The Medical News Report

August, 2017, #67

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

www.samlamonte@gmail.com

 

Subjects for August, 2017

1. Food allergies

2. The dangers of NSAIDs (Ibuprofen, Aleve, etc.) and cardiovascular risk for all; cardiovascular disease risks in Migraine patients

3. Drug-Gene testing--Genetic markers to predict the best medication for diseases—i.e. psychological disorders--psychogenomics

4. A look at today’s physicians—the doctor/patient relationship--A must read!

5. The Blood System Series-Part 1-The blood and the bone marrow

6. Should vision, hearing, and dental services be included in Medicare?

7. Dehydration, Heat stroke, and heat exhaustion—a summer reminder and update

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment. If you want to be added to my mailing list, send me your email address to

samlamonte@gmail.com

   Don’t settle for a visit to your doctor without them giving you complete information about your illness or health status, the options for treatment, medical instructions for care, possible side effects of medication and treatments, and plans for follow up.

Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

Thanks!! Dr. Sam

 

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A note about last month’s report on false positive and negative results of medical testing, especially screening tests.

After publishing last month’s report, an article came out about the knowledge women have about the harms and benefits of mammography. Of the participants who had a mammogram, almost all were aware of the benefits of the test, such as saving lives, peace of mind, earlier diagnosis with less needed treatment, etc. Less than a third were aware of the harms such as over-diagnosis, over-treatment, a missed cancer, unnecessary biopsies, infections, etc.

  It is very clear that physicians must be sure that both the benefits and harms must be discussed with each patient when considering a screening test. This also goes for other tests such astravelling health screenings such as ultrasound for carotid stenosis, aneurysms, etc. Time constraints on physicians have a way of punishing the patient in the long run.

 

HEALTHCARE COMMENT

I know we are all anxious to see the healthcare insurance issue resolved, but remember the Obama administration took over a year to come up with something that has not work out like it was intended. There is no plan that will cost less (someone will pay for it), no plan that will please all, no plan that will be fair to all, and no plan that will please a Democrat at the same time it would please a Republican. So let us all give Congress a chance of improving our healthcare. Fixing healthcare as it stands now seems almost impossible, but rushing into a plan is no way to fix such a complex issue.

1. Food Allergies

Introduction

  Food allergies are very common (25-30% of households) and most are mediated by an immunoglobulin calledIgE antibodies. Proteins in food cause a hypersensitivity reaction by stimulating this immunoglobulin in the blood. The IgE antibodies attach to two types of white blood cell—mast cells and basophils that circulate in the blood stream and attach to the gastrointestinal tract, skin, and the respiratory tract. This antibody stimulates the release of histamine and cytokines that cause allergic inflammation.  Food allergies are likely influenced by environmental and genetic factors. Young people including infants and children (8%), and young adults (4%) are most commonly affected and males more commonly.

  There are, however, certain foods that are not mediated by IgE immunoglobulins which will be discussed.

I have discussed allergies and the mechanism of allergic reactions in 2 previous reports:

www.themedicalnewsreport.com #14 , #16

 

Common food allergies

  The common food allergies are eggs, peanuts, milk, soy, wheat, yeast, sesame, and seafood (shell fish is most common).There are many cross-reactions between   foods. 90% of those allergic to cow’s milk are also allergic to goat’s milk, while 50% of patients with allergy to peanuts are also allergic to other nuts, and 25% of those allergic to wheat are also allergic to other grains.

Processed meats have been singled out at as an aggravator of asthma. Sausage, salami, and ham on a regular basis make the symptoms of asthma worse. Being over-weight also complicates asthma even more. (Medpage)

Peanut Allergy-new information

  Recent recommendations by the National Institute of Allergy and Infectious Disease state that those infants prone to allergies can be exposed to small amounts of peanut-containing foods as early as 4-6 months of age. Research has reported that this reduced childhood peanut allergic reactions by 80%.

Infants with eczema (allergic dermatitis)or egg allergy are frequently allergic to peanuts. Testing for peanut- specific immunoglobulinIgE elevations is strongly recommended (0.35 or greater) or a performing a skin prick test. This is based on the fact that peanut allergy can begin as early as 12 months of age. It is also known that peanut proteins are frequently found in house dust and the entire environment. Desensitizing infants can prevent a life-long problem. Talk to your doctor or see an allergist.

Non-IgE mediated food allergies

There are certain food “allergies” that that are not mediated by the IgE antibodies. Cow’s milk, milk products, and soy are the most common. These types of allergens are harder to diagnose because there are no tests that specifically prove these allergies, and there is no elevation of the immunoglobulins. This is the case for dairy and soy. In fact, these are not classic allergies, rather are described as intolerances. The mechanism is different. Here are the symptoms of lactose intolerance:

Intolerance to lactose is not an IgE mediated allergy. It is an intolerance to the sugar,lactose, due to the absence of lactase (an enzyme produced in the small intestine), which is necessary to digest lactose. Removing lactose from the diet will eliminate the problem. The substitute milk product, Lactaid, can be ingested, since it does not contain lactose. Artificially taking lactase to help digest lactose in milk may be helpful, but check with your doctor.  This was previously discussed under bowel diseases:

www.themedicalnewsreport.com #14

Physician-monitored food challenge tests are necessary to diagnose specific food allergies.Because food challenges can cause severe reactions (asthmatic attack, anaphylaxis, and shock), physicians must be prepared to treat these acute reactions in their office.

 It is important to know what titer creates a positive reaction in food challenge testing, and there are laboratories that commercially providefoods with known titers for testing.

Eosinophilic esophagitis-a result of food allergy

There are diseases that are the result of allergies, such as eczema and asthma. Eosinophilic esophagitis is an example of an inflammatory disease caused by food allergy and may require a biopsy of the esophageal lining to diagnose this disease. Eosinophils are a certain type of white blood cell that infiltrates the lining of the esophagus. The presence of eosinophils usually indicates an allergic cause.

Skin testing and other allergy tests

The standard test you may be aware of is the scratch test (skin prick test) that takes a small sample which is used to scratch the skin with a needle, which if positive, causes   swelling in the skin (urticarial) at the site. The IgE serum blood test is an alternative to food challenging and has equal value as an allergy test for food except for milk and soy products. There are other tests on the horizon.

  A diet diary is necessary in the workup for food allergies. This consists of writing down every food consumed and any reaction to it and the severity.

  An elimination diet is another method to pin down what can be consumed and what cannot.

Patch testsare also used by placing the food on a patch and taping to the skin to see if there is a reaction.

 

Diseases that commonly have allergic causes

Atopic dermatitis (a form of eczema); Celiac disease; nonspecific enteritis, colitis; respiratory allergic syndromes (all targets of allergies)

There are certain allergic diseases that are mediated by IgE and some that are not. Testing will differentiate them. For patients all these diseases are considered allergies.

Patients that suffer from atopic dermatitishave a much higher risk of food allergies (35-40% have IgE mediated food allergies). This is a form of eczema, a chronic form of allergic dermatitis. These are extremely itchy rashes.

Eczema

30% of patients with eczema have or will develop asthma, urticaria (hives), food allergies, and allergic rhinitis (hay fever). Since the majority of patients do not develop these problems, I will discuss eczema and its treatments next month.

Celiac disease is a gastrointestinal disease due to a reaction to gluten-protein in grain. It is not mediated by IgE, and therefore is considered another intolerance to a protein substance, gluten, rather than an allergic response. I have discussed this disease previously: www.themedicalnewsreport.com #14 , #20

Dermatitis herpetiformisis related to Celiac disease and is also a non-IgE mediated allergic blistering type of skin disease and usually resolves with gluten elimination. It is an extremely itchy rash and is confused with other forms of dermatitis.

  Below is an example of the rash seen in dermatitis herpetiformis, so named because it looks like fever blisters (herpes).

Upper and lower respiratory tract infections can also be caused by food allergies including acute asthma, although food allergies do not usually trigger chronic asthma.

  There is no specific treatment for food allergy compared to elimination of the offending foods.

Manifestations of food allergy

Acute urticarial rashes are the most common skin manifestation of food allergies, although angioedema, dermatitis herpetiformis, and flushing are also common. These signs of food allergy are cell-mediated by IgE antibodies.

 

 

It is critical that the laboratory tests are reliable, that the patient has not had any medication containing anti-histamines for several days prior to the test.

Prognosis

  Most infants and children grow out of their food allergies for milk, eggs, soy, and wheat.  However allergiesto  peanuts, tree nuts, fish and shellfish are more persistant and more likely to cause severe reactions such as anaphylaxis in adulthood.

Carrying childhood allergies to adulthood

  85 % of children grow out milk allergy by age 3-5. 50% of patients with allergies for the other foods resolve their issues by age 8-12. That still leaves a lot of people carrying their food allergies into adulthood.

Patient Education

  Patients should always carry epinephrine injectors (EpiPen) in case of a serious reaction.  Being taught to use these injectors is critical for patients and caregivers. Knowing the early signs of a reaction is critical so that action can be taken immediately.

  Proper reading of food labels, and even asking food servers (managers)how food is prepared in restaurants could prevent a serious event. (Even if a pan or preparation table is used to prepare or cook shellfish and then used to cook other foods, there can be a reaction).

 

 

Medications that the patient should have available:

Epinephrine injectors for acute allergic symptoms, antihistamines for milder reactions, and bronchodilators may be helpful if the patient has asthma as a result of food. Adjunctive medications include corticosteroids, histamine-2 blockers (Benadryl), and intravenous fluids to combat hypotension. The hormone, glucagon, may be used  for refractory anaphylaxis.

Signs of Anaphylaxis

  Itchy throat, stridor from swelling in the airway, eye swelling and itching (pruritis), difficulty speaking or hoarseness, cough, shortness of breath, wheezing, nausea, vomiting, diarrhea, flushing, and urticaria-hives (elevated patches of swelling of the skin). Even nasal congestion, runny nose, sneezing, abdominal pain can occur. Cardiovascular collapse and death can occur. Call 911 even if aEPiPen is used.

Hives (urticarial)

Differential Diagnosis(this term is uniformly used by clinicians to list other diseases that need to be excluded before a definitive diagnosis can be made)

  Of course, symptoms such as described in food allergy vary greatly because of so many systems are involved, and therefore, the list of possible diseases to exclude is quite long. Clinicians are trained to shorten the list with a good history and physical, lab testing, skin testing, and in the case of food allergy elimination diets.

  A board certified allergistis trained in internal medicine with a fellowship in allergy medicine (The American Board of Allergy and Immunology). ENT doctors also may become certified in allergy medicine. They also work very closely with allergists because of nasal and sinus disease.

The future of food allergy treatment

  Oral and sublingual allergy immunotherapy is on the rise and may be a significant treatment in the future.

 

2. Cardiovascular disease in Migraine patients; dangers of NSAIDs and cardiovascular risk

A. Migraines and cardiovascular disease

Patients who suffer from migraines, a vascular disease, and often have underlying cardiovascular disease that may go undiagnosed or occur from side effects from the medications used to treat the headache.

  Recent studies have outlined the concern for patients takentryptans, the category of migraine medications most commonly used.

  One in five women suffer from some type of vascular headache.

  For a review on migraine headaches please click on my previous reports:

www.themedicalnewsreport.com #26 , #28, #29

  The journal Headache reported in the November,2016 issue that about 2.6 million Americans suffering from migraine are likely to be suffering from cardiovascular complications from the medications used to treat the disease. The risk was more likely to occur in males than females, while the overall incidence occurred in 15% in men and 12% in women, and increases with age.

  Some of the typtans are imitrex (Sumatriptan), Zolmitriptan, Eletriptan, Rizatriptan, etc.). These drugs are designed to constrict blood vessels in the brain stem.It also reduces substances that trigger migraine symptoms are caused by dilation of blood vessels. All of these drugs work best when taken when symptoms first appear. Patients must stick to the recommended prescribed dose.

Constriction of blood vessels can interfere with an already constricted vessel causing angina, heart attack, stroke, etc.

  The bottom line is prior to treatment with tryptans, ergot alkaloids, and NSAIDs, physicians must screen for an underlying yet unknown cardiovascular disease.

  Because women are more likely to have migraines, the overall number of complications is greater in women. Since migraines are more common in smokers and those overweight, these issues must be addressed as well. It is also important to continue to monitor migraine patients over time ascardiovascular disease increases with age. These medications may have been safe when the patient was younger, but could complicate underlying disease beginning to become clinically significant.

  If there is no underlying cardiovascular disease present, but multiple risk factors present, the initial use of tryptans should be monitored with serial EKGs with the first and subsequent doses according to the FDA.

Newer Medications

 Another approach is to avoid those meds that can complicate cardiovascular disease. Newer medications that target receptors tied to migraines that do not have cardiovascular complications are being studied (5HT1F and CGRP receptors) as well. Other treatments to be considered should include biofeedback, cognitive therapy, and nerve blocks.

  Since migraines tend to worsen or even begin with menopausal transition, it is a very important time to evaluate for cardiovascular disease. Migraine is linked to estrogen levels in women and is reinforced by improvement in migraines when menopause transition is complete (post-menopause). Yet, in those with continued migraine, hormone replacement can be of benefit.

Reference—The Journal Headache

B. NSAIDs and cardiovascular risk

NSAIDs and Heart Attacks

NSAIDs (Non-steroidal anti-inflammatory drugs) are a very common over-the-counter pain and arthritis medication. There have been previous studies regarding the increased risk for heart attacks over time, however, a new study cited a 3 fold increase in riskcan occur in as little as a week of continuous use in patients without a previous history of a heart attack.  If there is a previous history, the risk is considerably higher. The risk rises with increasing doses and represents a 20-50% increase.

  With NSAIDs, there is an increased risk of death in patients who have had a heart attack.

NSAIDs and Heart Failure

  There is a 10 fold increase in risk for patients with a cardiac history of developing heart failure.

Who is at risk?

Those at risk for cardiovascular disease include a known history of heart and vessel disease, diabetes, kidney and most chronic diseases, and those with elevated lipids(cholesterol and triglyceride).

  All NSAIDs cause this risk including a subtype of NSAIDs called Cox 2 inhibitors (Celebrex, etc.), especially those that are longer acting (naproxen, etc.). These were popularized because they create less gastric irritation, however, they are no more effective than other NSAIDs.

Value of NSAIDs with proper precautions

  NSAIDs,however, are very valuable as non-opioid options for sports injury, pain relief, and arthritis. If patients are prescribed these medications (or take OTC options) on a regular basis, it would be advisable to ask for a screening evaluation for risk factors (EKG, kidney functions, etc.) and also the advisability of continuous use, as the risk increases for the first month on continuous use.

British Medical Journal, 2017

 

3. Drug-Gene Testing--Genetic markers and enzymes to predict best treatment for disease—antidepressants--psychogenomics

It is well known that patients respond to individual drugs very differently. There are several classes of drugs that are influenced by certain genes that determine how drugs are metabolized which influence how effective a drug can be.Genotyping is now helping doctors to determine the best drug for certain disorders.

Drug response and drug/drug interaction

 Drugs are metabolized by the liver’s enzyme system (cytochrome enzyme-P450 system). This cytochrome system has more than 50 enzymes that metabolize drugs when they are ingested. However, 6 of these enzymes metabolize 90% of the drugs and the two most significant are CYP-3A4 and CYP-2D6. Some of the common medications metabolized by this system are beta-blockers, Coumadin, anti-depressants, and seizure medications. Gene testing is now being used to determine if a specific patient has these specific levels of enzymes.Other enzymes in this system can help determine how patients might be more prone to liver disease from alcohol.

  Genetic influence by these liver enzymes also plays a critical role in how different drugs interact with each other in a patient. There are medications that are enzyme inducers requiring that a patient start off on a smaller dose and increase that dose over time. Side effects are enhanced unless the dose is gradually increased.  Antidepressants and neuropathy drugs are good examples.

Psychogenomics

Many psychiatric patients do not stay on their medication because of the side effects. Also, many patients do not derive the maximum benefit of the medication. Psychogenomics has been developed to individualize medication choice and selection based on best response and minimum adverse reactions based an individual’s genetic markers.

Genetic variability (called polymorphism)

  How genes are configured influence how these liver enzymes will determine how a patient will respond to a certain drug and the resultant clinical response. The genetic variability can even determine whethera patient will even respond to a drug. A good example is Tramadol, a mild opiate medication. These enzymes at higher levels can inactivate this medication and make it ineffective.

50% of patients with depression experience poor control  of their symptoms and an even smaller percentage of schizophrenics go into remission with medication. We now know that the gene variability can influence these psychiatric medications.

Other variables involved

Just knowing the gene makeup of a patient is not the only issue when determining what medication and at what dose a patient should be prescribed. The variables include actual diagnosis, variations of the illness, patient age, diet, drug-drug interactions, genetics, medical co-morbidities, substance abuse, and an individual’s metabolic breakdown of the drug.

It has been determined that just under 10% of people (ethnicity varies) have this genetic variability which makes them respond poorly to certain medications including anti-depressants. 1 in 5 Asians have this variability profile.

  Analysis of genes is being studied to assist in the selection of a drug based on the genetic determination of response to the drug(s). The goal of such an undertaking is to create better compliance with fewer side effects and ultimately resolution of symptoms.

The influence of psychiatric drugs on neurotransmission

There are 28 pharmacogenomic markers for psychiatric drugs. The coding of certain neurologic proteins by specific genes involved inneurotransmission of these drugs is critical for the success or failure of individual drugs.

  The serotonin transporter gene is one of the most studied genes in pharmacogenomics, as this neurotransmitter is intimately involved with emotion and behavior. Most of the anti-depressant medication inhibits the breakdown of this chemical in the brain (serotonin).

Dopamine, another neurotransmitter, plays a central role in schizophrenia and mania. The receptors and transporters of this brain chemical are being intensively studied to analyze its influence on differences (polymorphism) in individual genetic markers.

DNA analysis-Genotyping

  A simple swab of saliva from the lining of the mouth is all that is required for analysis. Blood tests can also be used. Genomic assays are not uniformly covered by health insurances, however, Medicare does cover the analysis if properly coded for a psychiatric illness.

  This is a tool especially for difficult to treat patients and as in many other fields of medicine holds the secret to unravelling the body’s genetic role in how it is involved with a specific medication. Gene testing continues to play a role in cancer treatment as well. It is still not available for all medications.

  There is much to be learned about genetic markers and their influence on medications and diseases.

 Southern Medical Journal, December, 2016

 American Family Physician Journal

 

4.The Doctors of today, their practices, satisfaction, and the impact on patients; physician burnoutA must read!

A. Introduction

   Healthcare is changing, and it is affecting the doctor/patient relationship greatly. The changes in  healthcarehave created a negative working environment for many physicians, and it is the direct result of what has happened in attempting to reform healthcare. Governmental regulations have required more hours of clinician’s time, diminishing their patient time.

B.Factors affecting a physician’s practice-Burnout

 1- Healthcare reformhas added an additional layer of dissatisfaction that is measurable. Studies are reporting that the physician burnout issue is increasing. For student doctors, the stress has its beginnings in medical school and only one third seek help. One of my classmates became a catatonic schizophrenic and another committed suicide while in medical school. Although most doctors are tough enough to endure the rigors of long hours and tremendous stressover the years, it takes its toll.

  These studies have a lot to say about what specialty new doctors are choosing, and is a death knoll for family practice pushing the specialty into the hands of PAs and nurse practitioners. The number of PAs is increasing rapidly to try and meet the demand because of the lack of adequate numbers of primary care physicians. Many of you are now seeing a PA or nurse practitioner and are satisfied with your care, however, there is no substitution for a well-trained physician when more complicated or unforeseen issues need attention. That is the beauty of a team effort, and under the supervision of physicians, nurse practitioners and PAs are a wonderful addition to doctor’s practices. However, now 19 states allow nurse practitioners to work without supervision. 

  2-Physician pay cuts from Medicare and Medicaid

  Another issue that created stress in physicians is patient satisfaction data and Medicare quality standards that now punish doctors (and hospitals) financially for a poor result regardless of the cause.Improving quality of care is welcomed by all.

Medicare and Medicaid can withhold as much as 2% of physician’sreimbursement annually. 500,000 physicians are facing this “fine”. This is because they did not meet the Physician Quality Reporting System’s requirements. They are also getting fined for having too few or too many Medicare/Medicaid patients (presumably dodging these patients or over-treating a higher number).

CMS rewarded doctors for reporting how they did on certain quality measures defined by our government—more paper work!  Ref-Medscape, June, 2017

This year physicians who did not comply with electronic medical record standards found a 1% overall pay cut for the entire year (Medicaid/Medicare). There are many quality measures put in place by the Obama Administration that have cut payments to hospitals and doctors. Just think, what will happen when the government is running all of healthcare! Physicians who work in single payer countries make substantially less than American doctors.

  Soon, Medicare will pay doctors differently than fee for service. It remains to be seen if this is a good step.

3- Patient satisfaction surveys

Denying a patient a prescription for antibiotics, when a virus is the cause of the infection, or refusing a refill on pain meds creates negative feelings from patients. Now patient satisfaction surveys are commonplace. How do you think they would rate their doctor in this circumstance? Patients are very good at emotional manipulation, and physicians have trouble accepting rejection just as much as anyone. Physicians are accused of creating the opioid crisis while the medical profession pressures them to do a better job of relieving pain. Quality medical care does not always align with patient satisfaction.

C. Female physician issues

Physician burnout has increased especially in female physicians. Some say 50% of physicians experience it. This is a serious issue especially for critical care facilities (ICU, CCU, ER, etc.) not only for physicians but nurses. Burnout is a complicated matter.  Some studies correlate burnout and age (past 50 years of age), who have worked for over 20 years.                                                                                                                                    The Mayo Clinic differs with these findings. They found   younger and older physicians are most content and most burnout occurs in the middle years.

D. Defining Burnout

  Some define burnout as physical and mental exhaustion, depersonalization (an apparent unfeeling or impersonal feeling for patients), and dissatisfaction. This affects the doctor patient relationship. These doctors may be described as not having a “good bedside manner”.

  The specialties of family practice, pediatrics, neurology, critical care, and emergency medicine are hit hardest with physician burnout. There is already a shortage some of these specialties.

Medicine is the number one most stressful profession, and even though it is stressful, it still is the best profession of all, in my opinion. It is hard work to care for sick people, and even with the dedication and passion physicians have, the work and hours take its toll. We need patients to trust us and our decisions. In the end, satisfaction for caring for patients is such an honor and makes all the hard work worth it.

E.MajorConcerns for doctors

  The #1 concern physicians haveis not enough time spent with each patient.  The pressure for employed doctors to see more patients has caused a problem for doctors and patients alike. Seeing a patient with multiple health issues requires more time spent which may not be reimbursed by Medicare. It is a good reason why patients must prepare for doctor visits with questions written down, asking for copies of reports, asking for explanations, etc. to get the most out of any visit.

  Continuing education requirements are required to keep a medical license current. Doctors must continually update their knowledge to remain cutting-edge, but it is time-consuming and again take times away from patients.

E. Employed vs private practice doctors

   For an internal medicine specialist to make a good living, they must maintain between 2500-3000 patients in their practice, and many have over 4000 or more. The loss of autonomy and control over their practice is another major factor for employed doctors. For the first time ever, more than 50% of doctors are employed, which has created a corporate mentality by some large medical centers emphasizing the bottom line above quality of care.

Most doctors choose being employed to spend less time on administrative demands created by excessive federal regulations. Doctors have more financial security even with lower incomes, and less risk from legal action. For many this has been a welcomed move.

The administrative cost of care also continues to rise because the need for documentation (electronic medical records and Medicare requirements) has required many more employees in a practice.

F.Appointment time for patients—be informed

Because of time constraints, patients must be more proactive, preparing for visits, writing questions down and demanding explanation for illnesses, their treatments, and side effects of medications. Make use of that precious time!

G. Psychologic impact on physicians

  A study reported on 7000 physicians who were screened, and one third reported depression. Not having time for family is high on the list as a cause. Female physicians are reported to be more dissatisfied with their work and family balance than males.

H. Administrative burden

 It is estimated that 40% of a physician’s time is administrative, and the electronic medical record added to that. Some studies report administrative tasks now outweigh the time spent with patients.Patient portals, electronic prescriptions, consultations with specialists, reviewing lab and X-ray findings, and staff meeting issues are the reason. For surgeons and other hospital based practices, add procedures, hospital rounds, discharge instructions and correspondence with other specialists to the long list of a doctor’s day.

I.Harm to medical professionals

Harm to doctors has increased throughout the world. The World Health Organization reported 595 attacks on healthcare facilities in one year (2014-2015) with 954 deaths and 1561 injuries to healthcare workers. 26% were healthcare providers.

J. Occupational injuries to surgeons

  38% of surgeons (including me) suffer from chronic spine disease from leaning over an operating table for thousands of hours. It is the price of doing business but still creates problems especially for future years.

K. The electronic medical record (EMR)—a mixed blessing and another source of burnout

  The electronic medical record has created unintended consequences, although it was a necessary move. Thankfully with reform of the VA system,EMRs are finally coming to the VA.

There are 600 different vendors providing the technology for different EMRs. For those physicians who keep their head in a computer while interviewing a patient, tend to get very low scores on quality of care by the patient. It is very insulting to any patient for a doctor not to look you in the eye and talk to you without the distraction of a computer. Insist on them putting the computer down during your visit!!!! It still is a time consuming action but it should not rob a patient of complete concentration from their doctor.

  Here is a chart showing the average income by specialty. Single payer healthcare plans will employ all doctors paying them 20-30% less unless they become concierge physicians (many are).

L. Defensive Medicine

  Practicing defensive medicine has always been a serious costly issue, and until legal reform is part of the equation, true healthcare reform will not be success. 

M.Do doctors want to stay in medicine?

  One study (Medscape) cited 58% of physicians would choose medicine if they had it to do all over again. I would have expected a higher percentage, but then I had one of the best practices anywhere and never regretted a day.

  In the end, being a doctor is very stressful but most rewarding. It may be debated whether healthcare is a right or a privilege, but no one disputes it is a privilege and an honor for physicians to care for patients.  It requires intelligence, strength, motivation, a caring nature, endurance, and a desire to make a difference in patient’s health. It comes with a price tag, but it is worth it. My 30 years of private practice and medical school teaching was an awesome privilege.

 

5. The Hematological System Series-Part 1- The Blood and the Bone Marrow

This series will include several reports. As always, I start with the basics, and then proceed to disorders and diseases of the system.

A. What components make up the blood in our body?

  There is a liquid and a solid component that makes up the blood.

The plasma is the liquid portion of the circulating blood and makes up 55% of the blood’s volume. Blood makes up 7-8% of the body’s total weight (4.5-6 quarts--12 pints). The blood cells make up the solid portion of blood.

B.The main functions of cellular blood are:

a) Red cells transport oxygen and nutrients to the lungs and tissues, b) platelets form blood clots to prevent bleeding, c) white cells fight infections and provide immunity (antibodies), d) the plasma brings waste products to the kidneys, and e) regulates body temperature.

C. Plasma-liquid portion

Plasma is made up of water (92%), salts, and protein including glucose, amino acids, vitamins, sodium, potassium, uric acid, urea, carbon dioxide, hormones, and antibodies. The waste products are filtered through the kidneys.

D. Cells of the Blood--Red and white blood cells, platelets

The solid portion of the blood is made up of red and white blood cells, and platelets. The red blood cells carry life sustaining oxygen to the body using a protein that binds oxygen to the cell called hemoglobin(a red pigment). Iron is an essential component of the hemoglobin molecule.  Red blood cells circulate throughout the body every 60 seconds. Each red cell (made by the bone marrow) lives about 4 months and is replenished with new cells. There are 5 million red cells in 1cc of blood.

E.  Production of red blood cells—The Bone Marrow

1--The production of red cells is controlled by a hormone, erythropoietin, produced by the kidneys. The process of blood production is called hematopoiesis, and some medical circles the word hematopoietic is used interchangeably with hematological.

2--Blood is produced in the bone marrow (erythrocytes, granulocytes, lymphocytes and thrombocytes). In infants, blood is also produced in the liver and spleen, however, that ceases in childhood. Certain diseases can restart the process in those organs(abnormally) and cause enlargement of both organs. Rupture of the spleen, in these cases, is a great concern.

3--Components of the bone marrow—red and yellow marrow

Bone marrow produces2 types of stem cells-- precursor hematopoietic stem cells that become mature blood cells (red marrow-myeloid tissue), and stromal stem cells(yellow marrow) which produce fat, bone, and cartilage. Malignancies of certain precursor bone marrow cells are called leukemia, myeloma, etc.

Bone marrow stem cells

White cell precursors are called myeloid cells, and when leukemia occurs, they are described as myeloid leukemias (acute and chronic).

 

4--Testing the Bone Marrow

  Bone marrow samples can be removed from the pelvic bone at the rim, which was shown in the drawing above. These cells are the precursor or stem cells that transform into actual mature blood cells. They are called erythroblasts for red cells and myeloblasts for white cells. These names will come back up when discussing leukemia.

  Below the drawing shows the bone marrow is responsible for generating the blood cells all from a primitive (hematopoetic) stem cell. Red and white cells include leukocytes for fighting infection and lymphocytes to support the immune system and platelets (thrombocytes) for clotting. The marrow produces about 5 billion cells per day. 

F. Hemoglobin

Iron is an essential element of blood production. 70% of the body’s iron is in blood, and is part of the hemoglobin molecule.Hemoglobin, a protein, carries oxygen in the red cell to the body from the lungs and returns carbon dioxide back to the lungs for it to be removed. The hemoglobinname comes from “heme”, which is the iron containing portion, and “globin” for the protein globulins.

 

Platelets

The above electron microscopic photo demonstrates the 3 solid components of blood. Another photo of the red and white blood cells and the platelet is below:

G. White blood cells

  White cells are mostly produced in the bone marrow, are composed of different types of cells with different functions:

a) Neutrophils make up 70% of white cells and are the main cell that fights infection.

b) Lymphocytes (10-60%)—3 types of lymphocytes-Type T and Bprovide immunity, and Killer cells protect against viruses and tumors.

c) Monocytes (3-8%) mature into mast cells and macrophages which mount the majority of the inflammatory response.

d) Eosinophils (1-6%) fight parasitic infections and are involved with the allergies and asthma.

e) Basophils (0.1%) produce the histamine response in allergic reactions. 

An elevation of certain white cells helps physicians to monitor infections. The count is also elevated in leukemia. There are conditions that abnormally lower the white count making it difficult to fight infections.

H. Platelets

 Platelets (thrombocytes) are actually fragments of cells that clump together to form a matrix in the lining of blood

vessels and with blood products form fibrin clots (coagulation factors) when bleeding occurs. I have discussed coagulation in depth when reporting on the anti-coagulants (blood thinners).

www.themedicalnewsreport.com #34, #47

Arrows point to clumping of platelets creating a clot (below)

A clot forms with blood products, blood, and platelets. Platelets are very sticky and help create the clot. Normal clotting is necessary to sustain life, however, abnormal clotting can create a huge health issue in cardiovascular diseases (heart attacks, strokes, and other blockages of arteries and veins).

 

I. Testing the blood--complete blood count-CBC

  The CBC is the most common blood test used to measure the volume and quality of the blood.

  The CBC includes a red and white cell count, and the platelet count. The volume of red cells in the blood is called the hematocrit.For males, 38.8 to 50% and for females 34.9 to 44.5% is the normal range.

The hemoglobin is also measured and is the amount of that protein in the blood. Normal ranges are: males-13.5 to 17.5gms/ml; females-12.0 to 15.5gms/ml

  Other tests that are performed with the CBC are tests that measure the volume of hemoglobin (MCH) in a red cell, the size of a red cell (MCV), and the concentration of hemoglobin in a red cell (MCHC). These tests are important in defining types of anemia.

  A blood cell smear is also performed to examine the cells under the microscope looking at the color of the cells, appearance of white cells, etc. Certain blood diseases have cells with different shapes and sizes in such diseases as leukemia, malaria, and sickle cell disease.

J. Why is the CBC performed?

The CBC is the most common blood test performed and is a routine part of a physical examination. It provides so much valuable information about underlying diseases. It is preformed to evaluate fatigue, paleness, weakness, fever, weight loss, easy bruising, diagnose and monitor anemia, amount of blood that has been lost when a patient has bleeding or surgery, diagnose polycythemia (too much blood), diagnose and monitor treatment for infections, diagnose blood diseases such as leukemia, monitoring how medications and radiation is affecting the blood, in preparation for surgery, and detecting a shift in the type of white cells.

For normal values of a CBC, click on: http://www.webmd.com/a-to-z-guides/complete-blood-count#2-4

K. Other important blood tests

 a) ESR-erythrocyte sedimentation rate (sed rate)

This test is elevated in diseases that cause inflammation. It is not diagnostic of specific diseases but does confirm its presence.

  b) Reticulocyte count

  A reticulocyte is an immature red cell, and if the number is elevated, it implies recent bleeding or a disease that is requiring the body to make red cells faster than normal. There may be destruction of red cells called hemolytic anemia or some other cause that requires investigation.

L. The definition of terms—too many or too few blood cells

Red Cells

  a) Too many red cells--polycythemia

b) Too few red blood cells—anemia

White cells

  a) Too many white cells--leukocytosis

b)Too few white cells--leukopenia

Platelets

  a) Too many platelets--thrombocytosis

  b) Too few platelets—thrombocytopenia

 

6. Should Medicare cover dental, vision, and hearing services?

Some Medicare Advantage plans cover the necessary services of vision, hearing, and dental services, but it is estimated that only 12% of the 52 million Medicare recipients have some dental services covered in 2012. It is my personal experience independent dental insurance has a lot to be desired, but even getting an annual exam and cleaning would be a welcome start.

  70% reported they had not seen a dentist in a year. Of the 50.5 million who reported vision difficulty, 57% had not had a vision test in the prior year.

Eleven million Americans reported trouble eating because of dental problems. Dentures are expensive. CostHelper.com readers report an average cost of $9,000 for a full set of dentures including tooth extractions, etc. There are many diseases that are caused by or aggravated by gum disease. So many diseases (cardiovascular disease, etc.) have their cause based on inflammation, and dental disease is a common contributing cause.  Prevention is the key to good health.

  75% of Medicare recipients report some type of hearing trouble and 84% of those did not have a hearing aid(s) in 2012. Cost is the most common reason for not seeking these services (two digital hearing aids cost $5000-7000).

  In a recent study, the average expense for Medicare beneficiaries was $927 for dental, $715 for vision, and $1338 for hearing services if they chose to use these services.

  The federal cost for these services for a year is estimated to be $1.95 billion (assuming $150 deductible, 20% cost-sharing, with a maximum of $1500). With an estimated 6.4 million Medicare recipients willing to sign up for this type of plan, the premium is estimated to cost $25 per month. The services would include an annual vision test, hearing test, and dental exam with cleaning. It would also include more affordable hearing aids.

  There would have to be federal subsidies for low income beneficiaries. The estimated extra cost would be $1.05 billion a year.

Healthcare in the future

  Healthcare must include these necessary services for so many reasons. There is no excuse for not having plans inside the Medicare system.

  Sooner or later this country must come to grips with the fact that we have pushed ourselves into a corner and no matter what happens to the economy, no matter how many jobs are created, and no matter how many retrain, robotics and internet services will replace jobs. We are facing a large percentage of Americans who will need federal assistance often leading to socialism like it or not. We have allowed the influx of millions of refugees and immigrants to over-burden our system. Our generosity has backfired on us. Entitlements have made many people lazy and would rather live off the government than retrain or seek a job.

Summary

  If Medicare survives, we must strongly consider including dental, vision, and hearing services. The Congress must work together or we are doomed no matter who the president is.

As long as we have over-privileged U.S. Congressional members who make our rules and exempt themselves, we are never going to get our act together healthcare wise or in any other venue. 

Ref--The JAMA network

I am looking into the safety of hearing aids over the counter and will report on it when I have enough information.

 

7. Dehydration, Heat stroke, and heat exhaustion—a reminder and update

Summers are getting hotter and for those who want to enjoy the outdoor activities of this period of the year, we all must be careful to hydrate ourselves and be aware of the signs of dehydration, and heat stress.

  I have written on this subject before, and here is part of the article from the 44th Medical News Report:

Dehydration

We have all heard that 8 glasses of water a day is necessary for adequate hydration. It is not true. There are many factors that change the amount of water we need to consume each day including, ambient temperature, whether we are sweating, in dry vs humid conditions, mouth breathing, certain diseases, kidney function, etc.

  On the average, men need 121 oz. (15 cups) and women 91 oz. (11.5 cups) of water per day.  We usually get about 20% of our required water in foods per day. For example, an apple is made up of 84% water, banana 74%, broccoli 91%, ground beef 56%, cheese 39%, and even a bagel 33%.

  One of the symptoms of dehydration is the loss of thirst, because dehydration negatively affects the thirst center in the brain.

  Working out in a hot and humid environment can dehydrate a human in as fast as 30 minutes. Keep that in mind the next time you cut the yard, take a hike, or play 18 holes of golf. Rehydration with 5-10 ounces (a cup and half) of water every 20 minutes is recommended. Also, you are losing valuable sodium and potassium, which is necessary for muscle metabolism. Cramps and weakness will occur without replacement. Stay away from sugary sports drinks (choose G2 {instead of Gatorade} or sugar free Powerade) and always pre-hydrate with 2 cups of water 2 hours before a workout or strenuous activity.

  There are certain beverages that are dehydrating especially alcohol, because it affects a pituitary hormone called ADH (anti-diuretic hormone) that regulates the release of urine depending on the status of the body’s hydration. ADH directly affects the release or retention of water by the kidneys.  Sugars, caffeinated tea, coffee, sugar concentrated drinks all will dehydrate, however, depending on the volume of fluid taken in will counter the effect to some extent.

  Age, general health, and the weather all affect our hydration. The thirst center gets lazy as we age, and the elderly are frequently chronically dehydrated.

The difference between heat cramps, exhaustion, and stroke

 Heat cramps, exhaustion, and heat stroke are the result of getting overheated and not staying hydrated.

Heat cramps include sweating, leg and stomach cramps, thirst, and can be reversed with cooling and hydration of the body. If not treated, heat exhaustion will occur.

Heat exhaustion includes fatigue, nausea, headache, muscle aches, cramps, lightheadedness, anxiety, excessive thirst, cool, clammy skin with excessive sweating.

Heat stroke will occur if heat exposure continues. Symptomsinclude high body temperature (104 degrees), no sweating, flushed skin, high heart rate, rapid breathing, agitation, and confusion with unconsciousness . If not treated immediately, damage to the major organs can occur. It can lead to brain damage, seizures, delirium, coma, and death.

 If you recognize this, get the person in the shade, get to a cool place, remove clothing, and call 911. Rehydration with intravenous fluids is immediately necessary including heart rate and blood pressure monitoring. Pre-existing conditions can affect bring on heat related disorders much faster.

 The best treatment is prevention!! Stay hydrated, including potassium and sodium replacement, avoid alcohol, and get out of the heat. If a person notes any early signs or symptoms, act immediately.

3400 Americans died of heat-related illness between the years 1999-2003.

Reference: www.mayoclinic.org/diseases-conditions/heat-stroke/basics/definition/con-20032814

Heatstroke update

  Keep in mind, if someone is diagnosed with actual heatstroke, they should be admitted to the hospital for at least 48 hours to monitor for complications.

If seizures occur with heat stroke, there is a change in medication recommendations. Benzodiazopines (Valium) and, if necessary, barbiturates (phenobarbitol) are now recommended for the treatment of seizures (previously neuroleptics such as chlorpromazines-Thorazine were recommended).

 

This completes the August, 2017, Medical News Report. Remember to send me any changes in email addresses that you want on file. Also, if you are receiving these reminders, look in spam. Some have reported it gets sent there.

Next month, the subjects for September, 2017 are:

1. Penicillin allergy

2. Eczema (allergic skin disease)

3. Blood vessel disease in the abdomen

4. Obstructive sleep apnea—update

5. The Hematological system—Part 2—Polycythemia and anemia

6. Using an MRI for high risk breast cancer patients

 

As always, stay healthy and well my friends!! Dr. Sam