, to help people decide on and prepare for the best kind of birth they hope (in the absence of unforeseen emergencies), to have. We have such classes despite the fact that birthing is one of the more taboo, private, intimate acts in our culture. We have them so that young mothers and their helpers can “Build Your Birth Toolkit” (the name of the class my daughter teaches), with illustrative stories of many different options, customs, and outcomes, and networks of resources to help, and realistic information about the anatomy, physiology, and pharmacology involved…

The same should be true of dying. If I am diagnosed with serious-probably-terminal illness – if I’m so lucky as to have a physician who works at prognostication (though doctors are not taught this), and have an idea of how much time (years? months? weeks?) I may have – and if, like most people, I inhabit a world of complex social and emotional relationships with people nearby and far away – then I and my potential helpers could use some kind of Death Toolkit – despite the fact that dying is one of the more private, intimate, taboo acts in our culture.

What makes a death doula different from a hospice nurse is that a death doula doesn’t administer medicine or perform medical procedures… The death doula will remain – if the family wants – after the client dies to help with the funeral, which often is carried out in a place other than a funeral home.

…”When you get caught up in grief and losing someone and all of that is going on, you need help,” she said. “A hundred years ago, this is something that would have happened automatically. If I’m assisting in a death passing, what I’m really doing is assisting the soul to birth its new life – and that’s such an honorable, necessary thing.”

You have entered the liminal space now, and worldly considerations have no meaning or weight here. There is just the grace. You are aware that you are all held in a state of grace. As if from some signal, you find yourselves each with both hands resting on some part of the body of your friend, including the head and the feet, and one of you begins to sing. It’s a song that your friend loved and sang often and you are all comforted by singing it together. Many tears flow, but no one is ashamed. It just feels right. –Marian Spadone

Resources:
A Fine Farewell, by Marian Spadone and associates, Portland, Oregon
Natural Burial Company, by Cynthia Beal and associates, Eugene, Oregon
Cornerstone Funeral Services, by Elizabeth Fournier and associates, Boring, Oregon
A Sacred Moment, by Char Barrett and associates, Seattle area
State laws, with links
Oregon laws around funerals
Oregon Law in re: right to control disposition of remains
Oregon State form you fill out, to appoint someone in charge of your remains
Ask a Mortician: videos by Caitlin, of Order of the Good Death
A Family Undertaking, PBS documentary, available on Netflix & elsewhere

Fair Use of copyrighted works on this page for educational purposes does not imply any authors’ agreement or endorsement of any of my sentiments in any way.

Listen, I tell you a mystery: We will not all sleep,
but we will all be changed. — 1 Corinthians 15:51

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Babies’ and kids’ ear infections – new guidelines

By | March 9, 2013

Updated ear-infection guidelines from the American Academy of Pediatrics! Illustrated with ear-exam dos and don’ts.

What is the definition of AOM (acute otitis media, middle ear infection)?
–Fluid behind the eardrum, causing immobility of the eardrum, seen by puffing air out of and into the ear canal, with a good seal (pneumatic otoscopy).
–Severe eardrum bulging with a cloudy appearance
–Or new ear discharge not caused by an infected ear canal
–Or mild eardrum bulging and dullness with ear pain (ear holding, tugging, or rubbing, crying) for less than 48 hours
–Or intensely red (“hemorrhagic” appearing) eardrum.

WRONG. Nobody is holding the baby, who is going to raise hell when that thing touches the ear canal. The practitioner isn’t bracing his/her hand against the baby’s head to “shock absorb” the ear scope and prevent injury when baby raises hell.

How to prevent:
– Mother’s milk only, for the first 6 months or more. Any formula use at all doubles the risk of ear infection.
– Pneumococcal vaccine before 2 yrs old. (Older “7-valent” vaccine reduced ear infections caused by pneumococcus 29%, reduced doctor visits for earaches 40%. No data available yet for newer, broader-spectrum “13-valent” vaccine licensed starting in 2010.) (Note: the “non-typeable” Haemophilus influenzae bacterium causes AOM, but is not prevented by the HiB vaccine.)
– Influenza vaccine yearly (reduces ear infections 30-55%, because many of them follow after the flu).

WRONG. Also not bracing hand! Kid’s gonna squirm if it tickles, and the ear scope could cause injury. Additionally, not straightening the ear canal by gently pulling on ear, to visualize eardrum. Gazing from a foot away. Actually just pretending to perform an ear exam. If your practitioner does this, tell their teacher, because they surely are a brand new student.

WRONG. Holding child’s hands but not her head, and not communicating with her; child, obviously angry, is going to flinch. Looking from TWO feet away provides a crappy exam. Does the practitioner fear the patient? Is that the mom holding her, or a stranger? I’d be angry, too.

Management
All kids over 6 months old, severe:
– Severe symptoms in one or both ears (moderate or severe ear pain, OR ear pain for 48 hours+, OR temperature at least 102.2F/39°C): Give antibiotics for ten days.
– Treat pain with acetaminophen +/- ibuprofen. No ear drops.

6 months to 2 years, non-severe:
– Non-severe symptoms, but both ears are infected: Give antibiotics. Treat pain with acetaminophen +/- ibuprofen.
– Non-severe symptoms in one ear:
Watchful waiting for 48-72 hours from onset. Treat pain.
Antibiotics for ten days, if no better, or if worse, after 48-72 hours. Treat pain.

Older than 2 years, non-severe:
–Watchful waiting for 48-72 hours from onset. Treat pain.
–Antibiotics if no better, or worse, after 48-72 hours. Treat pain.
–Give antibiotics for seven days for ages 2-5, and for five days for ages 6 and up.

RIGHT. This practitioner is up close and personal. She has braced her hand, straightened the canal, and like a boss is also holding an insufflator (blue bulb) to check eardrum mobility – which she undoubtedly remembered to squeeze BEFORE inserting the scope – not after… Okay, the blue part might just be her uniform. You’d have the bulb in the other hand.

What antibiotic?
–Amoxicillin,
UNLESS the child already received it within 30 days,
OR has crusty, pus-y eyes too (“otitis-conjunctivitis syndrome” often caused by “non-typeable” H. influenzae bacteria, which makes beta-lactamase enzyme and so is resistant to plain amoxicillin)
OR is allergic to penicillin (rapid development of skin rash, swelling, and/or wheezing).
– Re-examine and change antibiotic if no better, or worse, after 48-72 hours.
–See below for antibiotic details.
– Some antibiotic liquids are bitter. If you use cefuroxime, cefpodoxime, or clindamycin, ask to have it made with chocolate flavoring. Strawberry is an okay second choice.

RIGHT. Also well done – up close and personal, braced and straightened, and the patient is consequently being patient. Bonus points if the practitioner brushed his teeth after that last cup of coffee.

Recurrent ear infections:
– See above for diagnostic criteria. Persistent ear fluid alone does not need treatment (see below).
– Ear tubes (“tympanostomy tubes”) may be indicated. Do not give continuous or long-term antibiotics.

Persistent ear fluid:
– Is NOT the same as an ear infection. It takes time for the fluid to be reabsorbed.
– 60-70% of children still have fluid in the middle ear at 2 weeks after cure of infection.
– 40% have fluid in the middle ear at 1 month.
– 10-25% have fluid in the middle ear at 3 months.
– No treatment is necessary. It goes away by itself.

RIGHT. Lady is holding child’s head flat against her chest so he doesn’t thrash around. You can barely see that the practitioner has steadied his hand against the lady’s hand, and is also straightening the canal. He probably should have taken off his forehead reflector first, but he’s an ENT (ear-nose-throat doctor), and has likely forgotten he’s wearing it.

Arms are for hugging:
…especially during an ear exam. How to do it:
1. Sit facing the practitioner, with your child seated sideways across your lap.
2. Tell your child it’s time for a big hug. Place your lower arm across the child’s body, gently pinning their arms underneath. Place your hand on their head, gently pinning the side of their head against your chest. Turn your face the same direction as theirs, so you can whisper to them. Suggest they listen to your heart beating. Hold them absolutely still, so the practitoner can work swiftly and painlessly.
3. Let go of the child’s arms and head, and catch your breath. Turn them around on your lap, facing the other way. Time for another hug. Repeat the process.
4. This technique is easiest if your lower arm comes around the child’s body from in front of them, and your upper hand comes from behind, to hold their head flat against your chest, without obscuring their vision (opposite of the photo above, actually). However, there isn’t any wrong way, as long as you focus on hugging, rather than gripping or grabbing.

RIGHT, though a bit odd looking, because he is using an old-school operating otoscope. It has a lighted magnifying glass separated from the speculum (earpiece), to allow room for instruments. Those puppies take D batteries – heavyweight! – and make your hand tired. However, he’s clearly an old pro, accustomed to holding a baby’s head still with a single pinky finger on the wee jawbone, which doesn’t stimulate the rooting reflex as much as on the cheek. You can barely see his other hand straightening the canal. (The offscreen nurse appears superfluous here – she just wanted to touch the baby’s curly head, I think.) If a caregiver can’t hug the baby still for an ear exam, then lying down is the way to go, possibly gently leaning your elbows on a baby blanket that holds down those little fists.

Recommended Antibiotics

Initial Antibiotic Treatment:
Amoxicillin (80–90 mg/kg body weight, per day, in 2 divided doses)
Amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) [amoxicillin to clavulanate ratio, 14:1]

Alternative Initial Treatment (if Penicillin Allergy):
Cefdinir (14 mg/kg per day in 1 or 2 doses)
Cefuroxime (30 mg/kg per day in 2 divided doses)
Cefpodoxime (10 mg/kg per day in 2 divided doses)
Ceftriaxone injection (50 mg IM for 3 d)

Second Antibiotic Treatment (after 48–72 hrs of failure of initial antibiotic):
Amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses)
Ceftriaxone (50 mg IM or IV per day for 1 or 3 d)

Alternative Second Treatment (if Penicillin Allergy):
Ceftriaxone, 3 days
Clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin
Clindamycin (30–40 mg/kg per day in 3 divided doses) plus third-generation cephalosporin
Tympanocentesis (ear tube a.k.a. “grommet”)
Consult specialist

Notes:
– Macrolides (erythromycin, azithromycin) do not work well against the bacteria that cause AOM (non-typeable H. flu and S. pneumo).
– Clindamycin doesn’t work well against H.flu.
– Although one shot of ceftriaxone is approved by the FDA for the treatment of AOM, more than 1 shot dose may be required to prevent recurrence.
– Some children with persistent symptoms after 48-72 hrs of initial antibiotics may have combined bacterial and viral infection.

References:
http://www.medscape.com/viewarticle/779817

http://www.healio.com/pediatrics/practice-management/news/print/infectious-diseases-in-children/%7B415f5e73-779e-48cb-96c9-2ea8adb0bf9d%7D/pneumatic-otoscopy-an-old-diagnostic-tool-revisited

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Adventures in independent practice*

By | February 11, 2013

It’s been four months since I went fully independent. By this I mean, since I started working directly for my patients, and not for anybody else. The benefits, for me and for my patients, have been considerable.

For example, my office visit fee is no longer based on how insurance companies value my services, but is based on my informal nationwide survey of family and friends, of what they think is fair to pay for a doctor visit.

My old fee schedule that I wrote in 2009 (and never revised), for example, included a $276 visit for a new patient with multiple or complex issues. The cheapest visit was $119, for an established patient with a simple issue. (Insurances think these visits should be 45 and 15 minutes, respectively. I ignored that; as you know, all my appointments are 60 or 30 minutes long.) I used to give 30% off for out-of-pocket payors. This made my cheapest visit – if, and only if, a patient paid out of pocket for a simple medical issue – was $84.

Insurances think this is fair, for primary care. (Specialists charge more. For example, one local pain specialist charges $500, flat, for a first visit. Numerous patients have told me they were billed $350 for a 15-minute cardiology appointment. Last year, I myself paid $442 for a rheumatologist visit. Et cetera.)

As a patient, you either pay the high corporation-based fee to your doctor directly, because you don’t have insurance, or can’t afford good insurance (example: $10,000 deductible). If you have employer-based health insurance, you pay it in premiums – as well as working harder and earning less at work, because your employer goes along with what the insurance corporation wants, too.

It was a great moment when I realized I didn’t have to value my work according to what the insurance corporations said. (I felt rather foolish for not having seen this before.) I looked at what other independents around the nation were charging, and I asked my patients and my friends and family what they thought was fair, and what they would be able to afford, to go to the doctor. The consensus was, $50-75 dollars. (One friend said that if a doctor visit cost that much, she and her husband could both see a doctor, instead of trying to decide which one of them could.)

I picked $60. It makes my yearly income about the same as a high school math teacher’s, which I consider fair. (Please don’t ask about my student loans, however.)

This means I lowered my fees by a range of about 1/3 (from $84 to $60) to 3/4 (from $276 to $60). Another way of looking at it is, my prices fell from “gouging the sick and injured” to “feasible for an ordinary person.”

$60 is:
~~ a tank of gas
~~ one ticket to a Ducks game
~~ a month of cellphone service
~~ a carton of Marlboros and a case of Pepsi
~~ getting your hair done in a salon (perm, partial weave, or color)
~~ a single session of massage, acupuncture, reiki, or psychotherapy
~~ dinner and a movie for two
~~ new shoes

…I think $60 for an hour with a skilled medical professional is reasonable, relatively speaking.

However, a few insured folks have been disconcerted by my universal out-of-network status.

There are two kinds of conversations I’ve had about this process, that have made me a little sad. The first is when people say, “I already pay too much for my insurance; why should I have to pay again?”

To me this is just an arithmetic problem. When you used to go to the large group practice, you waited for an hour in the waiting room (did you need a day off work, or a babysitter?); you might or might not have even gotten to see a doctor; you got ten minutes of care (and the practitioner did most of the talking); you didn’t have time to get the uncomfortable details of each of your problems discussed; and of course you had a $30 “co-pay,” required by the insurance that you already pay too much for; later, when the bill came, you were surprised by an additional 20% co-insurance. That’s 20% of the corporation-approved fee, of course. You may end up paying close to $60 for your “covered” visit.

This is usually the case even if you have good public insurance, like Medicare. You can easily end up needing three separate appointments to get your issues taken care of. For example, the doctor at the large group practice wouldn’t give you lab results, or change your medication, over the phone or by email – you had to make another appointment to get results, change dosages, or get a refill. Or the doctor prescribed something you can’t afford and that your insurance doesn’t cover; you decide either to schedule another visit, or do without. (Most of my patients manage most of these problems by calling my cellphone or by email.)

Over the course of a year, even with the free “preventive” visit your insurance corporation was forced by law to provide, it adds up, in my opinion, to very close to $60 per visit, or more.

The second kind of conversation goes, “You don’t accept insurance/ Medicare/ OHP?” or “I can’t see you because you don’t accept my insurance.” This hits more of an ideological nerve with me. You don’t even know it, but the word “accept” bugs me.

The implication is that those other doctors – who contractually provide only the kind of doctoring the insurance company agrees to – they’re more… accepting. It seems that no matter how many times I point out that I accept patients, but don’t work for corporations, people still vaguely feel that I’m somehow rejecting them or shutting them out. They identify themselves with their insurance.

In general, people tend to psychologically identify themselves with necessities they have to pay a lot for. The psychologist Leon Festinger showed this back in the 1950s, in experiments. For example, people who were made to do a very boring job for low pay, described the job as actually rather interesting and important. In another study, people who believed the world was about to end, only believed it more strongly when the world did not, in fact, end.

I think insurance is so expensive in so many ways for people, with so little observable benefit, that people tend to over-identify with it. They experience themselves as powerless to change it – they are passive participants. They worry about losing the small amount of “coverage” they’re able to obtain, for example by offending their insurance by seeking out-of-network care. They stay in jobs that are harmful to their physical and/or mental health, to “keep their insurance.” They stay in families and marriages that are harmful to their physical and/or mental health, to stay “covered.” They lie, misrepresent, and falsify the details of their lives, because they are afraid of “losing their insurance.” If they do “lose it,” they blame themselves, for making bad decisions, instead of blaming the corporations for unfairly profiting off of people’s vulnerabilities, including doctors’ psychological and financial vulnerabilities.

I say all this with love – as someone who has only had insurance, ever, a few times in my life: who’s felt the anxiety of not being “covered,” and the hopes dashed every time I was denied “coverage” again, due to “pre-existing conditions”; who’s sat in the Medicaid office time and again, and meekly agreed that, if by a miracle I were “accepted,” of course I could only see one of the special Medicaid doctors – and who’s unhappily searched for a doctor who “accepts my [crappy] insurance.” In the past, as both a doctor and a patient, I danced to the corporation’s tunes, in so many ways. Note: I worked harder, while the corporations got richer.

You may or may not be fully aware of how much you’re actually paying for your health insurance. As I mentioned, your employer can’t pay you as much, and can’t hire as many workers, so you have more work to do, rather than less, as you gain in seniority.

Your health insurance has raised your premiums and reduced their coverage over the last few years – because they can. But did you know they also have steadily reduced the amount they pay doctors, too? Your primary-care insurance contractor, in the large group medical practice, is an employee in the same predicament you are – not getting paid as much, and working longer hours, while their personal costs (student loan payments, malpractice insurance, etc) continue to rise.

One inevitable outcome is the ten-minute nurse visit, with the $30 co-pay, the hour-long wait, and the possibly-unnecessary “followup” visits, mentioned above. Or this:

“Abigail Lawrence doesn’t have health insurance… On advice from a friend, she checked into a ZoomCare clinic… where she could quickly come in for a 15-minute doctor’s visit. ZoomCare charges uninsured patients a flat $105 fee for a medical visit… She said it was odd her appointment didn’t include the familiar check of her blood pressure or temperature… Lawrence went to the free clinic… a few days later. She waited three hours to see anyone, but soon learned she had much bigger health problems… “One nurse took my blood pressure two or three times, not believing how high it is,” Lawrence said. Her reading was 209/143 mm Hg, much higher than the normal reading of 120/80 mm Hg.” ZoomCare reps explained that they don’t consider blood pressure checks routinely necessary. Note: $105 for fifteen minutes. She notes that, at the free clinic, she waited for three hours, to have this serious health condition detected – but it was free(ish).

Anyway… I’ve had a few people sadly say they can’t be my patient anymore, because they already pay so much already, they can’t justify paying still more, to a doctor who doesn’t accept their insurance. I review the arithmetic, so they’re fully informed, but naturally encourage people to seek the best care for them and their families – including helping them find a more appropriate primary-care physician for their needs.

However, over the past year that I’ve been discussing this with patients, I’ve been pleased (and not surprised) by how many folks, including those with red-carpet health insurance, say the opposite: “I’m so glad you’re doing this,” “I really agree with your style of practice,” and “I can’t believe you lowered your prices instead of raising them.” More than a few have said “You’ve got to raise your prices – I’m worried you won’t be able to stay in business.”

(I can stay in business, earning the same reasonable income as a high-school math teacher would, if everybody chips in their $60 a visit – unless there’s some misfortune related to student loan payments in the near future.)

As a matter of fact, I’d like to give a shout-out to the handful of patients who, over the past few months, independently and unsolicited, added on a “tip” to help provide free visits for other patients. Two of you each handed me $100, and four others gave an extra $40, $50, $25, and $15, on top of your office fee – explicitly to make sure that someone out there, who thought they couldn’t afford it, could come in and receive care.

The funny thing is, of course they “always-already” can come in – nobody has ever been denied attention because they didn’t have money or owed a bill! What you generous people were actually doing, though none of us thought about it that deeply at the time, was encouraging me, and everyone who hears about it – affirming, to all of us, that reaching out, to people who are sick or in trouble, is, in fact, not just the right thing to do, but is sustainable, in community.

And for that – I thank you.

*This post features Google images found by doing a search on the words “independent practice”! Funny, eh?

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Sinus infection? Beware…

By | February 9, 2013

FYI: The official guidelines of the ear-nose-and-throat doctors (otolaryngologists) regarding “sinus infections” are posted here. They discuss the “ten-day rule” (see below) and note that we do not do x-rays, CTs, or any other imaging for uncomplicated acute sinus infections lasting less than twelve weeks.

Why? Because “sinus infections” are overdiagnosed and overtreated, contributing to the evolution of antibiotic-resistant bacteria. For example, we’ve known for a long time that the vast majority of recurrent “sinus headaches” or “sinus infections” are actually migraine headaches. Yes – migraines can cause stuffy nose, watery eyes, and localized facial pain.

Most true sinus infections are viral, and are associated with a viral cold. After a week of feeling miserable, you might go to the doctor or the urgent care and get antibiotics (which don’t work on viruses). Lo and behold, after 2-3 days of antibiotics, you feel better. This does not mean the antibiotics “worked,” if you had a virus. It means that after 10 days, you recovered from your cold.

Hence the “ten-day rule.” A bacterial sinus infection can’t be diagnosed until after 10 days of persistent or worsening symptoms (see below) – particularly the “secondary invader” kind of situation, where you were recovering normally from your cold, but then developed sinus symptoms that persisted or worsened for more than ten days.

(Only 0.5-2% of viral infections develop “secondary invader” bacterial infections. About one in a hundred!)

What counts as “symptoms”? First of all, a sinus infection isn’t merely annoying: having an infection in your sinus makes you SICK. The ENT doctors say, “Purulent nasal discharge… Nasal obstruction… Facial pain-pressure-fullness.” Interestingly, this consensus statement did not find fever (>101F) especially diagnostic – but I think it’s safe to say that fever is often present, when a sinus is infected. In most cases, a single sinus is involved – only one side of the face is affected.

What is “purulent discharge”? When the immune system fights off an infection, it produces pus – dead immune cells. (Please excuse my military-industrial metaphors of production and warfare – that’s the way medicine talks these days.) Your doctor should look up your nose and see pus coming out of the sinus opening on the affected side. Note, however, that the immune system is active whether the germ is a virus or a bacterium, so the presence of pus doesn’t automatically mean antibiotics would be effective. The ten-day rule applies, regardless of the quality of mucus.

What about blood? Not usually significant – unless it’s a truly dramatic loss of blood. Blood-streaked mucus or small clots don’t correlate to severity of infection.

At this time of year, many folks have some minor nasal bleeding, due to the dry air from indoor heating. The delicate tissues get dried out and can spontaneously leak a little blood. If this happens at night, it can run down the throat, and when they wake up, they’re worried that they’re “coughing up blood.” (However, it is not the same as a lung hemorrhage, which is profuse.) When they blow their nose, blood mixed with mucus comes out. It doesn’t mean that blood came from inside the sinus!

Lots and lots and lots and lots of people in the US believe that they as individuals are particularly prone to sinus infections*, or that they have been cursed with an unusual number of sinus infections, mainly because they have been given antibiotics (and the diagnosis) over and over again, and have “always gotten better with antibiotics,” as hundreds have told me.

However, in many cases, they actually had sinus and nasal discomfort due to an upper respiratory virus, that persisted over a week at a stretch. Yes, they can be severe. Yes, they can make you miss work or school. But no, they don’t require antibiotics. And no, Dr. Leigh is neither cruel nor incompetent, when she denies antibiotics without evidence of bacterial infection.

I’ve never left anyone high and dry regarding symptoms, however!

Please see my handout containing natural home remedies.

I do recommend taking acetaminophen and ibuprofen for pain; there is no need to suffer, while you wait for your bold and dauntless immune system to “wipe out” the “invaders.” I do not recommend decongestant nasal sprays containing oxymetazoline, or pills or syrups containing mixtures of doxylamine, phenylephrine, dextromethorphan, and/or diphenhydramine. When you have an extra twenty minutes (or happen to be in the office), I’ll tell you why. (I also don’t recommend you waste your money on “Emergen-C,” when you can take a Flintstones vitamin and drink a glass of Kool-Aid instead, and get the same effect, for a quarter of the price. Just saying.)

On the other hand, I frequently advise: use a neti pot with salt water, once or twice a day – do an herbal facial steam, with peppermint or other teabags, four times a day – nap on and off all day – run a humifier in your room at night – don’t forget to wash your hands a lot – put store-bought or homemade vapor-rub on your chest and throat – lie down under quilts, and and keep warm – use expectorant herbs like horehound and osha – wash your hands after you touch your face – thin out the mucus with simple over-the-counter guaifenesin syrup or pills – try honey-onion syrup: super easy to make – take long hot baths and showers – stay home and just sleep – wash your hands often, or use hand sanitizer – make chicken soup, adding garlic and black pepper – put hot-damp towel-packs on your face – avoid caffeine, nicotine, and alcohol – wash your hands – drink miso soup with ginger, and eat hot spicy ramen – you could try a simple antihistamine, if allergies are acting up – call in sick, and plan to rest on the couch for 3 days solid – sleep sitting up on a million pillows – drink hot yarrow tea (it tastes bad, but it helps)… and other stuff.

It may well be, however, that the main thing you need to do is get out of your own way, and let your body do its work.

The biggest problem I have as a physician, with “sinus infections,” head colds, “stomach flu,” or anything else, is convincing people to stay home and rest. Stay home and rest, rest, rest, rest. It is NOT better to take antibiotics so you can get right back to work (especially when the odds are slim that your condition is bacterial), instead of resting.

Oh, and another thing: wash your hands.

*The definition of chronic sinusitis is lasting more than twelve weeks. This is usually due to an anatomical issue that requires careful evaluation, usually by a specialist.

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S A D

By | February 7, 2013

I’ve been talking to a number of folks about Seasonal Affective Disorder, a syndrome in which you get the blues in the winter, and about using light therapy (light that shines, not like ‘lightweight’). I told them I’d follow up with more data. Here they are – along with some words on the subject (below) from Emily Dickinson (American poet and SAD lady, 1830-1886).

NAMI (National Alliance on Mental Illness) says:
“Symptoms of winter SAD usually begin in October or November and subside in March or April… Most patients don’t feel fully back to normal until early May… The usual characteristics of recurrent winter depression include oversleeping, daytime fatigue, carbohydrate craving and weight gain, although a patient does not necessarily show these symptoms. Additionally, there are the usual features of depression, especially decreased sexual interest, lethargy, hopelessness, suicidal thoughts, lack of interest in normal activities, and social withdrawal.”

There’s a certain Slant of light,
Winter Afternoons –
That oppresses, like the Heft
Of Cathedral Tunes –

Light cafés have taken off in Sweden, which has nearly a million SAD sufferers… Stockholm, for example, gets only five hours of daylight in the winter months. But the city’s commuters can stop off in cafés, such as the Iglo, and sit bathed in UV-free lighting to the strength of 3,000 lux (the technical measure of brightness). This intense light, which compares with the 200-500 lux emitted by domestic or office lighting, simulates natural light and is thought to correct the hormone imbalance that causes SAD.”

Heavenly Hurt, it gives us –
We can find no scar,
But internal difference –
Where the Meanings, are –

“The pathogenesis of SAD is not well understood. It is believed that the decreasing daylight available in fall and winter triggers a depressive episode in people predisposed to develop the disorder… The hypothesis that appears to have most support involves the neurotransmitter serotonin. Evidence supporting this hypothesis includes:
Studies have found a decrease of central serotonergic activity in patients with SAD.
Serotonin appears to play an important role in the mechanism of action of light therapy.
…Variation in levels of serotonin transporter binding protein with season and duration of daily sunshine were found in healthy adults. Higher levels of the transport protein were found in the fall and winter, and associated with lower synaptic serotonin levels.”

None may teach it – Any –
‘Tis the seal Despair –
An imperial affliction
Sent us of the Air –

“Light therapy uses a lightbox which emits far more lumens than a customary incandescent lamp. Bright white “full spectrum” light at 10,000 lux, blue light at a wavelength of 480 nm at 2,500 lux, or green (actually cyan or blue-green) light at a wavelength of 500 nm at 350 lux are used, with the first-mentioned historically preferred.

“Bright light therapy is effective with the patient sitting a prescribed distance, commonly 30–60 cm [1-2 feet], in front of the box with her/his eyes open, but not staring at the light source, for 30–60 minutes… Discovering the best schedule is essential. One study has shown that up to 69% of patients find lightbox treatment inconvenient and as many as 19% stop use because of this.”

Here are some things to think about when buying a light box:
Is the light box made specifically to treat SAD?
…How bright is it? …It may be effective to use a light box that produces 10,000 lux.
…How much UV light does it release? Light boxes for seasonal affective disorder are designed to filter out most UV light, which can cause eye and skin damage… LEDs are also more efficient and lighter weight than standard lights, and appear to work just as well.
…Does it emit blue light? White light is the standard type of light used in light boxes. But some light boxes give off blue light with a shorter wavelength. Some research shows blue light may be slightly more effective… Blue light may pose a greater risk of harming your eyes than does white light. To help reduce this risk, don’t look directly at the light source in any light box.
…How much does it cost? Prices vary.

Here are some examples. Every one seems to get mixed reviews.
$58: click here
$71: click here
$128: click here

“Researchers at more than 15 medical centers and clinics in both the U.S. and abroad have had much success with light therapy in patients with clear histories of SAD for at least several years. Marked improvement is usually observed within a week, if not sooner, and symptoms usually return in about the same amount of time when the lights are withdrawn. Most users, therefore, maintain a consistent daily schedule beginning, as needed, in fall or winter and usually continuing until the end of April, by which time outdoor light is sufficient to maintain good mood and high energy. Some people can skip treatments for one to three days, occasionally longer, without ill effect, but most start to slump quickly when treatment is interrupted.”

I say, go for it. Even if you’re a poet or any other sort of romantic, and you worry that you won’t be as creative without depression. You’ll work better if your brain works better.

When it comes, the Landscape listens –
Shadows – hold their breath –
When it goes, ’tis like the Distance
On the look of Death –

…After Dickinson’s death [at age 55], Lavinia Dickinson kept her promise and burned most of the poet’s correspondence. Significantly though, Dickinson had left no instructions about the forty notebooks and loose sheets gathered in a locked chest. Lavinia recognized the poems’ worth and became obsessed with seeing them published.

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back after a brief hiatus

By | February 1, 2013

Hello! Dr Leigh has been a little out of the loop! My computer broke, right in the middle of everything, last week. I was able to swiftly obtain a new computer, and got the electronic medical records restored from their backup version, that same night – but my troubles were not over. The new operating system did not look at all like the old one, and of course none of the programs I rely on were installed. Every day seemed to bring a new roadblock and/or work-around.

As I slowly, slowly, got the system back on its feet, I was also scrambling to keep up with the usual steady stream of emails, faxes, and voicemails. I thank all my patients for their patience!

In the meantime, as you know, the nation has had a shower of infectious diseases. The Angel of Norovirus passed through my household, but miraculously left me unscathed. (Now that I’ve said that, however…)

Like many doctors, I’ve spent a lot of time carefully questioning people for possible “red flag” signs, before advising them to stay home, drink tea, rest in bed, don’t share drinks, towels, or toothbrushes, and wait to improve. The doctor’s office is no place for sick people, ironically! With the flu, the norovirus “stomach flu,” and the common cold, the best place for you is home in bed, not at work, at school, or in restaurants and grocery stores.

I thought I’d post a few interesting health news articles I ran across during this time of computer and human plagues. They are from Medscape, and if you don’t have a login to the site, you might not be able to read them, so I’ve excerpted them here for your interest. You can read these while you lie in bed with Vick’s on your throat or a bucket by your side!

Why did your hospital run out of antibiotics?
Over the past few years, there have been unprecedented shortages of a large number of essential drugs, including chemotherapeutic agents… According to Physicians Against Drug Shortages, the blame can be laid firmly at the feet of group purchasing organizations (GPOs). The real reason for the current situation is that there is no free market for drugs, medical devices, or healthcare supplies in the United States… 6 senior Congressman are calling on the Government Accountability Office to investigate the role of GPOs in drug shortages.

…GPOs were created to leverage the collective buying power of their members, which include most of the nation’s hospitals… Six GPOs control about 90% of the products purchased by hospitals through such organizations, and 2 of them account for approximately two thirds of the products under contract… The fundamental problem is that there are not enough buyers and sellers, so the price is not a real price set by the market, but one that is artificially maintained.

…[Take, for example,] propofol, which is often used in the induction and maintenance of general anesthesia. Three years ago, propofol was manufactured by 3 companies, but Teva, the largest supplier, has stopped making it, explained Dr. Zivot [medical director of the cardiothoracic intensive care unit at Emory University Hospital in Atlanta, Georgia]. “The number of vendors gets whittled away, and what you are left with is 1 vendor who sells to a preferred buyer.” …Some of the shortages are not drugs at all, but basic solutions for intravenous therapy, such as sodium bicarbonate injection and sodium chloride 0.9%.

…GPOs have been investigated before. Since 2002, there have been 4 Senate Antitrust Subcommittee hearings, federal and state investigations, media exposes, antitrust lawsuits, and academic studies. The general consensus is that rather than saving hospitals money by purchasing in bulk, GPOs actually inflate healthcare costs.

Anatomy is density
California will soon become the fifth state with a breast density notification law… There is also a federal bill pending in the US House of Representatives…. However, some experts are concerned whether this type of legislation is ahead of the science.

In 2011, Governor Brown vetoed the bill, which was opposed by a number of professional organizations, including the California Medical Association, the Association of Northern California Oncologists, the American Congress of Obstetricians and Gynecologists, the California Radiological Society, and the Medical Oncology Association of Southern California.

However, at that time the legislation was supported by a number of healthcare-related groups, including the California Radiological Society, the California Nurses Association, Planned Parenthood Affiliates of California, the California affiliates of the Susan G. Komen Foundation, and the Breast Cancer Fund.

…Having legislation on this topic can have unintended consequences, according to Debra I. Monticciolo, MD, president and chair of the board of directors of the Society of Breast Imaging… “There are many questions around this topic, such as how to consistently and accurately assign breast density in the first place, and yet we have a law,” she pointed out. “It may be well intended, but it’s premature.”

A recent study of a breast imaging practice showed an increase of 3.2 additional cancers per 1000 women screened after the adoption of a breast density notification law in Connecticut in 2009 (Radiology. 2012;265:59-69). However, there was also a very high false-positive rate and a low positive-predictive value for biopsies.

…”What happens now is this study becomes a piece of data that people use to justify screening breast ultrasound, [said Carl D'Orsi, MD, from Emory University in Atlanta, Georgia]… I’m not saying the data should never be used; I’m just saying it’s a little early to make a law out of it,” Dr. D’Orsi explained.

Less is more – more or less
Men with localized prostate cancer who elect to have prostatectomy or radiotherapy will experience problems with urinary, bowel, and sexual function in the long term, according to a new study.

…”In the long run, there are not a lot of differences between the 2 primary treatments for localized disease, whether they are surgery or radiation,” [said] senior author David F. Penson, MD, from Vanderbilt University.

…”A significant proportion of these men are not going to die from their disease and I think if a man has low grade prostate cancer, these data should really make him think carefully before he signs on to have any surgery or radiation.”

…[James Mohler, MD, from the Roswell Park Cancer Institute, Buffalo, New York, and chair of the Guidelines Panel for Prostate Cancer of the National Comprehensive Cancer Network,] stated that the NCCN prostate panel is concerned that men with low-risk prostate cancer are being unnecessarily treated.

“It is estimated that between 40 and 50% of the men treated for prostate cancer in America don’t need to be treated, they would be better off with active surveillance or observation. Men need to understand that if you don’t need to be treated in the first place, you certainly don’t need to be treated unnecessarily with a treatment that is going to adversely impact your quality of life,” he said.

“We need a test that will distinguish the potentially fatal prostate cancer from the indolent prostate cancer, and we don’t have that,” Dr. Mohler added.

~~~

Staring out of the abyss?
For the second time, the US Supreme Court has agreed to hear a lawsuit that challenges patents on the BRCA1 and BRCA2 genes, which identify a higher risk for breast and some other cancers.

The court will attempt to answer an elusive and contentious patent-law question: Can a human gene can be patented?

Starve a tumor
For the first time ever, a randomized controlled trial that uses calorie restriction as a treatment for cancer – and measures a cancer-related outcome – was approved by the institutional review board at Duke University in Durham, North Carolina, and is on its way to the clinic.

…The approval at Duke comes when single-group studies of calorie restriction as a cancer treatment are being planned (in breast cancer at Thomas Jefferson University in Philadelphia, Pennsylvania) or are underway (in pancreatic and lung cancer at the University of Iowa in Ames).

…”Contrary to normal cells, most malignant cells depend on steady glucose availability in the blood for their energy and biomass-generating demands, and are not able to metabolize significant amounts of fatty acids or ketone bodies due to mitochondrial dysfunction,” [investigators] write. In other words, cancer cells thrive on glucose and starve on fats and ketones, which are food-derived energy units that are plentiful in low-carbohydrate diets.

…The Duke study will involve calorie restriction in men with prostate cancer… The participants will have “failed” primary therapy for prostate cancer, as evidenced by a rising prostate-specific antigen (PSA) score after surgery, and will have experienced disease progression… A projected 60 men will be randomized to either a low-carbohydrate diet (<20 g/day) or usual care.

...The planned trial at Jefferson will employ a different calorie-restriction strategy, according to Nicole Simone, MD, a radiation oncologist... "Early-stage breast cancer patients will undergo caloric restriction concurrent with radiation." ...In this case, the calorie restriction, which includes fasting, is expected to have a synergistic effect with an established treatment, explained Dr. Simone.

...The Jefferson study shares some similarities with research being conducted at the University of Iowa, in which calorie restriction (a ketogenic diet consisting of high fat, adequate protein, low carbohydrates) is being administered at the same time as chemoradiation in separate trials of pancreatic cancer and lung cancer.

Simple tape measure is the new bioelectrical impedance analysis
Combining a measure of central obesity with body-mass index (BMI) is better for assessing mortality risk in patients with coronary artery disease (CAD) than using BMI alone, new research shows.

…Those with normal BMI but central obesity – increased fat deposits around the waist, especially in relation to the hips… had, for example, a 61% increased risk of dying compared with those with a BMI of 30 and no central obesity.

~~~

Yucking your yum
Every year, about 48 million Americans – 1 in 6 – get a food-borne illness.
…Nearly half of illnesses were linked to produce… Leafy greens were most often involved… Norovirus was often the germ involved.
…Contaminated poultry was to blame for the most deaths, involved in 19% of fatal cases. Many were linked to listeria and salmonella infections. Together, meat and poultry were to blame for 22% of illnesses and 29% of deaths.
…Dairy and eggs accounted for 20% of illnesses and 15% of deaths.
…Fish and shellfish accounted for 6.1% of illnesses and 6.4% of deaths.

Public health kicks butts
Introducing laws banning smoking in enclosed public places can lead to swift and dramatic falls in the number of children admitted to hospital suffering asthma attacks, according to a study in England.

…Before the ban on smoking in enclosed public spaces was implemented in England, hospital admissions for children suffering severe asthma attacks were increasing by 2.2% a year… That trend reversed immediately after the law came into effect.

…A study published in 2009 also found the ban on smoking in public places in England led to a swift and significant drop in the number of heart attacks.

~~~

Bright futures
Some children with an accurate diagnosis of an autism spectrum disorder (ASD) may eventually “outgrow” the diagnosis and have normal levels of overall functioning that are within normal testing limits, new research suggests.

…Investigators are now reviewing records of the various types of interventions the children received and what (if any) role they might have played.

…[The lead author's] best guess, based on literature and her own clinical experience, is that between 10% and 25% of children lose their ASD diagnosis.

“But there really is nothing that’s clearly distinguishing these kids when they’re very young. You can’t do an evaluation on a child when they’re 2 or 3 and predict what will happen. So that’s a reason for providing the best intervention for everybody,” said [Deborah Fein, PhD, professor in the Department of Psychology and the Department of Pediatrics at the University of Connecticut in Storrs].

What ails you
Most patients without acute conditions see their physicians not because of diabetes, heart disease, or cancer but because of skin problems, joint disorders, and back pain.

~~~

No more phoned-in Vicodin
The FDA’s Drug Safety and Risk Management Advisory Committee voted 19 to 10 in favor of reclassifying hydrocodone-containing compounds from Schedule III drugs under the Controlled Substances Act to Schedule II.

~~~

Painkillers = car crashers
Drivers taking 20 mg of morphine or more per day, or the equivalent, are up to 42% more likely to be involved in road trauma than drivers taking the lowest doses of opioids.

…Investigators used various databases to identify claims for physician services, emergency department visits, and hospitalizations for injuries related to road trauma and for prescription medications dispensed to eligible residents. Opioids included in the study were oral formulations of codeine, morphine sulfate, oxycodone or hydromorphone hydrochloride, and transdermal fentanyl patches.

…Risk for road trauma did not significantly differ between those who initiated opioid therapy in the prior 2 weeks and those with longer-term use.

Marijuana research shocker: biased results
A landmark study suggesting a link between cannabis use and a drop in teenage IQ may not have gone far enough in its research, with any falls in IQ more likely due to lower socioeconomic status than marijuana, according to a Norwegian study.

…Early cannabis use is more common for people with poor self-control, previous conduct problems, and high scores on risk factors linked to low family socioeconomic status… Given these factors, young people from lower status families tended to end up in less intellectually demanding environments, whether by choice or by circumstance, which would increase the difference in IQ levels as they aged.

…”We don’t know how much of the change in IQ we can explain by differences in education, jail time, occupational status, etc and whether this affects the estimates,” [said the author].

~~~

This is your brain on the bench
An athlete with concussion should not return to practice or competitive play until all symptoms have resolved, in order to avoid the risk for further injury… A growing body of research indicates that concussion is followed by a period of increased vulnerability to repeat injury, and sustaining another concussion during this time has been linked to worse outcomes and irreversible damage.

…”There is no same day return to play for an athlete diagnosed with concussion,” the statement advises… The statement also notes that there is no evidence that equipment, including helmets or mouth guards, reduces concussion risk.

Dr Leigh told ya so
An independent panel has recommended renaming polycystic ovary syndrome (PCOS) and clarifying diagnostic criteria… PCOS affects 5 million women in the US. Symptoms include weight gain, acne, thinning scalp hair, hirsutism, oligomenorrhea, amenorrhea, infertility, and ovarian cysts, and it elevates risk for insulin resistance. Obesity exacerbates symptoms.

…The panel defined “specific phenotypes” based on having 2 of 3 conditions, or all 3: androgen excess, ovulatory dysfunction, and polycystic ovaries. Because the eponymous polycystic ovaries are not required for diagnosis, the panel advised replacing the name PCOS.

…[Timothy Johnson, MD, from the University of Michigan] pointed out, “The challenge is that patients come in through different doors. A woman with irregular periods and excess androgens wanting to get pregnant comes through the obstetrician’s door. Another patient goes to a dermatologist, not happy with excess hair. Yet another goes to her internist because she’s overweight and pre-diabetic. We need to recognize that this is a condition that can manifest in a number of different ways.”

…Treatment is symptomatic. It includes weight loss, antiandrogens, and medications for infertility and/or diabetes. However, injections of human chorionic gonadotropin (hCG) can lead to ovarian hyperstimulation syndrome (OHSS), which can be fatal in women with PCOS

~~~

Love Generation: alert!
The reactivation risk for human papillomavirus (HPV) infections may increase around age 50 years, when many women experience menopause, researchers report… Rather than HPV infections clearing within a year or 2, the virus can linger in the background at undetectable levels, striking later in life to cause disease.

…Among the study limitations is the inability to determine whether HPV detected at baseline was new, reactivated, or persistently detectable. In addition, sex steroid hormones may play a role in the ability of aging women’s immune systems to hold HPV infections in check.

…Long-term follow-up of previously highly exposed women who will transition through menopause in the next decade is urgently needed to accurately estimate the potential risk of postmenopausal invasive cervical cancer in the US baby boom population.

Nominee for best documentary feature
Dying cancer patients are less likely to want aggressive end-of-life care if they watch a short video about cardiopulmonary resuscitation (CPR) than if they simply hear about it, according to a new study.

“These are huge differences. You will die very differently if you watch the video than if you don’t,” said Dr. Angelo Volandes, the study’s lead author from Boston’s Massachusetts General Hospital.

[See the 3-minute video at http://www.acpdecisions.org/#&panel1-4]

~~~

Turn off your mind, relax, and float downstream
Mindfulness meditation techniques designed to reduce emotional reactivity also reduce poststress inflammatory responses and might be useful in chronic inflammatory conditions such as rheumatoid arthritis, psoriasis, inflammatory bowel disease, and asthma.

…The authors present a comparison between an 8-week mindfulness-based stress reduction program (MBSR) and an 8-week active control health enhancement program (HEP) that included walking, balance, agility, core strength, nutritional education, and music therapy in 49 community volunteers randomly assigned to 1 of the 2 groups.

The intervention and active-control groups had similar levels of stress-evoked cortisol response and similar reductions in psychological distress, but the group trained in mindfulness-based stress reduction had significantly smaller poststress inflammatory responses.

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Chronic pain: thoughts from Down Under.

By | January 21, 2013

A few brief pieces by David Butler, one of the top-notch researchers at the NOI group (Neuro-Orthopaedics International), based in Australia. These folks are research leaders in the field of chronic pain. Some of their work is counter-intuitive to old-fashioned ideas about chronic pain. Dr. Butler’s work on “Words That Hurt” is, in my view, very important to the work of starting to heal a sensitive nervous system, rather than merely anesthetizing it. Watch the videos at the end for advanced-level thinking.

“David Butler is a physiotherapy graduate of the University of Queensland (1978). He also has a graduate diploma in advanced manipulative therapy (1985), a masters degree by research from the University of South Australia (1996) and a doctorate in education from Flinders University (2010).

“He is the author of numerous book chapters and articles and the texts ‘Mobilisation of the Nervous System’ (1991), ‘The Sensitive Nervous System’ (2000) and a co-author of ‘Explain Pain’ (2003).”
His current work, and his colleagues’, are found at http://noigroup.com.
The articles below were found at the previous website, http://explainpain.blogspot.com.

Words that hurt
There is a rhyme from school that we all know. “Sticks and stones will break your bones but words will never hurt you”. I recall getting in a schoolyard fight and being called a “Fat pig.”

I don’t recall any pain from the fight but I still remember being called a fat pig and to this day, I know the person who called me that. This is Cartesian dualism in the playground – the split of brain and body. Words do hurt.

Experienced clinicians will know of many words that hurt. They come from imaging reports (e.g. rupture, compression, degeneration, arthritic), they come from clinicians (“You have the back of a 60 year old”, “You’ll be in a wheelchair,” “It’s bone on bone,” “You have the back of an 80 year old,” “It’s slipped out”), and it comes from the internet, neighbours and friends.

Some therapists have plastic models of the lumbar spine including ones with a plastic disc with a big red bulge on it – it’s quite scary and disc bulges are not like that, nor do they have to hurt.

These words and phrases hurt. They lift awareness of the painful part and strongly suggest that there is still damage and disease. This raises the levels of stress chemicals in the body such as adrenaline and cortisol which may make the sore area even more sensitive.

Words that hurt – Part 2
“Degeneration” comes up a lot, probably due to its frequent use in radiological reports and so does “crumbling”, reminding one responder of an Oxo [bouillon] cube. “Permanent” was another and a patient got “All seized up, be very careful” recently from a surgeon who should have known better. I can’t help smiling when a patient says “Its bone on bone in there” or throws the thick package of imaging studies on the bed, saying “There it is.”

Different professional groups have different harmful words. “Your child’s membranes are strained” and “There is a severe compression of the base of your skull” were sent by a therapist experienced with craniosacral techniques. Equally, any benefits from the current manual therapy focus on spinal instability could be negated, depending on how a person views the word “instability.”

Most clinicians have heard these and other terms (even “slipped disc” is still around) and are realizing the impact of the language.

Reflect… say a person is told they have “a degenerate L4 disc pressing on a nerve root and the thecal sac.” They will repeat that phrase many times and internalise it even many more times. Googling “thecal sac” will reveal that the problem is close to the spinal cord and notions of paraplegia may emerge.

When we can conceptualise that the “degenerate L4…” phrase is a brain construction held in motor, perceptual, emotional, planning and other brain areas, we may realize that it is not much different to how a learned limp is held in the brain. Just as most therapists would try and reduce the limp, a search for new, variable and more positive language is therapeutic. Or even better, could the health community avoid the exaggeration, crazy metaphors and even lies at first encounter?

But what about the muscles and joints?
A continuing discussion and a source of angst for some readers is the role of body tissues in a chronic pain state. The discussion on “words that hurt” may suggest that we think “it’s all in the brain.” This is not true. Many chronic pain states (eg rheumatoid arthritis, severe trauma) are constructed with very significant contributions from body structures such as joints and muscles. However the key thing is that bodily damage or changes do not necessarily have to contribute to pain production. The ‘degeneration’ reported on the X-ray simply does not have to hurt.

In cases of chronic pain where tests such as imaging, blood tests, and physical examination finds little to report, yet pain persists, it is quite possible that a process of central sensitisation exists — a very real, physical and increasingly understood process based on synaptic activity in the spinal cord and brain. It is the representation of the structures in the brain, rather than the actual tissues which are at fault.

However, in this state, while the tissues have been through an appropriate healing time, they can still contribute in the following ways:

– By being unhealthy, unfit, weak, unused and sensitive. But remember they have been through their healing stage of inflammation, cell proliferations, remodeling and repair, thus they can’t heal again, but they can get healthier and ‘fitter’.

– By being the recipients of the brain’s attempts to help out what it perceives are the problem areas by increased levels of stress chemicals, tight muscles and inflammation.

Every human pain state is constructed by varying contributions of the body tissues, the representation of the tissues in the brain, and the stress systems called upon to defend the injured tissues or the brain’s perception of the injury.

The vital reconceptualisation – ‘pain as input’ to ‘pain as output.’
“Pain as input” is the natural way to think. When we injure ourselves it seems that the “pain bit” is something organised at the injury site and pain then goes into the nervous system to warn the brain. This is “pain as input thinking,” but the idea is biologically bankrupt and likely to be troublesome for the management of chronic pain. “Pain as output” is a better and more scientific way to think.

There are no pain fibres in the nervous system. When injured, the nerve fibres send “danger signals” not pain signals towards the brain. This is just an increase in amplitude and number of impulses in some fibres (nociception). It is up to the brain to decide if these danger signals are worth listening to. If you have a mild ankle sprain, but you are trying to escape something or score a winning goal, the brain won’t be too bothered listening to the danger signals. However if you have a backache and you have just heard that serious kidney problems can cause back ache and you have a relative with kidney problems, the brain may be particularly attentive to the danger message coming in from the back.

Therefore, while the danger messages from damaged and diseased tissue can contribute to pain, they don’t have to.

We believe that a good way to help with this reconceptualisation is to consider the notion of threat. While we all know that pain has an emotional influence, “threat” is a wider and more overarching concept. Threats are held in the brain as old memories (“Oh no, I have damaged the back again”), made in the brain as the injury occurs (“How will I work next week”), and are in the environment (workmates, insurance). There are a massive number of potential threats. If the brain perceives threats and adds them up, sometimes including the danger impulses, pain may be constructed.

There is research which shows that if a noxious chemical is placed under the skin and you check the brain activation patterns it looks similar to if the noxious chemical was put in muscle. This research supports the idea that the tissue injured may not be such a big contributor to pain as most of us thought in the past. Finally, lets never forget phantom limb pain – there are no tissues to create a pain input and what must be the most maddening pain now exists in fresh air.

Other resources:
~~ Understanding pain in five minutes. http://www.youtube.com/watch?v=4b8oB757DKc
~~ A TED talk: Why Things Hurt, by Lorimer Moseley, a collaborator with NOI (5 min). http://www.youtube.com/watch?NR=1&v=gwd-wLdIHjs
~~ L. Moseley, The role of the brain in chronic pain (24 min). http://www.youtube.com/watch?v=RYoGXv22G3k
~~ David Butler, mirror therapy: Restructuring the brain to heal chronic pain (7 min). http://www.youtube.com/watch?v=hMBA15Hu35M

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How effective is the flu shot?

By | January 14, 2013

Please don’t interpret my remarks as being judgey or dismissive, regarding those who make a well-informed decision to not get vaccinations. I truly understand that each person makes the best health choices they can, with the best information they can obtain. Most of the folks I know, who choose not to get vaccinated, also responsibly try to prevent spreading infections though the community, by quarantining themselves and their kids when sick, and washing their hands (et cetera) when well. My purpose in these vaccination-related articles is to provide my interpretation of medical information I have access to – data you might not easily obtain, or have time to evaluate, otherwise.

There’s a meme going around, with various official-looking illustrations, which says that the flu shot is causing a flu epidemic. It’s the usual stuff. But back in the reality-based community, the early rapid spread of this year’s flu has given the CDC a very good estimate of what is actually happening.

5 testing sites are established across the nation: in Seattle, Washington; Marshfield, Wisconsin; the University of Michigan (Ann Arbor and Detroit); Pittsburgh, Pennsylvania; and Temple, Texas.

1,155 kids and adults who went to the doctors in these areas during this flu season – who were sick with acute respiratory infections suspicious for the flu (sick enough to go to the doctor) – were tested, using tests for the presence of influenza viral genetic material.

Warning: you can’t nail down vaccine effectiveness without using a lot of numbers. I often find large floods of numbers confusing and annoying – like the writer is trying to make the data seem more impressive than it really is. That’s not the case here. Therefore, I have added cute kittens to signal my friendly and benign intent.

Only 36% of all the sick kids and adults tested positive for the flu.
(64% tested negative. They were sick, but not from the flu.)

Of all the sick kids and adults who DID have the flu, only 32% of them had been vaccinated.
(68% who DID have the flu, had NOT been vaccinated.)
I repeat: of all the people with the flu, only a third of them had been vaccinated.

Take-home message:
Of all the sick kids and adults who did NOT have the flu, a bit more than half had been vaccinated, and a bit less than half had not. So it’s a coinflip whether the flu shot will protect you from NON-FLU viruses. Big surprise?

This may be what’s behind the hysterical anti-vax meme going around, which says, “Ask the sick people in your office if they got the flu shot! Most of them did!” …Not all acute respiratory viruses are the flu.

What about the “match” between the shot and this year’s viruses?

Remember that “the flu” can be any of a number of flu viruses, since it is a segmented RNA virus. This means its genetic material is is stored in bits and pieces that easily remix to form a new genome. RNA does not replicate as faithfully as DNA does, so “mistakes are made,” and this also contributes to a rapid mutation rate. This is why it is a big deal every year for the international flu-science crew to determine what strains might be best to immunize against.

(They also have to figure this out well in advance, because a large supply of the virus has to grown up in chicken eggs, so you need enough chickens making enough eggs, in safe and controlled environments, first. And it’s a lot of chickens/eggs, for the worldwide supply! After the virus is produced, it is killed ["inactivated"], so that only bits of it are presented to the immune system through the shot. It’s given as a shot, because it is too weak to survive the digestive system, if swallowed – it simply wouldn’t work. It’s a balance between a shot that is weak enough to be harmless, but strong enough to catch the attention of your immune system.)

Some years, the vaccine-selection process goes better than others. How about this year?

This year’s flu shot is a combination of two kinds of type A and one kind of type B.
It’s 62% effective against A and B together.
It’s 55% effective against type A alone, and 70% effective against type B alone.

Of the 416 sick kids and adults who tested positive for the flu…

57% had type A. This is the type that passes readily between humans and other animals (ducks, pigs, chickens, etc.).
37% of these folks with type A flu, had been vaccinated. 63% had NOT.

43% had type B. This is the type that passes only between humans.
Only 26% of people with type B had been vaccinated. 74% who had this flu, had NOT.

(The remaining 32% of folks with the flu, had *both* A and B types, with the 62% overall vaccine effectiveness rate.)

Interestingly, more people who got influenza A had been vaccinated, than those who got influenza B (37% vs. 26%). This means the shot is not as effective against the duck-pig-human flu, as it is against the human-human-human flu. Not surprising!

So there you have it: what we currently know about this year’s flu-shot effectiveness. Of the people who were sick enough to go to the doctor, and suspicious enough to get tested for the flu, only 1/3 of them actually had the flu. Of the sick folks who did truly have the flu, most of them weren’t vaccinated.

Of the sick people who DID get the shot, about 62% of them don’t have the flu. About 38% of sick folks will have the flu, even though they did get the shot. They are more likely to catch the type-A, human-animal flu – which makes perfect sense, since the re-mixing between multiple animal species is what makes the flu so very unpredictable, not only for vaccine makers, but also for your own immune system.

Last year’s flu strains + a million flocks of ducks worldwide + a million herds of swine worldwide + the rest of the humans worldwide = a very very unpredictable strain, or ten, of flu virus. OOOoogh I just hate the flu!

I don’t allow comments these days, because I used to get a fair amount of hate-based mail from people who disagreed with a medical approach to health – and a fair amount of requests for advice from people who weren’t my patients. So, warning to readers: I am a medical doctor. I do not work for drug companies, insurance companies, state or federal government, or anybody else, except my own patients that I meet with face-to-face. I offer them individualized Western-medical evaluation and assistance. I also offer general health advice on my website – advice that members of the general public can also find at many other health-related websites (such as Mayo dot edu, or PubMed dot gov). That’s my entire sphere of practice, and no amount of Internet interest will expand or restrict it. Just saying!

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