Archive for August, 2007

Incidentalomas-I

Wednesday, August 29th, 2007

In the startling strange world of modern imaging we continue to be stunned by the unexpected. As more and more people are subjected to CT, MRI and ultrasound scanning, a plethora of unexpected or serendipitous findings are revealed. If only we had the knowledge and wisdom to ignore most of these incidental findings, how many untold patients, their families, and physicians would sleep more soundly at night.

The typical surprise finding is that of an unexpected mass, the quaintly but appropriately named incidentaloma. Many physicians are unaware of the frequency of these masses in the general population. For example, up to 10% of the population harbors an incidentaloma of the adrenal gland (cyst or benign adrenal adenoma), many of which are picked up on CT or MRI scanning of the abdomen. Benign fluid-filled (cystic) masses are frequently seen in the breast, thyroid, kidney, liver, spleen, pancreas, and pituitary gland. The most common clinical example of a cystic or solid mass is the thyroid nodule, 99% of which are clinically meaningless. Another interesting statistic: Up to half the population over age 50 has cysts of the kidney.

The problem remains, when is an unexpected finding on a scan report an incidentaloma, and if so, what is to be done? More on this when I discuss the cascade effect, another noxious byproduct of modern medical science.

Early Experiences of a Medical Blogger

Monday, August 27th, 2007

After I announced: We welcome appropriate comments, all of which must include your e-mail address. Back links masquerading as comments will not be published, I was naive enough to think that would eliminate spammers attempting to infiltrate. It’s getting worse, of course. Mercury Is rising. There are currently 13 posts and 14 comments, contained within 4 categories. If I have to spend 15 minutes a day deleting junk mail that’s attempting to set a link, it’s still worth it.

Mostly, the blogs have been fun, but it seems that Vitamin C is still the hottest medical issue among the various topics covered, so at least one article struck a nerve. As for the lack of comments on the other nine posts, we’ll have to wait and see. Would you like the posts to be shorter?

Any comments on these comments?

Medical Errors: Who Will Pay?

Wednesday, August 22nd, 2007

In an attempt to save millions of dollars in health care costs, a new policy recently announced by the Bush administration states that Medicare will no longer pay the extra costs of treating “preventable errors, injuries, and infections.” Private insurers are also considering changes which they say could save them money and benefit patients.

Conditions for which Medicare will no longer reimburse additional charges include, among others, pressure ulcers (bed sores), infections resulting from prolonged use of blood vessel and urinary catheters, injuries resulting from falls, and preventable events due to negligence, such as sponges or other objects left behind in surgery.

Most of these new rules seem reasonable, even necessary, especially withholding payment to hospitals if they fail to control preventable infections. The widespread distribution of methicillin-resistant staph aureus (MRSA) over the past three decades is a national disgrace. Among developed countries, the United States has one of the worst records for curbing, not only MRSA, but other drug-resistant infections. The CDC itself noted a 32-fold increase in MRSA hospital infections between 1976 and 2003. 25 years ago Denmark, Finland, and the Netherlands faced similarly soaring rates of MRSA, but have nearly eradicated it. See this.

Stopping Medicare payment for extra care resulting from preventable errors seems to make obvious good sense, and patients undoubtedly should benefit. Will the costs be balanced by reducing hospital stays, fewer misadventures and deaths? Let us fervently hope so.

Yet, with profound changes in reimbursement there are always unforeseen consequences. Hospitals and physicians will have to perform additional testing (much of it in retrospect will prove unnecessary), documentation and internal auditing will explode, more employees hired, more lawyers consulted, more hospital bureaucracy and finger-pointing. And more malpractice suits?

What about infections and other conditions already present when the patient is admitted? How to prove the hospital is at fault? Moreover, serious complications, occur even when physicians and nurses take all the recommended precautions. Will the new Government rules stop payment for extra care and hospital days in every diabetic, cancer or dialysis patient, or post-op case of infection? What about patients at the end of life prone to pressure sores no matter how well they are cared for? Will every confused patient have to be in restraints for fear he or she will fall out of bed and sustain a fracture? Then there is the (imagined?) danger that unscrupulous hospitals will attempt to charge patients for charges Medicare refused to pay. Note: the law clearly states, “The hospital cannot bill the beneficiary for any charges associated with the hospital-acquired complication.”

There’s more, so stay tuned.

Times to Call 911 or Visit the Emergency Room

Friday, August 17th, 2007

A rough guide to life-threatening emergencies is listed below. I have adapted and revised this list which has been published thanks to the American College of Emergency Physicians (ACEP), see this. This list is clearly not meant to be inclusive. At the same time, common sense should prevail: Not every cut needs stitches, nor does every injury or case of simple indigestion require advanced medical treatment:

1. Any chest pain lasting 2-5 minutes or more, especially unexplained frontal chest pain with or without radiation to the back, neck, head, shoulders or arms.*
2. Non-chest pain, particularly significant or severe unexplained abdominal pain lasting more than an hour. Significant steady abdominal pain lasting more than 4-6 hours generally indicates an acute surgical condition.*
3. Any uncontrolled bleeding.
4. Vomiting blood. Coughing blood, depending on amount and frequency, may or may not be an emergency, again depending on common sense assessment.
5. Severe or persistent vomiting or diarrhea.
6. Difficulty breathing, shortness of breath, persistent wheezing or uncontrollable cough.
7. Sudden dizziness, weakness, or change or blurring of vision lasting more than a few minutes.
8. Sudden onset of one-sided weakness of an arm and/or leg, or facial droop on one side.
9. The “worst headache ever.”
10. Change in mental status (e.g., confusion, difficulty arousing) or unexplained loss of consciousness. A brief episode of fainting does not qualify as an emergency, particularly if relieved by recumbency.
11. Sudden development of any symptoms, such as hives, wheezing, or generalized itching, either spontaneous or following an insect bite, ingestion of food, or exposure to an animal.

*As a general rule, every case of unexplained chest or abdominal pain, even if not obviously severe or acute, requires an urgent physician visit, preferably within 24 hours

Taking action can mean calling 911 for paramedics, or going directly to the nearest ER, obviously a choice depending on time and proximity. Other measures include applying direct pressure on a bleeding wound, performing CPR, or splinting an injury. Never perform a medical procedure unless you are competent to do so. For example, do not attempt to manipulate an acute back or a dislocation, or deal with a psychiatric emergency. A good idea for all of us: take a course in first aid and CPR.

Noise Pollution and Hearing Loss

Monday, August 13th, 2007

Exposed to endless music issuing from shopping malls, supermarkets, and elevators, sounds of vehicles on the streets or overhead aircraft, construction, seasonal outdoor home maintenance, and basement workshops, we live in a world where it is difficult to avoid noise, the most prevalent type of air pollution.

Hearing can be damaged by a one-time exposure to an intense “impulse” sound, such as a gunshot, explosion (think Baghdad), or by continuous exposure to loud sounds over an extended period of time, for example, in the workplace, a long motorcycle ride, and especially the “sound of mucous” in the form of MP3 players like iPods, TV, radio, and concerts-especially the rock variety. Here are some striking statistics:

*Three out of 4 children have an ear infection, by the time they are 3 years old. An unknown number of these result in hearing loss.

*Almost 10% of Americans, 30 million people have hearing impairment. Of these, 10 million Americans have suffered irreversible noise-induced hearing loss, and 30 million more are exposed to dangerous noise levels each day.

30% of people over 65 and 40% of those over 75 have hearing loss.

* At least 12 million Americans have tinnitus (ringing, buzzing, or roaring in one or both ears; it can also be a high pitched whining, hissing, humming, whistling sound, or a “whooshing” sound). usually the result of temporary or permanent hearing damage from excessive exposure to loud sound. Of these, at least 1 million experience it so severely that it interferes with their daily activities.

*Only 1 out of 5 people who could benefit from a hearing aid actually wears one.

The loudness of sound is measured in units called decibels, written “dB.” Decibels are tricky to understand unless you know a bit about logarithms and acoustical physics. It turns out that a 5 dB noise reduction is about 30% quieter and represents a 50% decrease in the risk of hearing loss! Decibel examples: rustling leaves, 20 dB, humming of a refrigerator, 45 dB, normal conversation, 60 dB, busy traffic 75dB-85 dB, noisy restaurant, 80 dB- all with no time limit of exposure. But for average factory noise, 85 dB, it takes only 8 hours for noise-induced hearing loss (NIHL-this can can be temporary or permanent).

Other excess levels include: passing motorcycle, 90 dB-8 hours exposure for NIHL, subway train or diesel truck, 100 dB-2 hours exposure , helicopter and power mower 105 dB 1 hour, and, ranking with auto horn, propeller aircraft, and air raid siren, live rock music 90-130 dB 20 minutes to 8 hours. THRESHOLD OF PAIN is 140 dB, the danger level, from a jet engine. A rocket launching is 180 dB. Long or repeated exposure to sounds at or above 85 decibels can cause hearing loss. See this link. The louder the sound, the shorter the time period before NIHL can occur. Sounds of less than 75 decibels, even after long exposure, are unlikely to cause hearing loss. A good rule of thumb is to avoid noises that are “too loud” and “too close” or that last “too long.”

Noise-induced hearing loss from impulse sound and loud continuous noise occurs primarily because of damage to the hair cells of the ear as well as the auditory, or hearing, nerve. This hearing loss can be temporary and disappear in 16 to 48 hours; it is often accompanied by tinnitus (see above). However, this so-called “temporary threshhold shift” is a serious warning sign and may lead to permanent increase in threshhold, i.e. long-lasting hearing damage.As the NIH reports, recreational activities that can put someone at risk for NIHL include target shooting and hunting, snowmobile riding, woodworking and other hobbies, playing in a band, and attending rock concerts. Harmful noises at home may come from lawnmowers, leafblowers, and shop tools.As the NIH further states, noise-induced hearing loss (NIHL) is 100 percent preventable. To protect your hearing:

* Know which noises can cause damage (those at or above 85 decibels).
* Wear earplugs or other hearing protective devices when involved in a loud activity (special earplugs and earmuffs are available at hardware and sporting goods stores).
* Be alert to hazardous noise in the environment.
* Protect the ears of children who are too young to protect their own.

An excellent discussion on the subject of hearing can be seen at this web site by “Abelard” from which I quote a few pearls about listening to music:”The big culprits aren’t the devices themselves [iPods and MP3 players], but the tiny “ear bud” style headphones that the music players use. The earbuds are even more likely to cause hearing loss than the muff-type earphones that were used on Walkman and portable CD players. …On average, the smaller [the headphones] were, the higher their output levels at any given volume-control setting. [Harvard Medical School study] …Tiny phones inserted into the ears are not as efficient at blocking outside sounds as the cushioned headsets, users tend to crank up the volume to compensate. A quarter of iPod users between 18 and 54 years of age listened at volumes sufficient to cause hearing damage.” [Australian research]

“As one researcher found was often the case, listening to music/muzak at 110 to 120 decibels damages hearing in less than an hour and a half. Thus, the “longer-lasting batteries and more storage capacity encourages people with portable players to listen longer, not giving the ears a chance to recover.”

I constantly worry about how many millions of our younger generation will add to the growing population of hearing-impaired over the next decades.

Bottled Water vs.Tap: True Lies

Sunday, August 5th, 2007

When asked why he didn’t drink water, W.C. Fields replied, “Because fish f… in it”

Water drinking is great for thirst, and a $10 billion gift to the bottled water industry. Over half the U.S. population drinks bottled water at a yearly cost of $1,500 per person, about 3,000 times the cost of tap water estimated at 49 cents per person. (Think how many mortgages might have been rescued in the past three years.) Is buying bottled water pouring money down the drain, or worse, is it really good for our health compared to tap water? Senior attorney Erik Olson of the Natural Resources Defense Council (NRDC) explains that the FDA has never adopted all the EPA regulatory drinking water standards, and has not even ruled on some points after years of inaction. According to the NRDC up to 40% of bottled water is actually bottled tap water, while the FDA rules allow bottlers to call their product “spring water” even though it may be from a pumped well and treated with chemicals.

Some key differences between testing requirements for tap water vs. bottled water, are shocking, for example, disinfection of bottled water, banning of E.coli, filtration for pathogens and testing for Giardia and Cryptosporidium are not required, but are mandatory for big city surface tap water. See this report.

While we may reasonably choose to use bottled water for convenience, taste or as a temporary alternative to contaminated tap water, it is certainly no long-term national solution to water consumption. As the NRDC also observers, a major shift to bottled water could undermine funding for tap water protection, raising serious health issues for the entire population. Moreover, manufacture and shipping of billions of plastic bottles causes significant and unnecessary energy and petroleum consumption. The Earth Policy Institute in Washington has estimated it takes 1.5 million barrels of oil to make water bottles Americans use yearly. Less than a quarter of these bottles are recycled, and those remaining are put in landfills or incinerated leading to release of environmental toxins.

By all means, keep that nipple handy when there’s no tap water available during a civil emergency, on a camping trip, or when you find yourself in a third world country. Otherwise you might think of protecting your health and saving some money.

The BMI:Who’s Fat and Who’s Not

Thursday, August 2nd, 2007

“BMI” still stands for Broadcast Music, Inc.; it’s also the UK’s second largest airline. But most of us know BMI as Body Mass Index, the famous number that supposedly tells us whether we’re normal, overweight, obese, or dangerously thin. It is defined as the ratio of weight in Kg. to height (in meters) squared. To do an easy calculation on yourself , go to this NIH site . It’s one of over 19 million url’s on Google found with the search term “BMI.”

According to the NIH, a healthy weight is a BMI of 18.5-24.9; overweight is 25-29.9; and obese is 30 or higher. The BMI is an inexact measure of body fat, though it supposedly establishes cutoff points and is claimed to be an easy method of screening for weight categories. It is not a reliable diagnostic tool to fully measure health risks. Further, BMI does not take into account age, gender, or especially muscle mass. Nor does it distinguish between lean body mass and fat mass. As a result, some people, such as muscular athletes, may have a high BMI even though they don’t have a high percentage of body fat. In the elderly the BMI may be falsely low-or high.

Is Nicole Kidman at 5’11” and 120 pounds with a BMI of 16 seriously thin? Do you think Charlize Theron and Halle Berry at a BMI of 17, Lindsay Lohan at 18 or Jennifer Lopez at a borderline 19 are too thin. (we’re not counting those stars who are suffering dangerously low BMI’s due to eating disorders.)

Getting to the men, would you consider President Bush (5’11”, 191 lbs), and actors Tom Cruise (5’7″, 170 lbs), Matt Damon(5’11”, 187 lbs) “overweight,” all with borderline BMI’s of 26? Then, there’s Johnny Depp at 27, and George Clooney, David Duchovny, and Harrison Ford, each with a shocking BMI of 29. Will Smith, and Matthew McConaughey are also considered overweight. Poor Mel Gibson at a BMI of 32 and Sylvester Stallone at 34. Both are defined by the NIH guidelines as officially obese! You might want to visit this site for an interesting rundown.

Is there in fact a real or an over-hyped obesity epidemic?

Old definition: BMI > 28 (men), BMI > 27 (women)
People under old definition: 70.6 million

The definition was changed in 1998 by the U.S. National Heart, Lung and Blood Institute to an upper limit of 25-29.9 for overweight.

People added under new definition: 30.5 million
Percent Increase: 43%

That translates into one-third of the U.S. population overweight or obese. Can you believe it?