Medicaid/CHIP: The Emergency Room Gateway to Specialists

Medicaid and CHIP (Children's Health Insurance Program) are two types of public insurance for adults and children, respectively. While these insurances provide an important safety net for people, they are notorious among health care providers for extremely low levels of reimbursement compared to other types of insurance (e.g., private, no-fault, workers compensation).

These insurances are also widely known for denying coverage for overly technical reasons (e.g., not adding a decimal point in a billing code) and for bogging health care providers down in paperwork. Accepting such patients also carries the risk of a government audit, which can have serious consequences (e.g., large fine and/or jail time) if found guilty of violating the rules.  Patients with Medicaid and CHIP also tend to have high no-show rates.

As such, many private outpatient health care providers refuse to see patients with these types of insurances. Even in public health care settings (e.g., state hospitals) where it is not legal to deny evaluations patients with these insurances due to government contracts, the numbers of patients seen per day, per week, or per month with these insurance are often capped.  These problems are becoming more and more salient across the country due to increasing economic strain caused by various factors such as declining reimbursement in general, decreased government financial aide, and the impacts of health care reform. As a result, many health care providers are under increasing pressure from the institutions they work in to bring in more money. This often means seeing more patients with higher paying insurances.

All of this creates a serious problem for patients who have Medicaid or CHIP who need to be seen by outpatient specialists (e.g., neurologists, psychologists, psychiatrists, gynecologists).  It is also a problem for the primary care physicians (PCPs) who refer these patients because without input from the specialist it is much more difficult to coordinate care.

If the patients calls the specialist office themselves, one of the first questions they will be asked is “What insurance Do You Have?” If the answer is a private insurance, the patient will often be seen relatively quickly. If it is Medicaid or CHIP, there is a much greater chance of being put on a waiting list, given an appointment many months later, or told there are no appointments at this time.  The same can hold true if a staff member from a PCPs office calls the specialist’s office to make the appointment.

Due to this problem, patients with Medicaid and CHIP and their PCPs find ways to work around these obstacles. One of the most effective ways this is done is by going to the Emergency Room (ER), even though the medical situation may not be a true emergency. In an upcoming article in the Annals of Emergency Medicine, researchers explored this topic more by interviewing 26 specialists and 14 primary care physicians in Illinois.

The results of the study confirmed much of what was discussed above, including how the ER is used by PCPs and patients to access specialty care. The study also found that specialists will often take patients from the ER out of sense of obligation and because referrals from the ER often have established mechanisms in place to distribute these patients equitably so that no one provider is seeing too many low-paying patients. Referrals from PCPs, however, often do not have such equitable distribution mechanisms. Specialists are also more likely to take patients from the ER is the specialty service is affiliated with the ER in some way (e.g., located in the same hospital). For urgent situations that a patient cannot get an outpatient specialist to evaluate for many months, showing up in the ER usually means that the specialist will be paged to see him/her that day for an evaluation.

Other factors that the study found was associated with the specialist accepting a Medicaid/CHIP patient was a personal request (i.e., call) from the PCP, informal economic relationships between the specialist and PCP, patient hardship, the more urgent the case was, and geography. With regards to the latter, it appeared that providers were more willing to see Medicaid/CHIP patients who lived closer to their office (probably because it decreased the no-show risk that can result from transportation problems).

Suggested reading: Confessions of Emergency Room Doctors

Related Blog Entry: Who Uses the Emergency Room Most? The Answers May Surprise You

Reference: Rhodes KV, Bisgaier J, Lawson CC, Soglin D, Krug S, Van Haitsma M. (2013, in press). "Patients Who Can't Get an Appointment Go to the ER": Access to Specialty Care for Publicly Insured Children. Ann Emerg Med.

Child Paralyzed after Tonsils Removed

In an upcoming article in the journal, Anaesthesia, a case study was reported in which a 7-year old boy in India developed quadriplegia after an elective surgery to remove his tonsils and adenoids. Quadriplegia is a loss of the ability to move and/or feel both arms, both legs, and the parts of the body below the area of injury to the spinal cord. The tonsils are a pair of oval masses at the back of the throat.

The adenoid is a mass of tissue behind the nasal cavity, where the nose blends into the throat. The tonsils and adenoid are often surgically removed in children if they become large enough to obstruct airflow.

During the surgery of the 7-year-old child, he was treated with two types of powerful anesthesia known as fentanyl and thiopental. This was maintained with two forms of inhaled anesthesia known as isoflurane and nitrous oxide. The muscles were relaxed with another medication (atracurium). The surgery lasted 40-minutes. After surgery, he was drowsy and not breathing spontaneously. Medication was administered to try and reverse the muscle relaxing effects of anesthesia, but the breathing problems continued, and she became agitated and weak in all four limbs.

Although residual effects of anesthesia are sometimes the cause of these problems, the authors of the case report noted that a more serious cause should be explored the longer they persist. Initially, no obvious cause could be found. To investigate the situation further, the boy was sent for an x-ray and MRI (magnetic resonance imaging) of the spine. MRI scans produce extremely detailed pictures of the inside of the body by using very powerful magnets and computer technology. The results revealed a previously undetected condition known as atlanto-axial instability (AAI), which is increased flexibility between the first and second bones of the neck. He underwent surgery to fixate these bones and had  a slow but complete recovery of motor power over 7-months. He still needs some slight supplemental oxygen support.

As it turns out, the child has been evaluated before surgery for what were signs and symptoms of AAI, but the doctor falsely attributed them to failure to thrive due to tonsil disease despite a neurological exam showing weakness in the arms and legs, muscle wasting, and abnormal reflexes. The signs and symptoms included tiredness, poor weight and height gain, difficulty climbing stairs, and mild neck pain,

Because AAI was not recognized, when the head and neck were moved around during the surgery, the authors stated that the head hyperextended which resulted in a subluxation (signification structural displacement ). This, in turn, caused compression of the cervical spine. This compression causes impairment of the nerve signals that normally travel through this area of the spinal cord. It resulted in quadriplegia in this case because the compression was in the cervical (neck) region below which impulses regarding sensation and movement travel to and from the arms and legs.

The authors noted that the most common warning sign of AAI (85% of cases) is neck pain and headaches in the back of the head that radiate to towards the top of the head.  However, because signs and symptoms of AAI may be misinterpreted and because some patients may have no signs and symptoms, the only definitive way to detect it is with diagnostic imaging. Although the authors did not suggest performing x-rays or other imagine scans on patients before surgical procedures, it would be the only way to know for sure. However, exposure to radiation from x-rays and high financial causes of more advanced scans are likely barriers to this happening.  

Suggested reading: Walk, Don't Run: One Woman's Battle with Quadriplegia, A Memoir of Hope and Healing
 
Reference: Agarwal J, Tandon MS, Singh D, Ganjoo P. (2013, in press). Quadriplegia in a child following adenotonsillectomy. Anaesthesia.

Ovarian Tumors in Children: They Happen

When people think of ovarian tumors, they most commonly think of women. However, ovarian tumors (also known as neoplasms) can also occur in children. Tumors are abnormal masses of tissue that form when cells in a certain area of the body reproduce at an increased rate.

The ovaries are a pair of glands that contain the eggs (female reproductive cells) and produce female hormones. Hormones are natural chemicals produced by the body and released into the blood that have a specific effect on tissues in the body.

Most ovarian tumors in children are known as germ cell tumors. As the name implies, these are tumors derived from germ cells. Germ cells are any cells that give rise to other cells that fuse with another cell during fertilization. These types of tumors can be cancerous (malignant) or non-cancerous (benign). Cancer is any of a large group of malignant diseases characterized by an abnormal, uncontrolled growth of new cells in one of the body organs or tissues.

The second most common type of ovarian tumor in children is the surface epithelial neoplasm, although information about them in children is limited. These tumors can also be cancerous or non-cancerous and arise from the epithelial surface of the ovaries, endometrial tissue (lining of the uterus) that is out of place, of Fallopian tube tissue. The uterus is a hollow organ in a female's body where the egg is implanted and the baby develops. Fallopian tubes are two structures that serve as passageways from the ovary to the uterus.

In an upcoming issue of the American Journal of Surgical Pathology, researchers reported detailed findings on surface epithelial neoplasms in children at the Stanford University School of Medicine between 1974 to 2010. Over that 36 year time frame, the researchers found 69 such tumors in 64 children. In 57.8% of the cases, the tumors were non-cancerous. In 37.5% of cases, the tumors were of borderline/low malignant potential. Only 4.7% of these tumors were malignant but no high-grade tumors (fast growing and aggressive) were found. This is unlike adults, where a high percent of high-grade ovarian tumors are found.

The types of surface epithelial neoplasms in children were classified as serous, mucinous, or mixed (different subtypes combined). The serous tumors are filled with serous fluid, a type of pale yellow and transparent body fluid. The mucinous tumors are made of epithelial cells in which the apical surface is lined with mucin (a gel-like secretion). The apical surface is the part of the cell exposed to the lumen (the inside space). 

Of the 64 children, 17 had follow-up data obtained on average 22 years later. Of these patients, recurrences occurred in about 12% of benign tumors, 33% of borderline/low malignant potential tumors, and 100% of malignant tumors. Recurrences occurred anywhere between 11 to 144 months after initial diagnosis and mostly occurred in the same ovary suggesting that incomplete surgical removal of the tumor was the likely cause of recurrence. Recurrence rates were similar in the 3 subroups (serous, mucinous, mixed). While all children with benign and borderline/low malignant ovarian tumors survived, only half of children with malignant ovarian tumors survived.

The authors noted that although two patients were treated with chemotherapy and one with sterilization procedures, that most cases can be treated by surgically removing the tumor. The researchers advocated for uniform treatment models, conserving the ovary, and trying to preserve fertility in any child with a suspected ovarian surface epithelial lesion.

Suggested reading: Memoir of a Debulked Woman: Enduring Ovarian Cancer

Related blog entries: Ovarian Cancer: Treatment with Avastin

Childhood Tumors: How PET/CT Scans Can Help
 
Reference: Hazard FK, Longacre TA. (2013, in press). Ovarian Surface Epithelial Neoplasms in the Pediatric Population: Incidence, Histologic Subtype, and Natural History. Am J Surg Pathol..

Rocky Mountain Spotted Fever: Knowledge Gaps in Health Care Providers

Rocky Mountain spotted fever (RMSF) is the most deadly and most common illness caused by Rickettsia, a group of bacterial parasites. A parasite is an organism that lives in or on another organism to obtain nourishment. The specific type of Rickettsia that causes RMSF is known as Rickettsia rickettsi, which is spread by a group of ticks known as Dermacentor ticks (American dog ticks).

Signs and symptoms of Rocky Mountain spotted fever include an acute (sudden) onset of fever, muscle pain, and headache one to two weeks after a tick bite. This makes RMSF initially appear flu-like, which can delay accurate diagnosis and treatment. This is followed by a rash in about 80-90% of cases. The initial rash begins about 2 to 5 days after fever onset and is initially small, pink, flat, and not itchy. The rash begins on the arms and legs and moves towards the trunk. The spotted rash for which the disease is named after is red but only develops in 35 to 60% of cases. The disease can affect the brain, kidneys, intestines, and lungs.

RMSF can cause severe long-term health problems, which is why knowledge of proper treatment is essential. Delays in treatment can cause severe problems including paralysis, loss of hearing, amputation, loss of bladder control, loss of bowel control, disorders of speech and movement, and death. Standard of care treatment for adults and children of all ages is antibiotics, specifically doxycycline. Doctors recommended beginning this treatment even before laboratory confirmation of the disease. The treatment continues for at least three days after the fever stops and until there is clear improvement of the patient. Treatment usually lasts for a total of 5 to 10 days, but can last longer in more severe cases.

RMSF gets part of its name from the Rocky Mountain Laboratories, which is where much of the early research in this condition began. The disease can and does present throughout most of the U.S. and some other countries. Thus, it is not isolated to the Rocky Mountain region. One state outside of the Rocky Mountain region where RMSF is very common is Tennessee. This is because the tick that causes the disease is common in the southeastern U.S.

In the most recent issue of the American Journal of Tropical Medicine and Hygiene, researchers presented the results of a survey of 1,139 Tennessee healthcare workers (physicians, nurse practitioners, physician assistants) on their knowledge, perceptions, and attitudes on RMSF diagnosis and treatment. About 90% of those surveyed were current practicing and most surveyed were physicians. The response rate in the study was low (14%) which limits the generalizability of the results.

While 93% of respondents correctly identified that doxycycline was a treatment they would use in RMSF, only 39% correctly identified that doxycycline was the treatment of choice for RMSF in children younger than age 8. This was particularly a problem among family medicine and emergency room physicians, which can lead to unnecessary deaths among children. Twenty percent of providers preferred to wait for a rash to develop to initiate treatment, which is a problem because by the time a rash develops (if it develops) it may be too late to begin effective treatment.

Only 42% of providers correctly identified the fatality rate of untreated RMSF. Although correct diagnosis of RMSF requires laboratory testing, 26% of providers stated that they always or almost always treat RMSF without laboratory testing. Fortunately, most providers were aware that RMSF is common in their region and that the condition should still be considered if the patient does not recall a tick bite.

Doctors practicing emergency medicine, internal medicine, and family medicine; and nurse practitioners, physician assistants, and providers practicing for less than 20 years demonstrated less knowledge regarding RMSF. Thus, providers with more education and experience were more knowledgeable of RMSF. The authors suggested targeted educational campaigns about RMSF, particularly focused on the need to treat patients less than age 8 with doxycycline.

Suggested reading: Rocky Mountain Spotted Fever: History of a Twentieth-Century Disease

Reference: Mosites E, Carpenter LR, McElroy K, Lancaster MJ, Ngo TH, McQuiston J, Wiedeman C, Dunn JR. (2013). Knowledge, Attitudes, and Practices Regarding Rocky Mountain Spotted Fever among Healthcare Providers, Tennessee, 2009.Am J Trop Med Hyg. 88(1):162-6.

Individual Medical Insurance: Making the Right Choice

Beginning on January 1, 2014, most Americans will be required to have individual medical insurance. For those who are not currently insured and for those whose employers decide to drop their health insurance coverage, they will need to decide how to pick an insurance company that best meets their personal and family needs. 

One feature that is helpful to look for is whether the health insurance company allows you to lock in the rate for an extended period of time (e.g., one to three years). This is important, because insurance companies can raise their rates during the year. The trade-off is that you are paying a modest amount more initially to lock in the guaranteed rate. Another useful feature is whether the plan offers supplemental cancer coverage and critical illness coverage which can both help protect you from expenses that are not covered by the primary insurance company. Thus, it is very important to understand the annual coverage limits of the primary insurance company when signing up and if you have the option of buying more coverage if needed. It is also important to know if the insurance pays for prescription drug coverage and diagnostic testing.

Lastly, it is also important to understand the distinction between an HMO (health maintenance organization) or a PPO (preferred provider organization). In an HMO insurance plan, you will receive all or most of your care from a provider contracted with the insurance company and it is required for a primary care physician (PCP) to coordinate your healthcare by making referrals to other in-network providers. In a PPO, the insurance plan contracts with a network of health care providers from who you can chose, it is not required to select a PCP, and you can make appointments with specialists without a referral (unless the specialist has a policy requiring this). In a PPO, you can chose a provider outside of the network, but this will likely cost more. Generally speaking, PPOs are the better option due to the added flexibility they provide.

Childhood Tumors: How PET/CT Scans Can Help

When patients are evaluated for a possible tumor, the types of scans they hear about most often are CT (computerized tomography) scans and MRI (magnetic resonance imaging) scans. CT scanning is an advanced imaging technique that uses x-rays and computer technology to produce more clear and detailed pictures than a traditional x-ray. MRI scans produce extremely detailed pictures of the inside of the body by using very powerful magnets and computer technology.

CT scans and MRI scans are known as structural scans because they provide important information about the structure of the body. However, these scans do not provide information about how the area that is pictured actually functions.

There are other types of scans known as functional imaging scans which do provide this important information about function. One such imaging technique is known as a PET scan. A PET scan involves injecting the patient with a small radioactive chemical and being placed in a machine that detects and records energy given off by the substance. The computer translates the energy into 3D pictures which provides information about how cells in the body are functioning because normal cells react differently to the chemical than healthy cells. One type of chemical injected is known as FDG (fluorodeoxyglucose), which is a type of radioactive glucose. When a PET scan uses this substance, it is known as FDG PET.

One problem with functional imaging scans is that they do not provide good information about structure. This problem is solved by combining PET scan data with CT scan data, so that functional imaging data can be superimposed on structural imaging scans. When PET and CT scan data are combined, this is known as PET/CT and can be used to scan the entire body.

In the current issue of the American Journal of Roentgenology, researchers in Toronto, Canada, examined whether FDG PET/CT could reliably differentiate malignant (cancerous) tumors from benign (non-cancerous) tumors in 21 children (13 girls, 8 boys). Tumors are abnormal masses of tissue that form when cells in a certain area of the body reproduce at an increased rate.

The question of whether FDG PET/CT can do this is important because by itself, FDG accumulation can occur in benign masses as well as malignant masses during PET scans. To solve this problem, measuring cell uptake of FDG at two time points (instead of one) is performed, which is known as dual-time imaging. The reason this is done is because FDG is absorbed differently over time in benign and malignant processes. Essentially, malignant lesions will show an increase in FDG uptake (absorption) over time whereas benign areas will remain stable. The uptake of FDG glucose is known as the standardized uptake value (SUV).

In the study reference above, scan 1 was performed 60 minutes after FDG injection. Scan 2 was performed about 2 hours after the first scan. In children with malignant disease, the results showed that the average SUV increased from 7.3 to 10.9 between the two time points. In children with benign masses, the average SUV changed from 4.5 to 4.2 between the two time points. The researchers concluded that dual time point FDG/PET CT is useful in distinguishing malignant disease from benign processes in pediatric patients.

Suggested reading: Happily Hungry: Smart Recipes for Kids with Cancer

Related blog entry: Ovarian Tumors in Children: They Happen

Reference: Costantini DL, Vali R, Chan J, McQuattie S, Charron M. (2013). Dual-Time-Point FDG PET/CT for the Evaluation of Pediatric Tumors. AJR Am J Roentgenol. Feb;200(2):408-13

Chronic Pain: Know the Causes and Risks

All of us have experienced pain of some form in our lives; whether it was the slight bruises of childhood or a stomach ache, we know the feeling. But chronic pain is a slow eater that most of us are unaware of. Unlike the temporary/acute form of pain, chronic pain can be devastating and life changing.

Chronic pain does not attack anyone in a certain age group or in a specific medical condition. It can become a liability on anyone. Untreated pain (and other untreated symptoms) can grow into a fierce form of chronic pain that can put a lot to risk.

Any physical trauma ranging from an injury to an illness can become a chronic nuisance if not treated on time. Chronic pain is any pain that lasts for months or years, and does not necessarily remind one of an untreated medical condition. The pain can be experienced in two situations: after treating an injury e.g. arm pain after treatment of an arm fracture, or due to some uncured (or probably unidentified) illness. The latter form is rather alarming and beckons for immediate attention.

Chronic pain must be probed immediately for its cause, as it can be associated to serious conditions like arthritis or cancer. In some cases, the pain might not have any origin at all; it could be a chronic muscular pain.

The most common cause is an injury that took place in an accident or even something like carpal tunnel. No matter what the case, the pain can be excruciating and majorly affect the person’s lifestyle.

In all instances, the pain must never go untreated. Immediately consult a medical facility to get advice from pain management doctors and chronic pain experts. You will be given advice on how to control the chronic pain, and eliminate it completely. Just how the pain takes months to become a permanent pest in your body, it will take some time to go away.

Treatment of chronic pain is not very effortless; apart from pain-relieving medication you will need to alter your lifestyle to make it healthier. Doctors suggest exercises, yoga, meditation, balanced diets and even acupuncture for pain treatments. A healthy lifestyle will help the body stay in shape, and combat the causes of pain more efficiently.

Those suffering from chronic pain also suffer from emotional distress, anxiety, insomnia, and even immobility. The pain can greatly affect a person’s quality of life and morale, causing long-term depression to seep in and create further problems. In more severe cases, patients might need to consult an emotional therapist in order to come back to normal life.

Untreated pain can have severe physical and emotional consequences. Never leave a pain treatment for tomorrow; you never know what might be causing the pain in the first place. In most cases, it is the non-drug treatments and lifestyle improvement that make the most difference. Treat pain before it becomes chronic and almost invincible; the sooner the better!

The above post is a guest blog post.

A New Technique to Treat Foot Infections in Diabetes

Diabetes mellitus is a complex, chronic disorder in which the body is not able to effectively use a natural chemical called insulin. Insulin's main job is to quickly absorb glucose (a type of sugar) from the blood into cells for their energy needs and into the fat and liver cells for storage.

Because of this, high sugar levels can occur in people with diabetes which can damage the body. For example, people with diabetes are more prone to infections because high levels of sugar in the blood make it more difficult for the body to fight against infections.

One common area where infections are likely to occur in diabetes is the feet. This is because the accumulation of sugar can damage nerve fibers in the feet, causes decreased sensation, and poor blood circulation. This makes the feet more prone to ulcers (open sores), infection, and eventually gangrene (tissue death due to poor blood supply or infection of a wound). In the worst case scenario, this can lead to amputation of the foot or feet to prevent a more widespread and potentially deadly bodily infection.

When diabetic foot complications arise, they can be difficult to manage and treat because people with diabetes often have other medical diagnoses (e.g., kidney problems, heart problems) that make it more difficult to maintain adequate levels of antibiotic medication at the site of infection without causing harmful effects (e.g., organ damage) on the body as a whole. This can lead to ineffective treatment.

As a result of this problem, new methods are needed to deliver targeted antibiotics to the infected limb for extended periods while limiting harmful effects on the rest of the body. In the current issue of the American Journal of Translational Research, researchers reported success for the first time with a new non-surgical technique designed to accomplish exactly that and the hope is that this can be applied to humans, particularly those with diabetic foot infections.

In the study, the hind limb of 11 sheep was treated with an antibiotic named Gentamicin using one of two methods. The first method was standard intravenous administration to 6 sheep, as would typically occur in a hospital. The second method was a technique known as a percutaneous recirculation circuit. As the name implies, this technique involves establishing a circuit of blood supply by inserting a catheter (flexible plastic tube) in the femoral vein (large vein in the leg) and femoral artery (large artery in the leg). An artery carries blood away from the heart, whereas a vein carries blood to the heart.

The system caught the venous return of blood via the catheter, re-oxygenated it with a special device known as a membrane oxygenator, and returned it to the femoral artery with a special pump called a roller pump. In this way, when medication was administered via this system, it was kept more localized to the hind limb.

To test how much Gentamicin was in the hind limb, tissue samples of the back limb were taken, which included bone, skeletal muscle, and synovial (joint) fluid 30 to 60 minutes after the medication was administered. After the 60-minute point, the animals were euthanized and samples of the liver, kidney, and lung were taken to determine how much Gentamicin was present.

The results of the study showed that there was a significantly greater amount of Gentamicin in the bone, skeletal muscle, and joint fluid of those receiving Gentamicin via the circuit method versus compared to the standard intravenous method.  In fact, there was 10 times the amount of Gentamicin found in the joint fluid, which the authors stated could serve as a reservoir for longer effectiveness. With the circuit system, there was a non-significant amount of Gentamicin found in the liver, lung, and kidney. The difference in antibiotic levels in these organs was not significantly different between the two groups but there was a trend for less antibiotic levels in these organs with the circuit method.

The authors concluded that the circuit method is a safe and effective non-surgical method to deliver a greater amount of antibiotic to the affected limb without causing greater harm to the rest of the body. The authors stated that this method may be directly useful for patients with diabetes who are at high risk of tissue or limb loss due to infections that are otherwise non-responsive to treatment.

Suggested reading: The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes

Reference: Byrne, M., Idrizi, R., Power, J., Kaye, D. (2013). Percutaneous re-circulating isolated limb perfusion of gentamicin in a large animal model: targeted delivery of gentamicin to limb. Am J Transl Res, 5(1):47-52

Is Your Drinking Water Contaminated by Utility Poles?

These days, many people purchase bottled spring water, bottled filtered water, and/or have their own water filtration system attached to their faucet. This is partly due to improved taste perceptions but is also often due to fears of water contamination. While public water is usually safe to drink there are always exceptions. The risks are increased with private well water.

In the most recent issue of the American Journal of Public Health, researchers described two scenarios of private drinking water being contaminated from utility poles treated with pentachlorophenol (PCP). PCP is a chemical that is used as a wood preservative to coat utility poles in the U.S. This helps utility poles last for 35 years as opposed to 7 years when untreated. PCP is also used as a pesticide and disinfectant and is also used as a wood coating for railroad ties.

PCP is known to be highly toxic and can degrade slowly in the environment (taking up to 5 years depending on the bacteria present in the soil). It can cause harm to the body by short-term exposure to high levels or from long-term exposure to low levels. PCP can damage multiple organs and body systems such as the brain, kidneys, and liver. It can also poison the blood and is known to be carcinogenic (cancer causing).

In the U.S., PCP levels in the water supply must be measured by water companies and disclosed to the public if it exceeds a certain level (0.001 milligrams per liter). A milligram is one thousandth of a gram so only a very small amount of PCP is allowed in water.

In the study in the American Journal of Public Health, two scenarios in Vermont were described in which private drinking water was contaminated by PCP from utility poles. Specifically, two people called the Vermont Health Department due to chemical-like (e.g., gasoline smell) smell in their drinking water, one from a shallow dug well and another from a private spring. In the first case, the cause was determined to be a utility pole coated with PCP that was likely in contact with the water table. In the second case, the cause was three new utility poles placed by a private spring. Both people were advised to avoid contact with the water.

When the water was tested, the PCP level was 2.06 milligrams per liter in the first case (2000 times the accepted level) and 0.007 milligrams per liter in the second case. In both cases, the utility company replaced the PCP poles with non-treated cedar poles. In the first case, a new well was dug. In the second case, a filtration system was put in place. The water then tested negative for PCP in each case.

Interestingly, the authors note that environmental regulations do not apply to PCP treated poles. For example, while the Environmental Protection Agency can regulate the sale and use of pesticides, there is an exemption if pesticides are used as a protective treatment. The authors recommended better utility pole placement guidelines (e.g., not near wells), using non-treated poles, cement/metal poles, or less toxic wood treatments, and removing legal exemptions for utility poles.

Suggested reading: The Drinking Water Book: How to Eliminate Harmful Toxins from Your Water

Reference: Karlsson L, Cragin L, Center G, Giguere C, Comstock J, Boccuzzo L, Sumner A. Am J Public Health. (2013). Pentachlorophenol Contamination of Private Drinking Water From Treated Utility Poles. 103(2):276-277.

Preventing Post-Partum Depression in Adolescent Mothers

Post-partum depression (PPD) is a type of depressive disorder that occurs in a parent after childbirth, although it usually occurs in the mother. It is a fairly common problem, with prevalence rates estimated to be as high as 25%.

Signs and symptoms include but are not limited to frequent crying, sadness, irritability, anxiety, social avoidance, tiredness, sleep disturbance, appetite changes, disinterest in the infant, and fear of being left alone with the infant.

PPD onset occurs within 4 weeks after childbirth but usually begins about two weeks after childbirth. The depression typically lasts between several months and 12 months.The cause of PPD is not well understood, although several possible causes in mothers include hormonal changes, vitamin deficiency, lifestyle changes, or a response to inadequate social support. However, there are contradictory studies supporting and refuting some of these hypotheses.

There are numerous treatments available for PPD which include medication, psychological counseling (individual and/or group), dietary changes, and behavioral changes (e.g., improved sleep routine). However, the ideal situation is to prevent PPD from occurring in the first place. Presently, methods of preventing PPD include educating pregnant women about the risks of PPD, proper exercise, and a nutritious diet.

In an upcoming study published in the American Journal of Obstetrics & Gynecology, researchers in Rhode Island reported on the results of a randomized controlled trial to study the effectiveness of a psychological intervention to prevent postpartum depression in adolescent mothers (13 to 17 years old at time of conception) who were pregnant for the first time.

There were 106 mothers in the study. Subjects were not included if they had prior treatment for a mental health disorder or current evidence of an emotional disorder, substance abuse, or psychosis (disengagement from reality). In terms of race, 53% of mothers were Hispanic, 17% were black, and 16% were white.

Of the 106 mothers, 54 were randomly assigned to a new intervention program and 52 (the control group) were assigned to a standard educational program. The new intervention program was known as REACH (Relaxation, Encouragement, Appreciation, Communication, and Helpfulness) and is specifically geared towards adolescents.

REACH is based in a type of therapy known as interpersonal therapy. As such, the program teaches communication strategies to better manage conflicts before and after delivery, how to manage stress, education about motherhood and depression, how to develop a healthy social support system and relationships, how to set realistic goals, and educating the mother about psychosocial resources. All mothers (in the REACH group) and the control group, were provided with the book Baby Basics: Your Month By Month Guide to a Healthy Pregnancy. However, the control group was not provided with access to the material from the REACH program.

The programs took place before delivery of the infant. Each program took place once a week for five weeks with the session length being 30 to 60 minutes. The mothers were monitored at 6 weeks, 3 months, and 6 months after delivery to monitor for depression. The overall results showed that mothers receiving the REACH intervention had half the rate of depression (12.5%) than mothers receiving the non-REACH control program (25%), supporting the usefulness of the REACH intervention.

Suggested reading: Postpartum Depression For Dummies

Related blog entries: Anti-depressants in Pregnancy: What are the Risks?

Reference: Phipps MG, Raker CA, Ware CF, Zlotnick C. (2013, in press). Randomized controlled trial to prevent postpartum depression in adolescent mothers. Am J Obstet Gynecol.

Klinefelter Syndrome: An Underdiagnosed Genetic Disorder

Each person has 23 pairs of chromosomes (46 in total). One of each pair of chromosomes is inherited from the mother and one of each pair is inherited from the father. The 23rd pair of chromosomes is involved in determining gender. The 23rd pair of chromosomes consist of X and/or Y chromosomes.

As the names imply, an X chromosome is shaped like an X, whereas a Y chromosome is shaped like a Y. If a person has two X chromosomes, the person will develop as a female. If a person has an X and a Y chromosome, the person will develop as a male.

In Klinefelter syndrome, the male has at least one extra X chromosome which is why it is known as XXY syndrome or 47,XXY (since there are 47 chromosomes). Because of the extra X chromosome, Klinefelter patients can present with more feminine features such as less hair on the face, armpits, and groin and less masculine features such as small testes which makes it the most common genetic cause of infertility. Many Klinefelter patients tend to be tall with abnormal body proportions. The more X chromosomes present, the more of these abnormal bodily features for males tend to be present.

Klinefelter syndrome is believed to be present in 1 out of every 500 to 1000 male births. While some patients with Klinefelter syndrome show some of signs noted above, the only way to definitely diagnose the condition is by genetic testing.

Klinefelter syndrome is incurable. It is treated with testosterone supplementation at birth (if identified then), which can help normalize body proportions and yield more body hair but it does not treat infertility. Psychological counseling is sometimes used to treat depression and anxiety that results from feeling different. Early identification of Klinefelter syndrome can also help better understand the learning difficulties known to occur in the condition, which typically involves decreased verbal abilities.

In a recent article published in the American Journal of Medical Genetics Part C (Seminars in Medical Genetics), researchers in Denmark published age specific recommendations for medical management in four ranges: ages 0-2, ages 3-10, puberty, and adulthood summarized in a helpful and easy to use table. It is particularly important for health care providers to be more aware of Klinefelter syndrome and these age specific treatment recommendations because as the researchers note, the condition is highly undiagnosed (75% undetected) with only 10% of cases diagnosed before puberty. Typically, Klinefelter syndrome is diagnosed in adulthood during evaluations for infertility. This is troubling because as noted previously, early detection and treatment can improve the lives of these patients.

Suggested reading: Living with Klinefelter Syndrome
 
Reference: Aksglaede L, Link K, Giwercman A, Jørgensen N, Skakkebaek NE, Juul A.(2013). 47,XXY Klinefelter syndrome: Clinical characteristics and age-specific recommendations for medical management. Am J Med Genet C Semin Med Genet.163(1):55-63

Fetal Alcohol Syndrome or Not? The Shocking Results

Fetal alcohol spectrum disorder (FASD) is a broad term which refers to birth defects in the fetus caused by high maternal levels of alcohol consumption during pregnancy. A fetus is a developing human that is inside the mother from the end of the 8th week to birth. There are numerous FASD subtypes, the most common of which is fetal alcohol syndrome (FAS).

FAS, which was first described in 1968, is a pattern of mental and physical deficits that involves specific facial abnormalities (e.g., small eye openings, thin upper lip), growth failure, and is the leading cause of mental retardation in the Western world. For patients who do not meet full criteria for FAS (e.g., have slight facial abnormalities, normal growth) a diagnosis of partial FAS can be given. Some use the terms fetal alcohol effects, alcohol-related birth defects, and alcohol-related neurodevelopmental disorder but each have been sources of controversy.

Diagnosis of FASD relies on clinical coding system criteria but there are no objective biomarkers (e.g., blood test results, imaging findings) to confirm the diagnosis. As a result, the condition can be over-diagnosed.
Children presenting with signs of FASD are sometimes referred for genetic testing during the course of a diagnostic evaluation to determine is there may be another explanation for the patient’s presentation although this is not routinely done. In a recent article in the American Journal of Medical Genetics: Part A, researchers from The Netherlands evaluated 27 children referred to a genetics department between 2005 and 2010 who were suspected of having FASD. The results may surprise you.

First, when the researchers applied the most widely used coding systems for FASD based on clinical criteria (e.g., facial abnormalities, growth abnormalities), they found that more than half of the children did not meet criteria for FASD. Even more interesting is that 30% of the children appeared not to have confirmed prenatal alcohol exposure. Two of these children were found to have abnormal microstructural rearrangements of chromosomes (structures that contain genes). Genetic testing also found that in 92% of children had factors other than prenatal alcohol exposure that could have affected their intellectual functioning, such as social deprivation and intellectual disabilities inherited from family members.

The lesson from this study is that things are not always as they seem and that clinicians need to think critically when evaluated cases of suspected FASD. This includes referral for genetic testing.

Suggested reading: A Mother's Story of Raising a Child with Fetal Alcohol Syndrome
 
Reference: Abdelmalik N, van Haelst M, Mancini G, Schrander-Stumpel C, Marcus-Soekarman D, Hennekam R, Cobben JM. (2013). Diagnostic outcomes of 27 children referred by pediatricians to a genetics clinic in the Netherlands with suspicion of fetal alcohol spectrum disorders. Am J Med Genet A. 161(2):254-60.

Uses and Applications for Stem Cell Research

Stem cell research and development has been around for a little while now, but it is still surrounded with controversies. In spite of these battles however, research has managed to make a number of advancements and discoveries that can benefit people like nothing else available.

Although the controversy may never completely go away, it is helpful for people to know more about and understand how stem cell research is done, and what it can do for people and the medical community.

What Is a Stem Cell and How Can It Be Used?

According to the Mayo Clinic stem cells are the “raw material” or cells our bodies are made of and they are where all other “cells with specialized functions are generated.” So much of what makes these cells valuable and controversial is that they can be divided to make more cells. This can help people with certain diseases or injuries by creating new and healthy cells for someone’s blood, brain, heart muscle, and bones.

Traditional Stem Cell Harvesting

Typically the stem cells are harvested from the inner cell mass of a growing embryo. When this inner mass is removed, the embryo is no longer viable and is destroyed. The traditional harvesting method is commonly referred to as somatic cell nuclear transfer. In this process a nucleus is removed from a somatic cell and placed into a donor egg that has had its center removed leaving it to act like a fertilized egg that divides into new cells. One of the ethical dilemmas in this procedure is that this egg could potentially grow and form into a human being.

What is Going on with Research Right Now?

A lot of the controversy over stem cell research is how the scientists harvest or recover the cells because the ones that are most valuable are embryonic cells that have to come from newly formed embryos that are less than a week old. Recently however there is new technology developing to help called Altered Nuclear Transfer which is supposed to allow for stem cells to be removed without having to destroy the embryo. In ANT an embryo is not actually created but instead the nucleus of the somatic cell is altered through genetic reprogramming so that the cell DNA produces stem cells but no embryo.

Benefits from Stem Cell Research

As researchers have been diligent in their stem cell research and used applications like custom antibody production to identify, separate, and examine proteins as well as sorting and classifying cells they have been able to find a number of huge benefits in using stem cells. Just a few conditions that healthy stems cells can help with are:

•         Transplant needs
•         Parkinson’s
•         Type I diabetes
•         Arthritis
•         Burn victims
•         Cardiovascular diseases
•         Alzheimer’s
•         Birth defects
•         Spinal cord injuries
•         Help fight cancer
•         Stroke victims

The healthy stem cells help to replace or repair damaged cells that are causing the patients’ health problems and can allow for restorative treatments and cures.

The Future of Stem Cells

Susan Solomon, the co-founder of the New York Stem Cell Foundation refers to stem cells as the “black boxes for diseases”. Aware of the controversy over embryonic cells, she is excited about pluripotent stem cells now being created. These are skin cells altered for use, which could cut down on or even eliminate the need for embryonic stem cells.

Stem cell research and application has come a long way. But it is clear that with all of the good it has done, there is still a long road ahead.

The above post is a guest blog entry.

Suggested reading:  The Stem Cell Hope: How Stem Cell Medicine Can Change Our Lives

Understand Prescriptions and Their Costs

Living in the decade you do, you are lucky to be able to utilize the science and technology around you. One of the areas where science has greatly advanced is in prescription medications.

Because of these advancements individuals can take medication for things that years ago could have done serious harm or even killed them. Now there are medications that can help your heart, your love life, pain and inflammation, and even medicine that has helped change people’s outlook for diseases like AIDS and HIV.

Moldy Bread Saved the World

Antibiotics were one of the biggest game changers in modern medicine. Since Alexander Flemming’s discovery bacterial infections like the mumps, measles, and common cold that were once killers throughout society, are all but history. Zithromax has become a top antibiotic to give to people for respiratory infections, skin infections, STD’s and so much more. It is a popular antibiotic to give because it has convenient and easy dosing, and it has relatively little side effects. The average cost for this medication is $44.

Helping High Cholesterol

Lipitor has been a leading drug in the fight against high cholesterol for a number of years now. It was ranked number 7 on Forbes’ The Most Popular Prescription Drugs, and totals around 51.5 million prescribed users. However it also cost people an average of $136 a month and can be a reason why scientists need to continue to look for more options in battling cholesterol.

Treating Anxiety

Alprazolam, or sometimes known as Xanax, is one of the more common drugs to help people who suffer from anxiety. This mood stabilizer has been popular since the late 1980s and is regularly prescribed to about 44.4 million people a month. The average cost a user pays is about $70.

Expensive Prescriptions

A struggle people have today with prescription medication is that although science has given us amazing medicines, there can be big price tags to go with them. A few are:

•  Folotyn- Cancer drug: $320,000 a year.

•  Elaprase- Fights Hunter syndrome: $375,000 a year.

•  Soliris- Treats paroxysmal nocturnal hemoglobinuria: $400,000 a year.

Why High Drug Costs?

One reason why prescription costs are so high is because of expensive pharmaceuticals. There are people who have rare diseases that need medication that can run up to hundreds of thousands of dollars a year. There are even more people who need drugs to fight conditions like cancer and multiple sclerosis that can cost $50,000-100,000 per person a year. Also, there is no regulation is the US for prescription drug prices.

How Can People Afford Medication?

It is imperative that doctors and scientists continue to do research and look for cures. Just like with the discovery of antibiotics there may be serious diseases around today that can be eradicated tomorrow. In the meantime people can participate in money saving prescription plans like the Big Apple Rx, which is free and available to anyone who lives in New York City. You simply print out the card and use it for discounts when you go to purchase your medication. According to news sources this program alone save Brooklyn residents $295,000 and overall city residents overall $3 million.

Modern medicine is certainly something to be thankful for, but we’re not ready to rest yet. There is still plenty of work to do on cures, advancements, and more cost effective treatments. However, cities and independent businesses are helping with prescription savings plans and people are finding ways to get their medication safely and affordably. Knowing your options can help you as a consumer too.

The above entry is a guest blog entry.

Autism and Schizophrenia: Shared Genetics?

Autism (autistic disorder) is a type of neurodevelopmental disorder that causes impairments in social interaction, impairments in communication, and restricted, repetitive, and stereotyped patterns of behavior, interests, and activities.

The onset of autism is always prior to three years of age. Schizophrenia is a neurologically based mental disorder in which one loses contact with reality, experiences abnormal thinking, and has poor emotional responsiveness. The onset of schizophrenia is typically in the late teens to mid 30s.

Unlike autism, schizophrenia does not have an onset prior to age three. In fact, even onset of schizophrenia during adolescence is rare. If schizophrenia does present in childhood/adolescence, it presents after years of normal or near normal development (assuming no other condition is present). It is possible for someone with autism to later develop schizophrenia and some studies (not all) have shown that autism increases the risk for schizophrenia.

Unlike schizophrenia, autism does not present with prominent delusions of hallucinations. A hallucination is a strong sensory perception that one has of an object or event while awake, when no such object or event exists. A delusion is a persistent false belief that is strongly held despite clear evidence that the belief is actually false.

Despite their obvious differences, autism and schizophrenia share some common features. This includes disturbances in language, affect (the outward way a person shows feelings/emotions), and problems relating socially to others. Both conditions are also known to be associated with rare structural genetic abnormalities. These abnormalities are usually copy number variations (CNVs) which mean that a cell has an abnormal number of copies of one or more section of DNA (an abbreviation for deoxyribonucleic acid). DNA is a chain of many connected genes. Genes contain coded instructions for how proteins should be constructed and how certain bodily characteristics should develop. There are many different forms of genes. Each form is known as an allele. Some alleles are normal and others are abnormal. Abnormal alleles can cause diseases.

The above commonalities have led some to question whether autism and schizophrenia have shared genetic abnormalities. Researchers in the American Journal of Medical Genetics: Neuropsychiatric Genetics recently published a study that examined this issue. The study involved analyzing the genes of 2,737 people with autism spectrum disorders (autism and closely related conditions) and 3,332 Europeans with schizophrenia. The authors examined whether autism and schizophrenia shared alleles in common (known as common risk alleles). The results of the study showed that there was no important sharing of common risk alleles between autism spectrum disorders and schizophrenia.

Suggested Reading: Autism: A Practical Guide for Parents

Reference: Vorstman JA, Anney RJ, Derks EM, Gallagher L, Gill M, de Jonge MV, van Engeland H, Kahn RS, Ophoff RA; the Autism Genome Project, the International Schizophrenia Consortium. (2013). No evidence that common genetic risk variation is shared between schizophrenia and autism. Am J Med Genet B Neuropsychiatr Genet. 162(1):55-60.

Colonoscopy Prep Made Easy: A New Cleanser

Many people who have gone through a colonoscopy to screen for colon cancer will tell you that the worst part is not the procedure itself (since you are asleep during it) but the preparation. The colon is the major part of the large intestine. In a colonoscopy, a flexible viewing scope is placed inside of the colon to examine for abnormalities, some of which can be removed with other devices during the procedure.

For colonoscopy to be effective, the colon must be properly cleansed of feces. The standard way that this is done is by not eating the day before, consuming clear liquids, and drinking a large amount (2 to 4 liters) of an intestinal cleanser which causes diarrhea throughout the day. The worst part of the cleanser is often described as the consistency and the taste because it is quite salty and somewhat thick. These cleansers typically contain a chemical substance known as polyethylene glycol (PEG) that forms the basis of a laxative.

Many people simply cannot stomach these cleansers, vomit or gag while drinking it, and thus do not comply with its use. This can result in the procedure being cancelled or a less thorough exam. Worst of all, hearing stories about this can result in people deciding not to go for a colonoscopy at all (or not to return for one in the future) and thus not detecting and removing pre-cancerous masses. This is a problem, considering that 50,000 people died from colorectal cancer in the U.S. in 2011. Thus, a better option for intestinal cleansing is needed.

In a recent development, the U.S. Food & Drug Administration approved a newer and alternative intestinal cleaning solution for colonoscopy preparation known as Prepopik. In scientific literature, it is sometimes referred to as P/MC because it contains sodium picosulfate and magnesium citrate, both of which work as laxatives, the former by stimulating intestine movement (peristalsis) and the latter by causing water absorption. This is why P/MC is referred to as a dual action cleanser. It is fascinating that it took so long for this to be approved in the U.S. since similar cleansers have been used for about 40 years throughout the world with established safety, effectiveness, and tolerability.

In an upcoming article in the American Journal of Gastroenterology, researchers summarized the results of a head to head comparison between the new intestinal cleanser (P/MC) and the standard cleanser (2 liters of PEG-3350, natural orange flavor) combined with two 5 milligram bisacodyl tablets (another type of laxative). The study involved randomly assigning 603 adults (ages 18 to 80) to one type of intestinal cleanser or the other. The results of the study showed that the new cleaner (P/MC) was just as effective as a cleanser and that patients rated it as significantly more tolerable and acceptable.

These results are great news because no longer will people need to drink 2 liters (67 ounces) of PEG-based cleansers. With Prepopik, you consume only 10 ounces of prep followed by 64 ounces of an approved clear liquid on a more flexible timing schedule. If you are going for a colonoscopy in the future, you can ask your doctor about Prepopik.

Suggested reading:  American Cancer Society's Complete Guide to Colorectal Cancer

Related blog entry: Liver Transplants Increase Survival Rate for Non-Resectable Colorectal Metastases

Reference: Katz PO, Rex DK, Epstein M, Grandhi NK, Vanner S, Hookey LC, Alderfer V, Joseph RE. (2013, in press). Am J Gastroenterol. A Dual-Action, Low-Volume Bowel Cleanser Administered the Day Before Colonoscopy: Results From the SEE CLEAR II Study.

Non-Fried Fish Reduces Risk of Pancreatic Cancer

Cancer of the pancreas (aka pancreatic cancer) is the fourth most common type of cancer in the U.S. Cancer is any of a large group of malignant diseases characterized by an abnormal, uncontrolled growth of new cells in one of the body organs or tissues. The pancreas is a long organ behind the stomach that produces several types of hormones and helps digest food with pancreatic juices that contains enzymes.

Unlike some type of cancers (e.g., lung cancer) there are no established guidelines for how to specifically prevent pancreatic cancer. This is unfortunate given the poor prognosis that this disease typically has. There is some evidence that vitamin B can reduce the risk of pancreatic cancer when consumed in food, but not when consumed in vitamin tablet form. Some fish, such as tuna and trout, are high in B vitamins. Fish is also high in a type of “good fat” known as long chain polyunsaturated fatty acids (LC-PUFAs). LC-PUFAs are types of “good fat” because they have many positive health benefits such as supporting normal growth, supporting the immune system, and improving brain and heart health. They may also be beneficial against cancer due to their anti-inflammatory properties (inflammation plays an important role in cancer development).

While fish intake has never been associated with decreased or increased pancreatic cancer risk, the association between types of fish and fish preparation methods and pancreatic cancer is unknown. In an upcoming research article published in the American Journal of Epidemiology, researchers from Indiana University presented the results of a study that analyzed this topic in more detail. It was a very large study, involving 66,616 adults ages 50-76 years. Subjects were followed-up for an average of 6.8 years and during that time, 151 people developed pancreatic cancer.

The researchers found (via questionnaire) that a lower incidence of pancreatic cancer was associated with non-fried (e.g., broiled, baked) fish and LC-PUFAs. Of note, frying fish significantly reduced LC-PUFAs. There are different types of LC-PUFAs and the researchers found that the association between lower pancreatic cancer and LC-PUFAs was greater for docosahexaenoic acid (DHA) than for eicosapentaenoic acid. The authors noted that this may be because DHA is better at reducing inflammation because it is more readily incorporated into tissues.

Consumption of fried fish and shellfish (e.g., shrimp, lobster, crab, oysters) was not shown to help decrease pancreatic cancer. The authors noted that chemical byproducts from frying foods may contribute to the development of pancreatic cancer and that combining non-fried fish with fried fish or shellfish would likely decrease the benefits of eating non-fried fish regarding pancreatic cancer incidence.

Suggested reading: 100 Questions & Answers About Pancreatic Cancer, 2nd ed

Reference: He K, Xun P, Brasky TM, Gammon MD, Stevens J, White E. (2013). Types of Fish Consumed and Fish Preparation Methods in Relation to Pancreatic Cancer Incidence: The VITAL Cohort Study. Am J Epidemiol. 177(2):152-60.

Are You Prepared For Your Child's Potential Health Emergency?

If you think you are protecting your child by simply knowing the 911 digits and having 24/7 access to a phone, then you are not doing enough. Helping your child in a potential health emergency requires you to take immediate action as well; so are you prepared to face a bad day without waiting for the emergency team to arrive?

If you answered no for the above question, it is time for you to learn some important first aid techniques. Our children are our most prized assets, and anything coming in the way of their health is unwelcomed.

You never know when your child would knock over a boiling teapot on themselves, cut their hand, or even have an unforeseen seizure. Be equipped with the essential information needed in such a situation; here are some pointers to remember:

Call the Health Helpline

It is not good to rely solely on the emergency medical teams, but you cannot help your child without professional consultation either. In case of an emergency, your first step should be to call a medical agency like Md Aligne Telehealth Services. If you are busy looking after your child, instruct someone else to do so. Always keep phone numbers of unswerving emergency teams handy, you might never know when the need to dial them arises.

Help Reduce Fear

Calm everyone down in the house, including the child. Panic is your worst enemy in such a situation. Relax, and think what needs to be done foremost. If you are in a state of alarm, you might give your child incorrect medical aid. For example, some burns require you to hold them under running water, whereas others need to be covered under a blanket (depending on the degree and nature of the burn); you might give the wrong treatment under panic.

Know How to Handle Most Situations

This is very important; you must know how to deal with multiple emergency situations including seizures, broken limbs, burns, head injuries, and fainting. Your child might start choking during dinner, or get hurt during playtime. Every parent must know how to handle such emergencies.

Stock your First Aid kits with all the necessary items. Antiseptic ointments, wiping medical towels, bandages, sterilized cotton, instant cold packs, disposable gloves, and aspirin are the basics every household must have. Keep a stock of medicines that are anti-diarrhea, anti-histamines, anti-allergic, anti-burn, and even strong instant pain relievers. Have a first aid manual that tells you about the correct dosages of these medicines.

Note that most First Aid items are for limiting the spread of infection; it is important not to trigger any further infections while you are helping the child. When you are treating wounds, clean them with antiseptic first.

Millions of children receive medical aid every day; you never know when it is your child’s turn. Having someone at home with sound knowledge of first aid emergencies is crucial. The actions taken during the first few minutes of an emergency are most important; ensure that these actions are in your favor!

The above entry is a guest blog entry.

Who Uses the Emergency Room Most? The Answers May Surprise You

There is a stereotype that the most frequent users of emergency rooms (ERs) are those who do not have health insurance and/or who present for non-urgent reasons. While the uninsured do use the ER often, the best way to determine who uses it the most and why is to do a formal research study on the topic.

In an upcoming article in the American Journal of Emergency Medicine, researchers presented the results of such a study.

In the study, frequent use of the ER was defined as 9 or more visits in a one year period. This represented the top 1% of ER use. The researchers administered questionnaires to adults in this group. Of note, patients excluded were those who presented to the ER intoxicated, with altered mental status, or acute (sudden) psychosis (detachment from reality).

Over a one year period from 2009 to 2010, the researchers identified 115 frequent ER users. Twenty three percent had a psychiatric condition (usually presenting for suicidal thoughts). The average patient presented to the ER 22 times. The average age was 44. Regarding gender, 57% were male and 47% were female. Regarding education, 44% had a high school education or GED, 43% had less than a high school education, and 11% had a college education. Lower educational level was not correlated with higher ER use. Regarding race, 92% were black, 11% were white, and 1% were Hispanic.

In terms of annual income, 69% earned less than $10,000 a year. Only 5% earned more than $40,000 a year. Patients used the ER more frequently if they had lower income, transportation problems, problems with shelter, and high prescription costs (32% could not afford prescriptions). Twenty-seven percent reported being unable to afford a clinic visit. Seventy-eight percent reported having adequate health insurance whereas 22% did not. The number of ER visits between insured and uninsured patients was comparable.

Seventy-five percent of patients had one or more chronic medical conditions and identified the ER as the primary place they went for health care. Of the ER users, 63% were admitted to the hospital and 50% were admitted more than once. The most frequent reason for admission was end stage renal disease. Four hundred and sixty hospital admissions were for medical reasons and 22 were for psychiatric reasons.

In terms of the most frequent medical diagnoses, 59% had high blood pressure, 19% had congestive heart failure, 19% had diabetes mellitus, 16% had end stage renal (kidney disease), 12% had coronary artery disease, and 9% had chronic obstructive pulmonary disease (COPD). Congestive heart failure is an imbalance in the pumping action of the heart that causes inadequate blood circulation. In diabetes mellitus, the body is not able to effectively use a natural chemical called insulin, which quickly absorbs glucose (a type of sugar) from the blood into cells for their energy needs and into the fat and liver cells for storage. Coronary artery disease is a narrowing of coronary arteries, which are blood vessels that supply the heart with blood. COPD is a general term for diseases that are characterized by long-term or permanent narrowing of small airways (known as bronchi) connected to the lungs.

The authors noted that their findings echoed prior studies that found that the most frequent ER users have some form of health insurance and access to a primary care provider, but used the ER as their primary source of health care despite such access. The authors noted that it is plausible that the primary health care providers may not be able to meet the needs of these patients which is why they go to the ER. The authors noted that future studies should examine if a medical home may be a better place for these patients to meet their needs to ease the strain on the ER. A medical home (or patient-centered medical home) is a team-centered health care system led by a medical doctor, nurse practitioner, or physician assistant to provide comprehensive and continuous health care. At present, there are not many medical homes in the U.S.

Suggested reading: Confessions of Emergency Room Doctors

Related blog entry: Decreased Child ER Visits after LA Lakers Title Games

Reference: Miller JB, Brauer E, Rao H, Wickenheiser K, Dev S, Omino R, Stokes-Buzzelli S. (2013). The most frequent ED patients carry insurance and a significant burden of disease. Am J Emerg Med. 31(1):16-9.

Endometriosis 101: A Primer

Endometriosis is a condition in which the tissue that normally lines the inside of the uterus (endometrium) is found outside the uterus. This condition, which affects up to 10% of reproductive-age women, is described in detail on MedFriendly.com, which you can access by clicking the previous link. An updated review on endometriosis was recently published in the journal, American Family Physician. In the review, the authors noted that endometriosis occurs in 25 to 40% of women with pelvic pain and 70 to 90% of women who are infertile (not able to reproduce).

While some women with endometriosis do not have symptoms, it can be associated with symptoms such as severe pelvic pain, painful menstruation, and pain during intercourse. While patients with endometriosis may initially present to their family practitioner, a referral to a gynecologist typically occurs, especially if the woman remains infertile and has persisting symptoms.

Diagnosis of endometriosis is based on a medical doctor evaluating the patient’s signs and symptoms and can be aided by a biopsy, in which a tissue sample is removed and analyzed under a microscope.

Initial treatment often included medications to reduce inflammation. Birth control medications are also used that effect levels of progestins and/or estrogen levels. These are both types of hormones. Estrogen is believed to promote endometriosis, which is why use of medications that lower estrogen levels can be used to manage the condition. Progestins thin the uterine lining and suppress the natural cycle of the ovary, the latter of which interferes with the menstrual cycle. The authors of the review article noted that there is some evidence that these medications can be helpful and have few side effects.

There are other treatments for endometriosis such as gonadotropin-releasing hormone agonists (GnRH). These medications produce a massive increase in GnRH which overwhelms the body and causes the ovaries it to shut down estrogen production. Another treatment is Danazol, which also reduces estrogen levels and shuts down the estrogen cycle. Surgery is another option, which involves removal of the endometrial tissue. The authors of the review noted that these interventions may control symptoms better than initial treatments but that they can have significant side effects and limits on how long the therapy can last.

For more detailed information on endometriosis discussed in this blog entry, please see the MedFriendly entry on endometrosis and/or the article below. Also, feel free to leave your comments regarding personal experiences with endometriosis in the comment section below.

Suggested reading: 100 Questions & Answers About Endometriosis

Reference: Schrager S, Falleroni J, Edgoose J. (2013). Evaluation and treatment of endometriosis. Am Fam Physician. 87(2):107-13.

Aquariums for the Treatment of Dementia (Alzheimer’s) in Nursing Homes

Dementia is a disorder characterized by a significant loss of intellectual and cognitive abilities without impairment of perception or consciousness. There are many different cause of dementia such as severe traumatic brain injury, stroke, and progressive neurological disorders.

Of the progressive types of dementia, Alzheimer’s disease is the most common form of dementia in the elderly. Dementia is very common (>50% prevalence) in people living in nursing homes.

There are many signs of symptoms of dementia such as memory loss, language impairment, emotional blunting, decreased energy, and weight loss due to poor nutritional intake. Weight loss leads to many problems in patients with dementia, particularly those with advanced forms of the disease. For example, because the person has less muscle mass, they are more prone to falls and injuries that can result for this such as bone breaks. Due to decreased mobility, weight loss can also increase the risk for pressure sores (skin ulcers), pneumonia, and other health problems. Decreased food intake also results in costly waste of food for uneaten prepared meals.

As a result, interventions are needed to help increase weight in people with dementia. While there are medications designed to increase appetite, they have had mixed results and can lead to numerous side effects including sedation, blood clots, and edema (swelling). Encouraging eating by staff has also produced mixed results and is a costly intervention in nursing homes due to the one on one attention it requires.

To address this issue, researchers from Purdue University studied whether individuals with dementia who observed aquariums increased food intake and maintained body weight. The study involved 70 residents in three extended care facilities in two states. A large aquarium (30 x 20 inch viewing area) was placed in the common dining area of both facilities. Each aquarium had 8 large colorful fish that were quick swimmers. The study found that aquarium placement was associated with a 25% increase in food intake over the 10-week study period. This amounted to an average 2.2 pound weight gain during the study. Eight of the 70 residents (11%) experienced weight loss during the study. A benefit of this intervention is that there are no side effects.

The authors stated that attraction to the natural environment (especially animals) is so innate that it survives dementia. Watching aquariums has been associated with decreased stress, less blood pressure, and increased satisfaction in other studies. It is possible that increased satisfaction and mental stimulation from observing the aquariums leads to increased food intake.

Suggested reading: The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Disease, Related Dementias, and Memory Loss

Reference: Edwards NE, Beck AM. (2013). The Influence of Aquariums on Weight in Individuals With Dementia. Alzheimer Dis Assoc Disord, in press.