Merry Christmas

I will be taking some time off from blogging over the Holidays and want to wish all the readers a very Merry Christmas and a Happy New Year.

It has been a wonderful year with many blessings and I have enjoyed the discussions and conversations tremendously.

May all of you and your families find the holiday season enjoyable and enriching.

I will be back after the first of the year.

A Little Math Fun for the Holidays

YOUR AGE BY EATING OUT:

Here is a little game you can do over the holidays.

Tell someone whose age you don’t know and ask them them to do the following but without saying the answers out loud. Tell them you will then be able to tell them how old they are and how many times they like to eat out each week:

1. First of all, have them pick the number of times a week that they would like to go out to eat. (more than once but less than 10)
2. Multiply this number by 2
3. Add 5
4. Multiply it by 50
5. If you have already had your birthday this year add 1757 and if you haven't, add 1756.
6. Now subtract the four digit year that you were born.
7. You should have a three digit number.
8. Have them write down the 3 digit number

***The first digit of this was their original number. (i.e., How many times they wanted to go out to restaurants in a week.)

***The next two numbers are their age

THIS IS THE ONLY YEAR (2007) IT WILL EVER WORK, SO SPREAD IT AROUND WHILE IT LASTS

Brain changes with migraines

The latest research from the Journal Neurology suggests repetitive migraine attacks may lead to or be the result of structural changes in the somatosensory cortex (SSC) of the brain.

This could explain the high correlation with other pain disorders observed in migraine patients.

The study showed that migraine patients had their SSC 21% thicker than those of non-migraine patients.

The study did not show correlation between clinical data including migraine duration, age at onset, frequency, and disease time span.

What this actually means for patients is still unclear, but it may help explain some of the symptoms that patients describe.

Malpractice Rates

Here is a welcome news alert sent out by the ISMA and the Department of Insurance.

It appears that malpractice rates in Indiana may actually go down slightly.

This is rare but very good news.

New Type of Visa Debit

If you are having a hard time finding the right gift for someone this holiday season and if you want to show them you care, here is a new and novel type of gift card.

This gift card was launched last month by Pittsburgh-based insurer Highmark. http://www.givewell.com/.

This Visa Gift Card can be purchased in any dollar amount ranging from $25 to $5,000 and can be used to cover office visits, copays, prescriptions, vision and dental care, elective procedures, and even health club memberships.

Highmark believes this is the first of its kind and anticipates good sales.

I believe that most doctors’ offices already accept debit cards and this should be a welcome addition. Any time we can get paid immediately, it saves tremendous downstream costs for our practice.

This is a novel idea that I think may go over well with many consumers.

Turkey Stress Test

Here is a nontraditional stress test for an elderly gentleman.

While 83 year old Chuck Ritter from Traverse City, Mich. was relaxing in his apartment, an unwanted 25 lb. turkey came crashing through his window.

The on-call maintenance workers at the apartment complex tried to corral the bird but were having difficulty amid the blood and shards of glass.

Finally after about 30 minutes of trying to coax the turkey toward the window with a broomstick and a fishing pole, Ritter cornered the bird, grabbed it by the neck and threw it out the window. It is unclear whether the bird was dead at that point.

Ritter said after the ordeal that the turkey would make a nice dinner, and he was looking for a needy family to give it to.

I guess this turkey was either late for thanksgiving or early for Christmas.

Ritter’s heart seemed to hold up well under the ordeal.

Insurance Hassle

I’ve written before about the frustration from all the hassles and paperwork associated with insurance companies and the tremendous cost they add to a practice, but here is a recent example.

This is a 3 page document they want answered and faxed back to them before they will decide if my patient can continue using the medication that has helped her for the past year or more.

This patient had tried other medications and they were either ineffective or not well-tolerated.

But since her insurance changed, I now have to spend time completing this 3 page document.

This cannot be cost effective for anyone involved and puts the patients at risk for complications when their drugs are delayed or denied.

If this drug is denied, the patient and I will have to complete another process to try and get the decision overturned.

This is just one drug on one patient. The burden to the practice is becoming overwhelming!

Banning Words

Back in February of 2000 Gary Schwitzer first published an article on the 7 words that should not be used by reporters or healthcare workers. These included the following:

• 
  Cure
  Miracle
  Breakthrough
  Promising
  Dramatic
  Hope
  Victim

It was felt that each of these terms was vague and sometimes meaningless when used in a health care context.

These terms can be exciting and possibly help sell papers or move a reporter's story onto page one, but they can be also be dangerous terms that mislead vulnerable people in times of crisis.

Political correctness and the banning of certain words can also be a problem. There are terms that may describe a patient and/or their behavior that is less than flattering, but it is accurate and does add valuable information to the chart and the history.

I disagree with some reporters that using terms like incompetent cervix; the patient failed chemotherapy; or the non-compliant patient represents harmful language by healthcare workers.

Journalists may want to tone down certain words, but physicians need to accurately describe the patients and/or their condition and some of this terminology is very helpful when communicating amongst healthcare workers.

News reports that cover clinical trials also face a challenge with word choices. Trials are performed in an effort to define and decide what new treatments work and which ones don’t.

There should be unbiased reporting although in today’s era, I am not sure this is possible.

Stories shouldn't lead people to believe that the evidence of efficacy and safety is already in hand while the trials go on. "Therapeutic misconception" is a legal term referring to a situation in which people who agree to enroll in clinical trials believe there will be certain benefit from their participation in the experiment.

The clinical trial is an experiment and is not truly a treatment or a therapy, and journalists shouldn't refer to it as such until the evidence is in.

To be more accurate, using the term "patients" to refer to people who agree to enroll in trials is also incorrect in some ways. In these clinical trials, these people are research subjects or participants (more polite terms than guinea pig).

Sensationalizing by journalists can spread "therapeutic misconceptions" by hyping unproven ideas. How often do we hear about a new “wonder drug” only to have it taken off the market a couple of years later?

Words used to describe health care and medical developments are important just as they are in many other arenas. We need to choose wisely and in the appropriate settings.

Richard Horton, editor of The Lancet, understands this problem very well. He is already beginning the process of discouraging use of the word "conclusion" in scientific papers. Horton says that the notion of any single truth, or conclusion, in medicine is nonsense, and that the word, therefore, loses its meaning. "Rather," he writes, "the word interpretation implies an uncertainty that seems more appropriate. The interpretation readers take away from a piece of research depends upon their own background and perspective, as well as their own personal reading of the paper!"

Journalist and newscasters should also heed his advice.

Kid Cop

Michelle Perin is a contributor to a publication called “Police Life” and she recently submitted an article about her son and the zero tolerance policy at his school.

The principal called and explained to her that her son, a six-year-old, had taken down a fellow student at Lego® gunpoint and arrested her for robbery.

The principal told her he discussed the magnitude of the situation with her son and felt he understood the errors of his ways. Mrs. Perin wasn't so sure.

What the principal may not have fully understood was that the boys' father and stepfather are both cops.

Both he and his older brother grew up listening to tales of the street since it was part of their everyday lives.

Numerous studies show that parental influence plays a major role on their children. How often do you see kids in a family choosing career paths similar to a parent? This isn’t by coincidence.

Our current society might be taken aback by this child's oblivion to the unusualness of his games, but when taken in context, it is not unusual at all.

There is no way a 6 year old can grasp the full context of his behavior in this situation and there is no way he would understand how people outside of the immediate family environment would view the behaviors.

Several studies show how children manifest their understanding of their parent's role through interaction with peers. We need to keep this in mind when we hear about stories such as these.

In a post-Columbine America, zero-tolerance policies and the culture of fear permeates teachers, administrators and other parents. This can lead to stereotyping the children of officers, hunters, etc as potentially violent and a threat to others.

Trying to remain politically correct and always walking on eggshells is not a healthy environment. Rules are helpful to guide people and situations, but a small dose of common sense would go a long way in rectifying some of these overblown concerns.

There is a saying that goes like this;

“Raising children is like being pecked to death by chickens.”

Let’s try to help each other and not be another pecking chicken. Parenting is hard enough

Zyrtec goes OTC

The U.S. Food and Drug Administration finally approved the nonprescription use of Zyrtec-D. It will be available over-the-counter soon. It has been available by prescription since 2001.

This is a great allergy medicine and in my opinion has always worked better than Claritin (alavert). The approval for nonprescription use will enable people to have access to another effective treatment for their allergy symptoms without necessarily seeing their physician.

Zyrtec-D is a combination drug with an antihistamine and decongestant. The FDA approval means the drug can now be purchased without a prescription.

Most common side effects of Zyrtec-D include drowsiness, fatigue and dry mouth but it is typically very well tolerated.

Since the decongestant contains pseudoephedrine, it will hold the same restrictions as other drugs and will be kept behind the pharmacy counter. The illegal production of methamphetamine caused this change to occur a couple of years ago.

Stuck past Curfew

Trying to impersonate Santa Claus did not work out too well for a 17 y.o. at the Judson Center Social Services Agency in Royal Oak, Mich.

He was evidently trying to sneak back into his room because he was out past his curfew.

During his slide down the chimney, he became stuck and a worker from the center followed the moaning noise to the chimney where she found him.

Firefighters and police officers had to pull him out.

Police later said the teen appeared only to have suffered scratches on his back, but he was taken to a hospital as a precaution.

So do you punish him for breaking curfew, or do you let the natural consequences of his actions be enough, or do you punish him for breaking curfew and being stupid?

Hmm, tough questions!

Do you know what's covered?

Nearly every day, patients ask me or one of my partners one of the following questions:

"Do you know which mail-in prescription plan I have?"

"Do I have a mail-in plan?"

"Is that specialist covered by my plan?"

"Does my health insurance cover that treatment?"

"Which pharmacy should I use?"

Our answer is almost always the same:

“As a good consumer, it's your job to know what your health plan covers.”

Knowing this information will make the patient's life easier because they will know they have to use a specific hospital, lab, or pharmacy.

They will also save money and a lot of headaches if they use physicians and providers in their network.

There's no way primary care physicians can possibly keep up with the intricacies of every plan. They are too far reaching and change much too often.

Patients only have to keep up with one plan . . . their own!!

This responsibility belongs to the patient or family and it makes them better informed and better consumers of their healthcare.

In addition, when they become dissatisfied, it gives them the perfect opportunity to vent their frustrations to the people who may be able to make a difference: their plan representatives.

The take-home advice is know your coverage, know where you can use it and don't wait until you need it to find out!

Vioxx settlement

Merck & Co has recently announced and agreed to pay $4.85 billion to settle claims that its painkiller Vioxx caused heart attacks and strokes in thousands of users.

The agreement covers lawsuits filed against the company in U.S. courts, resolving a major legal battle that cost the drugmaker a third of its market value in 2004. How do you think they will make up this deficit and settlement?

In the settlement Merck did not admit Vioxx caused patient injury and did not admit fault.

The drugmaker, whose shares rose in pre-market trade on news of the deal, said it would take a charge of $4.85 billion to cover costs of the agreement.

This settlement is a reversal from what Merck previously said it intended to do regarding the lawsuit.

Merck said it will still defend all claims not included in the settlement.

This reversal may be in part related to the litigation over Wyeth's Phen-Fen diet drug that was only now coming to a close after 10 years in the courts and over $21 billion in settlement costs.

Since the withdrawal of Vioxx, Merck has won 11 court cases over the drug and lost 5. It is appealing those cases that it lost.

Merck shares tumbled on news of the withdrawal of the drug in 2004, losing more than a third of their market value. But with Vioxx victories in court, and a string of successful new medicines, the company's value has recouped those losses.

Their recoup of losses certainly couldn’t be related to the high price for the drugs; could it?

AED Use by Bystanders

People question whether automated external defibrillators (AEDs) really are beneficial in saving lives or just another gimmick to make people feel better because they were able to “do” something.

A recent review of out-of-hospital cardiac arrests showed an increase in survivors with the public availability of AEDs

There were 11 cities in the United States and Canada participating in the Resuscitation Outcomes Consortium (ROC) and the findings were presented at the American Heart Association (AHA) 2007 Scientific Sessions.

The results showed that bystander AED programs appear to improve survival from cardiac arrest greater than 2-fold over solely EMS-based defibrillation.

Another study called the Public Access Defibrillation (PAD) trial showed that training and equipping lay volunteers to use an AED in community settings doubled the number of survivors after an out-of-hospital cardiac arrest compared with training in cardiopulmonary resuscitation (CPR) alone. The survival rate went from 15% to 30% survival to hospital discharge (Hallstrom AP et al. N Engl J Med. 2004;351:637-646).

This current study included patients if they experienced a nontraumatic out-of-hospital cardiac arrest between December 1, 2005 and November 30, 2006.

A total of 10,663 patients were included; most were men, and the average age was about 60.

The bystanders who applied the AED were mostly either untrained lay bystanders or healthcare workers.

Of the arrests, about 50% occurred in private settings and 50% in public settings.
If the bystander had an AED and placed it on the patient, whether or not it ultimately delivered a shock, survival increased to 23%, and if an AED was placed and a shock given, the survival rate was 36%.

Interestingly, the survival rate was only 32% when the EMS personnel were called to the scene for a patient who was in distress but not yet in cardiac arrest, witnessed the arrest, and provided defibrillation. This survival rate was no better than the bystander doing it.

If these findings are extrapolated to the whole population of 330 million in the United States and Canada, they estimated that 522 lives would be saved each year, or 2 lives every day

Neurolgic outcomes have not been published from the data and therefore we cannot say what functional outcomes AED’s are providing but previous studies have suggested that of patients who survive to discharge from the hospital, 95% have a good or excellent neurological outcome.

Zinc and the Common Cold

Flu season is not just around the corner.

It is here and Influenza A and B have both been isolated several times in our metro area.

The "common cold" is not Influenza and is treated differently. Adults get an average of three colds per year, and children can get as many as eight to 10.

Over-the-counter medications can help alleviate the sneezing, congestion, runny nose and sore throat, but medical science has yet to find a cure.

There are dozens of advertisements for remedies, but do any actually work?

Recently, the most popular lozenges, nasal sprays and nasal gels contain the essential element zinc.

Regardless of their mode of delivery, all of these zinc treatments claim to shorten the duration and lessen the severity of a cold if taken at the first sign of symptoms.

But the real effectiveness of zinc treatments on the cold is unclear.

There are numerous studies cited on the usefulness of zinc, but there are just as many showing no benefit.

A medical student in his last year of training at the Stanford University School of Medicine decided to bring together and analyze all of the available research on zinc as a treatment for the common cold.

He along with his professors gathered every study on zinc and the common cold published between 1966 and 2006. There were 105 studies in all.

Only 14 of the 105 were so-called randomized, placebo-controlled clinical trials, considered the gold standard of medical research.

Their study, published in the September issue of the journal Clinical Infectious Diseases, found that exactly half of those 14 studies reported a positive effect of zinc on the common cold, with the other half reporting no effect.

Then the author applied a further set of quality-control criteria and after this was done, only four of the 14 studies made the cut: two that examined zinc lozenges, one that studied a nasal spray and one that studied a nasal gel.

Three of the four found that zinc had no effect on the common cold. Only the study looking at the effectiveness of nasal gel found an effect: The patients who received the zinc nasal gel had colds that lasted an average of two-and-a-half days, whereas the patients who received a placebo were sick for an average of nine days.

All Zinc cold treatments claim to work by delivering zinc to the nasal tissue that has been infected by cold viruses and scientists propose that zinc fights colds by keeping rhinoviruses, the main type of cold virus, from attaching to cells in the nose.

The theory is that if they can't attach, they can't infect. Thus if someone began zinc treatment during the early stages of a cold, he or she might reduce the number of viruses that infected the nasal cells and therefore shorten the cold's duration.

This explanation is entirely theoretical and has never been demonstrated in an experiment.

The most common side effects of zinc cold treatments are an unpleasant taste in the mouth and an upset stomach and some people who have used the nasal sprays and gels report a stinging sensation and a lawsuit was filed because of the allegation patients lost their sense of smell.

As for now, the zinc market is a multimillion dollar business with no real clinical proof it does anything.