Eastside Family Health Center

FOOD POISONING

noreply@blogger.com (Dr. Frank) — Tue, 25 Oct 2011 18:34:00 +0000

For those who have ever had a case of food poisoning you know what a terrible thing it is! Especially when it occurs after a meal that you have spent money on! It is a complicated thing, like most things in medicine. This is a medical review of how your doctor approaches the problem.

Food poisoning is an illness that can cause nausea, vomiting, or diarrhea. The food can be contaminated with bacteria, viruses, or parasites.

Food can be infected by several means. One way would be by people who work with food who are sick and do not wash their hands. Another way is that the infected food is not washed properly or cooked enough. Another way is for one food product infects another food item.

Symptoms can happen right after a meal, days or even weeks later. Common symptoms include nausea, vomiting, abdominal pain, diarrhea that can be watery or bloody, and fever.

Other symptoms can include blurry vision or dizziness.

If this should happen to you, be sure to drink plenty of water. Eat small meals that do not include a lot of fat in it. See your doctor for abdominal pain, if you cannot eat or drink, vomiting blood or having blood in the bowel movements, or if you have fever more than 100 degrees.

If you are younger (child) or an older adult, see your doctor sooner as kidney involvement may occur sooner.

Here are some helpful recommendations

Do not drink unpasteurized milk or any unpasteurized products
Wash raw fruits and vegetables
Keep the refrigerator temperature at 40 degrees or colder
Use precooked or perishable or ready to eat food as soon as possible
Keep raw meat, fish, or poultry separated from each other
Wash hands, knives or cutting boards after handling uncooked food
Cook chicken eggs thoroughly until yolk is firm
Never leave cooked food at room temp for more than two hours

For pregnant women

Do not eat hot dogs, lunch meats or other delicatessen meats unless they are reheated until steaming hot. Microwave ovens may give uneven cooking
Avoid spilling fluids from raw meat and hot dog packages onto utensils or other surfaces that you will come in contact with
Do not eat refrigerated smoked seafood unless it has been cooked.

For more information, consult your health care provider.

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Dr. Frank Marinkovich and his wife Rita own and operate Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Be sure to find out more about their NEW specialized Laser Treatment. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.
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Men's Health Issue - PSA

noreply@blogger.com (Dr. Frank) — Fri, 16 Sep 2011 05:48:00 +0000

What is PSA? PSA stands for prostate specific antigen, which is a protein produced by both normal and cancerous cells of the prostate gland. It is used as a screening test for prostate cancer; although this is met with controversy. It is also used to assess response to the treatment of prostate cancer.

The PSA value increases with increasing age because the prostate gland size increases. As a result, the normal reference range may be appropriate based upon a man’s age. This may help understand what a true normal or abnormal number may be and help avoid needless biopsies in older men.

It is also known that different races have different PSA values; black men in particular tend to have higher PSA values than white men without cancer. As a result, there is discussion that the PSA value should be race dependent. This is still unclear, but you can see the issues surrounding PSA values.

It is interesting that the higher the BMI (obesity) the lower the PSA values tend to be. This may be due to higher plasma volume. If that is the case, consider the importance of the rectal exam (o joy!).

There are some medications that lower the PSA value (5-apha reductase inhibitors). When on such meds (i.e. finasteride) the PSA interpretation need be adjusted. Some say any increase in PSA value while on these meds need to be evaluated.

Other medications such as the cholesterol lowering statins (ex: Lipitor) also appear to be able to lower PSA values. So maybe a two-fer? Lower cholesterol AND lower PSA? It appears promising, if you like statins.

What are other causes for elevated values? There are several major causes of elevated PSA values: BPH (benign prostatic hypertrophy (enlarged prostate)); prostate cancer; inflammation and trauma.

Of these, BPH is the most common especially for men over 50 years old. Simply put, bigger prostates produce more enzymes. Unfortunately, it is not that simple, as bigger prostates may also have pockets of cancer as well. In addition, treatment of BPH may lower PSA values. What to do? Work closely with your doctor.

Prostatitis is another common cause. As a result many physicians will treat an elevated PSA value with antibiotics for presumed infection than repeat the PSA after four weeks or so. This approach is also controversial as to its effectiveness; it is however the usual practice.

In regard to trauma, vigorous bike riding may elevate the PSA value as can a digital rectal exam. Although not proven, the blood test probably should be checked before the exam or after a time of biking abstinence.

Other methods for screening prostate? There is something called PSA density that you may hear about to more accurately predict cancer if you have an elevated PSA value. This is the volume of prostate as measured by ultrasound. The density would be the PSA divided by the volume. This is also controversial as there are different standards regarding the measurements with the ultrasound.

The approach that has gotten the most traction is something called PSA velocity, or the rate of change of the PSA over time and not so much the actual value. This velocity seems more related to the risk of death from prostate cancer.

So, PSA is a valuable tool for prostate cancer but is not specific for cancer. The use of PSA velocity or density has not proven of great use. Thus, the number of biopsies done is still too high. The value of checking PSA seems higher the younger you are (starting age 40-50).

What about Glycemia - Hemoglobin A1c

noreply@blogger.com (Dr. Frank) — Tue, 16 Aug 2011 12:08:00 +0000

It has been known since the 1970s that glucose (sugar) can attach to proteins in the blood. If the sugar in the blood is high enough for long enough then the attachment of the sugar to the protein becomes permanent.

The demonstration that the development of microscopic complications in patients with type I diabetes can be slowed by treating high sugars led to the pursuit of measuring blood glucose levels, thus the development of the A1c test. In other words, when high sugars in type 1 diabetics were treated it reduced complications from developing and thus the need for the A1c test to measure.

The most useful test for measuring this phenomenon is called glycosolated hemoglobin, or the HbA1c. Red blood cells readily attach sugar molecules. Just as in the above scenario, the amount of sugar and the permanency of the bond is proportionate to the amount of sugar present in the blood. Since red blood cells only survive 120 days in the blood, the A1c is a measure of the average blood glucose over that 120 day time frame.

There are now many studies and plenty of data supporting the correlation of the A1c to diabetes control. In fact, the measure of A1c is now the means by which to diagnose new onset diabetes.

There are, however, sources of potential error related to the A1c values. This test is influenced by red blood cell survival. If a person has iron deficiency anemia or B-12 or folic acid deficiency the result of the A1c may be falsely high.

If there is a hemolytic anemia( blood loss) causing the marrow to produce young blood cells the A1c value may be falsely low.

If there is a hemoglobin problem such as sickle cell disease or thalassemia the values may also be off( high). Other problems such as a chronic disease state such as kidney disease may also give false values. Other issues that affect the A1c test includes: if you are on dialysis, taking erythropoietin or possibly of Black or Hispanic descent.

If the scenario exists where the A1c values are high but the blood glucose levels are excellent, I advise checking the before meals sugar as well as two hour after meals sugar and adjust medications appropriately.

Let’s consider the issue of high blood glucose values after meals for a moment. Optimal treatment includes changes in either nutrition or insulin regimen. For example, a large meal containing a lot of quickly absorbed carbs and low in fiber may cause a large post meal hyperglycemia. Changing the meal, eating less with each meal, eating more in between meals, increasing the amount of soluble fibers should lower post-prandial sugar level. Otherwise, using more premeal insulin of the short acting variety may be of benefit.

The level of A1c to help prevent complications for type 11 diabetes is clear: 7 %. This is based upon a large study called The United Kingdom Prospective Diabetes Study. For older patients is especial, care must be taken to avoid low( hypo) sugar reactions! That being said, it is very clear sugar values are directly related to future complications i.e. a one percent fall in A1c was associated with a 35% reduction in microvascular disease.

So, follow up with your doctor to check your A1c level every 3 months if you are diabetic!

http://www.medindia.net/patients/calculators/bloodsugar-HbA1c-convertor.asp

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Obesity

noreply@blogger.com (Dr. Frank) — Fri, 29 Jul 2011 16:07:00 +0000

As many are aware, obesity is a major issue in America and the problem is getting worse. More than 33% of Americans are obese ( defined as a BMI > 30 ). More than 64% of Americans are overweight (BMI>25).

It costs America approximately 100 billion dollars a year to treat obesity and the complications that arise from it. This is in addition to hidden costs, such as days missed from work and early death( less taxes).

There are several well documented health hazards with obesity, such as diabetes, heart disease, stroke, cancer, arthritis, liver disease, sleep apnea, and depression. The risks increase with the degree of obesity.

The most practical means of measuring obesity is the body mass index. This is calculated by dividing the weight in kilograms by the height in meters( kg/m).

BMI Categories : 25-29 overweight; 30-34 obese; 35-39 moderately obese; 40-49 severely obese; >50 super ( morbidly) obese.

Well, what to do? The hallmark solution will forever be diet and exercise, but for most people there has only been limited success and not for a lack of desire or effort. Surgery has come into medical community acceptance over the last several years due to studies showing the improvement in obesity complications.

Weight loss surgery (called bariatric from Greek word baros meaning weight) works by either malabsorption or restriction. Restriction procedures limit the amount of calorie intake by reducing the stomachs reservoir capacity or via creation of a blind stomach outlet. Gastric banding is a purely restrictive procedure. This limits solid food intake by restricting the stomach size as its only mechanism of action. The small intestine must then absorb nutrients. The weight loss with purely restrictive procedures is more gradual.

Malabsorptive procedures work by shortening the length of the small intestine. This is done by shortening of the small bowel or by diverting around it. Examples include jejunoileal bypass or duodenal switch operation. The weight loss can be huge, but the complications many such as protein loss or micronutrient deficiencies.

The famous Roux-en-y gastric bypass is both restrictive and malabsorptive. In this operation you are left with a small stomach pouch; however, the small bowel is rerouted favoring additional weight loss via dumping and mild malabsorption.

So, does surgery work? It does, especially for those with BMI >40. The mean weight loss percent of excess weight loss was 61%. Diabetes completely resolved in 77% and either improved or resolved in 84%. Also look at these results: high cholesterol improved 70%; high blood pressure improved 62%; sleep apnea resolved 86%; reflux improved as well as urinary incontinence. Because of these data, I am now a fan of weight loss surgery.

The amazing thing is that there is now data showing a decrease is overall mortality. The reduction of the complications of obesity reduces overall mortality by 29%. As always, if one can reduce BMI by diet and exercise this is the safest way. Otherwise talk to your doctor about weight loss surgery. There are several different types of surgery; an expert in the field will need be consulted.

Let’s review some of the indications for surgery intervention: Be motivated! Have a BMI>40. Or, have a BMI>35 with co-morbidities(other diseases or complications) such as diabetes, blood pressure, apnea, severe arthritis, heart condition etc. and having failed non-surgical programs.

The most common surgical technique is the laparoscopic gastric banding. The upper stomach is banded by a tight, adjustable soft silicone ring connected to an infusion port placed under the skin.

The port can be accessed with ease via a syringe and needle. The band is adjusted to deal with weight loss as well as nutritional issues. Data shows an expectation of about 40-75% weight loss at two years. But note! It is easier to cheat with the lap band! So, a comprehensive approach is needed as well as good motivation.

The decision to proceed with a surgery for obesity is a serious one as there are many potential complications. For this reason it is necessary to follow protocols.

We also have the BMI Calculator on our website. Check it out here: Eastside Family Health.

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Non-Sciatic Sciatica

noreply@blogger.com (Dr. Frank) — Wed, 27 Jul 2011 15:23:00 +0000

Piriformis Syndrome

This is an interesting disorder that is one cause of sciatica, other than a herniated disc in the low back. The sciatic nerve is compressed by the piriformis muscle causing an irritation of the sciatic nerve with numbness in the buttocks running down the lower thigh into the leg. When someone has these symptoms the biggest thing to rule out is a herniated disc of the spine. So, if there is sciatica but no clear spinal signs, think piriformis muscle inflammation.

piriformis distribution

What causes it? In approximately 17% of the population the sciatic nerve passes through the piriformis muscle rather than underneath it. This is the supposed cause of this syndrome (non-disc related sciatica). Also anatomically, weak gluteal (buttock) muscles, which may occur with a lot of desk type jobs that involve much sitting( hip flexion with accompanying shortening and tightening of the hip flexors). With weak gluts, other muscles have to compensate such as the hamstrings, adductor muscles( inner muscles of the thighs), and the piriformis. This results is hypertrophy of the piriformis with the resultant syndrome.

Other causes could include overuse injury such as strenuous use of the legs( anyone do the STP bike ride lately?) such as biking or rowing. Also, runners, who engage in forward type of activities as well, are susceptible to developing this syndrome. So, it is important to perform lateral (side) type of stretching to balance out the legs. If not properly stretched, the legs can develop overly tight adductors and out of proportion weak abductors. The piriformis muscle becomes large and sciatic nerve impingement is inevitable. The key is to keep the outside muscles of the hip, called abductors in proper stretch to take the strain off of the piriformis.

Interestingly, not only does the spasm of the piriformis cause sciatic nerve symptoms but the pudental nerve may also be irritated. This nerve controls the muscles of the bowel and bladder. The syndrome may present with loss of bowel and urine function as well as saddle anesthesia( numbness around the anus).

Some other potential causes of the syndrome include a falling injury, tight SI joints( sacro-iliac, or low back joints), over pronation of the foot, or sitting on a wallet.

How is it diagnosed? Diagnosis is largely clinical, i.e. there not really any good or reliable imaging tests for this syndrome. Presentation includes pain in the buttock, back of the thigh and lower leg made worse with prolonged sitting, activity or walking.

What is treatment? Treatment is conservative including avoiding such activities as running, biking or rowing for a while. Also, muscle relaxants , anti-inflammatories as well as physical therapy or massage to stretch and strengthen. If these do not work, see your doctor to consider an imaging study to rule out other pathology. Treatment for weak abductors and tight adductors include stretching and strengthening of these muscles. It is possible to see results after just a few days.

the piriformis stretch

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The Case of the Jumping Legs: Restless Legs Syndrome

noreply@blogger.com (Dr. Frank) — Tue, 12 Jul 2011 15:03:00 +0000

Do you have jumpy legs or legs that just need to move? Well, you may have a syndrome called restless legs (RLS). These are marked by a spontaneous movement of the legs. This usually only occurs at rest and are relieved by movement. Sleep disturbance, such as sleep apneas, is commonly associated. This is not the same as leg cramps.

Who has this? This is a very common problem, as up to 15% of Americans have it. More women than men have it; the prevalence of RLS increases with age. Sometimes it may occur in children and at times is misdiagnosed as growing pains.

What is the cause? The cause is usually unknown; however, there appears to be a genetic link, in other words a family history. There is a hypothesis that the neurotransmitter called dopamine is associated with this disorder. In fact, this hypothesis is the basis of how we treat it with medicine. There is also an increased incidence of restless legs in patients with Parkinson’s disease.

RLS may also be associated with iron deficiency, chronic kidney disease, pregnancy, movement disorders, diabetes, varicose veins, and rheumatism. There is some association with low thyroid and obesity.

What are some of the symptoms? Clinically, patients describe a sensation of crawling, creeping, pulling, itching, or stretching all deep in the leg rather than the skin. Pain is usually absent. Symptoms typically worsen at the end of the day and are maximal at night, usually within 15 minutes of getting into bed. In severe cases, symptoms may occur earlier in the day while the patient is seated. This makes sitting at a desk or meetings or in a movie theatre difficult. In milder cases, one may be fidgety.

So, how do you diagnose RLS? Here are the criteria by the International Restless Leg Study Group: an urge to move when in bed or periods of inactivity( sometimes other body parts are involved as well such as the arms or even the entire body); the urge is partially or totally relieved by movement such as walking or stretching. Supportive criteria include family history or a positive response to RLS medication.

What is the treatment? Some cases require the use of meds, but before that here are some these simple measures to try: stretching exercises of the posterior leg muscles before going to bed; use of iron replacement ( have your iron checked first); stop mental activating activities such as video games before going to bed; avoid caffeine; and lose weight. If these don’t work, there are some pretty successful medications your doctor can discuss with you.

Below is an example of stretching exercise to try:

Stand facing the wall, feet together, about two feet from the wall. Heels on the floor, lean forward to the wall, stretching the posterior leg muscles. Hold for 10-30 seconds. Repeat x5. Twice daily.

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Abnormal Uterine Bleeding

noreply@blogger.com (Dr. Frank) — Thu, 30 Jun 2011 12:09:00 +0000

What causes abnormal bleeding? Abnormal bleeding from the uterus (anything not consistent with a regular menstrual cycle for a female) can be caused be a wide variety of things such as medications( contraceptives, blood thinners, steroids, antipsychotics, chemo, dilantin, some antibiotics, others), or benign growths such as polyps, thick uterine lining, fibroids; infections of the uterus; issues of the cervix such as polyps or endometriosis; cancer of the uterus or cervix; sexually transmitted diseases. There are many other causes of abnormal bleeding—it just depends on where the location is in the genital tract.

Age, sexual activity, pregnancy possibilities, ovulation, eating disorder symptoms, and if this is like a normal period are all other factors in determining cause.

For example, causes of abnormal bleeding in women between age 40 and menopause are usually due to growths, either benign or malignant.

For women between teenage and about 20, the causes are broken down based upon whether or not one ovulates or not. If you ovulate and bleed abnormally, the bleeding is usually cyclic only heavy or prolonged. The cause is usually anatomic or physical such as a polyp, fibroid, endometriosis, cancer, or a foreign body. Hormone levels are normal in this circumstance.

What about bleeding outside of regular menstrual cycle? Anovulatory means bleeding that occurs outside of ovulation, hence it is unpredictable. It is the most common cause of abnormal uterine bleeding. The cycle of when sex hormones are produced is off so bleeding is irregular (bleeding is a function of hormone interaction). The most common cause of this scenario is too much estrogen causing the lining of the uterus to become too thick, outgrowing its blood supply and eventually dying off. This causes irregular, prolonged and heavy bleeding.

So, what can cause a woman to stop ovulating? There are many possibilities such as: thyroid disorders, polycystic ovary syndrome, liver or kidney disease, endocrine disorders such as Cushing’s disease, eating disorders, intense exercise, stress, pituitary growths, tumors of the pituitary or brain and other things. The most common of these are stress, polycystic ovary syndrome (PCOS)—comprised of obesity, abnormal hair growth, acne, and irregular periods., and abnormal exercise (too much of a good thing!).

For a teenager, ovulation is not always consistent. So, there may be episodes of no periods interspersed with times of heavy bleeding. This is because the hormonal axis in the body is still maturing. As always, make sure the person is not pregnant!

At the end of the day a biopsy of the lining of the uterus may be needed to help discern the cause of the bleeding. Most importantly, it is the way to rule out cancer.

What is the treatment? Treatment is diverse from correcting the underlying problem to attempting to regulate the hormones with birth control pills to surgical intervention. As one can see, a health care professional is needed for cases of abnormal bleeding.

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Tic, Tac Twitch

noreply@blogger.com (Dr. Frank) — Mon, 27 Jun 2011 15:48:00 +0000

Tics and twitches (medically called dystonia) are involuntary muscle contractions that result in a twisting or repetitive movement or abnormal postures. Examples would be a twisting of the neck or writer’s cramp or repetitive blinking of the eyes. The first time may have been triggered by an activity or event but over time the twitch becomes susceptible to less and less stimuli, even at rest.

Most tics/twitches occur early in age but some may present older (more than 26 years of age). The abnormal movement can involve a body part such as a finger, or a leg or the trunk or even one side of the body. Some are inherited, some occur at birth (such as from brain injury), and others are acquired later on due to unknown reasons. It is interesting that the earlier the onset, the more likely it will present in the limbs (arms, legs) whereas older presentations occur in the neck, arm or face.

Examples:

Common types include: neck—spasms of neck and shoulders
Blepharospasm—spasms of muscles around the eyes leading to involuntary eye closure and incessant blinking.
Facial—jaw, tongue, or facial muscles spasm out
Limbs—movements of the arm or leg
Voice—a high pitch tremor nasally sound
Occupational—writer’s cramp; typists; golfers spasm( the yips); and musicians mouth that twists including the jaw or tongue. Usually, when the activity is over so it the twitch.

Late onset twitch starts usually in the face, arm, neck. It rarely goes generalized. If so, further workup is definitely suggested.

There is good genetic linkage for early onset twitches and possibly with late onset. If interested, ask for the DYT1 gene testing. Always have a doctor evaluate the twitch as it may be unusual and need further workup.

The main idea here is that a tic, a twitch or a dystonia is common and does not necessarily mean a seizure disorder. Tics in particular are usually accompanied by a sense of having to perform the tic and are relieved by doing it. A tic as well may be temporarily suppressed. The movements of these are also quite variable in comparison to a seizure. Also, there is a degree of suppression that can be achieved as opposed to a seizure.

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Prostatitis

noreply@blogger.com (Dr. Frank) — Wed, 08 Jun 2011 15:46:00 +0000

What is prostatitis? Prostatitis refers to inflammation of the prostate gland. Note, this is not cancer. It is a very common condition affecting males over the age of 18. Prostatitis tends to occur in young and middle-aged males. The symptoms, though common are often not readily detected. Symptoms such as pain in the lower abdomen, perineum (area between anus and scrotum), testicles, penis, bladder pain, difficulty passing urine, and sometimes blood in the semen. Note that prostatitis does not cause impotency. There are two major forms, acute and chronic.

Acute Prostatitis

What are risk factors? Acute prostatitis risks include trauma such as bike riding (Training for the STP (Seattle to Portland bike ride)?), horseback riding, dehydration, and sexual abstinence. It can also occur if one has a chronic indwelling catheter. Most of the occasions of acute prostatitis are caused by bacterial infections.

What are the symptoms? The usual presentation is that of fever, chills, fatigue, pain on urination, pain in abdomen or lower, and cloudy urine. It is to be noted that these are similar symptoms for a bladder infection except for the fact that bladder infections are not common for males.

How is it diagnosed? Diagnosis includes the history as well as exam. The prostate typically feels swollen or “boggy”. The blood test called PSA( prostate specific antigen) may or may not be elevated. Treatment includes antibiotics. Anti-inflammatories also help to reduce the swelling. Antibiotics usually require four to six weeks to bring about cure. Rarely is hospitalization required. It is important to get treatment to help reduce the potential complications of chronic prostatitis as well as prostate abscess formation.

Chronic prostatitis

Chronic prostatitis should be considered in men who have pain on urination and frequency but not the symptoms of acute prostatitis, those who have recurrent urinary tract infections for no obvious cause, and for those who have chronic bacteria in the urine.

What are the symptoms? The symptoms of chronic prostatitis are more subtle than the acute phase. Patients may have no symptoms at all or may have some pain on urination or frequency, urgency etc. Exam may reveal a large prostate or be completely normal. Exam may also include prostatic massage, but this is not too popular.

What is the cause? The cause is usually bacterial infection. Obtaining fluid should be attempted as it will greatly help choose the proper antibiotic. The coarse needs to be at least four weeks of antibiotics.

The take home message is this: if you have any of these symptoms, get it checked out, as the condition may lead to a more chronic state that may become recurrent.

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The Wild Wacky World of Insurance: Part One

noreply@blogger.com (Dr. Frank) — Tue, 31 May 2011 19:27:00 +0000

Why should I have insurance?

1in·sur·ance

a means of guaranteeing protection or safety

The economy has stretched everyone these days. Gas prices are a record high, food prices continue to increase and insurance premiums have done nothing but go up as well. It can be tempting to just not get insurance at all, or to cancel. However, all it takes is one illness that goes from bad to worse, and you’ll wish you had insurance. We have an example for you. But first, ever wonder, where did insurance come from?

How does insurance work and what do all those terms mean?

When you join an insurance plan, you essentially enter into a contract with the plan. Your physician also separately enters into a contract with your insurance plan. That relationship between you, your insurance plan and your physician is what determines how much you pay for office visits, tests, and more.

There are a lot of terms to know when dealing with insurance. For some of the common terms, visit our blog on EOBs here http://blogs.eastsidefamilyhealth.com/2011/05/understanding-insurance.html

What’s the big deal about not having insurance? I rarely get sick!

We all live in a world where accidents happen. Germs are everywhere and we have no ultimate control over how our body responds to everything it’s exposed to. Sometimes we do silly things, like miss the potato and cut our finger instead. Life is unpredictable. Health insurance provides reassurance that when Murphy does come to visit, you have a way to get the care you need, and to be able to afford it much better than if you don’t have insurance.

Insurance premiums do continue to rise and it can sometimes be a strain on the wallet, but let me present it to you this way – I will let the numbers do the talking.

Say you wake up one morning, with right sided abdominal pain and you have no insurance. Your doctor is great about giving a discounted rate for your office visits, but that does cost $75.00 when you arrive to the office (you have also called in sick to work, since the pain is so bad you are doubled over).

While there, the doctor tells you that you may have appendicitis. The only way to know for sure is an ultrasound or CT scan. Those tests range from $150-$1500. If your physician checks your blood, so you’ll get a bill from the lab. Tests there also have a range from $10 to $300, depending on how many and which tests. Oh, and the CT / ultrasound confirms it – you have appendicitis! You’re sent to the ER for hospital admission and surgery, lest you risk your life by not going. The cost of the ER visit, the labs, the surgeon, assistant surgeon, anesthesiologist (assuming you don’t want to be awake during surgery), the medication you’re given, the anesthesia you’re given…. I think you get the idea. It sure does add up!

A case of appendicitis may run you at a minimum of $2-3,000 and depending on the severity, etc. could go all the way up to $20,000. Now compare that to the cost of insurance…. Remember the opening definition for insurance? “A means of guaranteeing protection or safety.” While you cannot guarantee a life free of mishaps, at least with health insurance, you will can rest easy knowing you are protected financially.

Now, there are so many options for insurance plans. Do not let the search for the perfect one be so daunting for you! There are resources available and questions to help you in your search. Look out for our next blog addressing what some of those are.

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So I was in a car accident but why do I need an attorney?

noreply@blogger.com (Dr. Frank) — Fri, 27 May 2011 15:27:00 +0000

The story of a motor vehicle accident (MVA), or a car accident, as its most commonly called, usually starts out with something like this: So I was in a car accident but why do I need an attorney?

The story of a motor vehicle accident (MVA), or a car accident, as its most commonly called, usually starts out with something like this: “I was just sitting at the stoplight.” Let me tell you, though, the story does not always end well. It usually ends with a damaged car, physical pain and a lengthy process of recovery.

A car accident can drastically change a person’s life. Your schedule now has to accommodate doctors’ appointments, physical therapy appointments, massage and chiropractic appointments. Sometimes, if the injuries are severe enough, there could be surgery and recovery time. If that is not enough, you’ll have the stress and emotions that come with juggling your appointments and work, and trying to go through “normal” life when even the way your body moves is anything but normal. It can be daunting just dealing with all of that. Now, add dealing with the car insurance company or companies and the other party, your stress level doubles and even triples.

All you want is for everything to be the way it was before the accident, right? For your body to be made whole, your car to be made whole... Sounds simple enough.

Car insurance is meant to protect you and to bring you back to wholeness. In another blog we looked up the definition of insurance which is a means of guaranteeing protection or safety. It is meant to protect you in case of harm: physically, by providing compensation for healthcare and financially, by paying for your vehicle repairs.

Your car insurance is meant to be your advocate. However, there are situations you may run into where you feel like things are not going well. The insurance company is trying to close your case and you don’t think it is time for that. Or your injuries are more extensive than your personal injury protection coverage will pay for. Will your car insurance agree to continue to pay for more treatment? Will the other party’s insurance? How will you know if what they are saying and what you are getting is fair? Are they thinking of what’s needed in the future or just closing your case? How do you know it’s time to close the case? Are you still in pain and still need medical care? Do you have more questions than answers (like this paragraph)?

We understand this process can be daunting, frustrating, and time consuming but we want to see you through the process and come out as healthy as you can. Sometimes, that means getting more help.

A lot of people cringe when they hear the word “lawyer” or “attorney”. All sorts of preconceived ideas come to mind. While seeing an attorney isn’t recommended at the beginning of a case, an attorney may be appropriate in cases with extensive physical injuries, a pre-existing injury is exacerbated by the accident, or when you come to a place where you are not sure if your car insurance or the other party are looking out for your best interests.
Not all attorneys are created equal though. A good attorney can be your advocate. If you are concerned about your recovery or if your car insurance is looking out for you, talk to your physician. Your physician may be able to refer you to a reputable attorney that they know and trust.

Confused about what to do if you’re in a car accident? For more details, visit this blog: http://blogs.eastsidefamilyhealth.com/2011/03/what-to-do-after-auto-accident.html

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Supplements: To Take or Not To Take?

noreply@blogger.com (Dr. Frank) — Thu, 26 May 2011 21:08:00 +0000

A myth commonly believed by many is that vitamins and supplements make up for an unhealthly diet and lifestyle. This is far from the truth as supplements are designed to supplement the diet .

Experts recommend eating a well balanced healthy diet and the use of supplements to fill in the gap. Dr. Demetrius Albanes MD, epidemiologist at the National Cancer Institute states “vitamins are safe when you get them in food, but in pill form, they can act more like a drug with the potential for unexpected and sometimes dangerous effects.” We must be educated and aware that supplements taken in too high doses , such as the fat soluble forms of vitamin A, D, E, and K, can build up in the body and cause toxicity. Thus having an idea what the FDA recommendations of the upper and lower limits of vitamin and mineral doses is important in determining a supplement regimen.

As a nurse practitioner, I see many patients that are taking supplements on their own initiative or at the guidance of a provider and yet unaware how some of their supplements could be impacting their medical condition in a negative manner. Therefore, it important that the provider review a current list of medications and supplements to identify any interactions and follow up with bloodwork to confirm normal values if necessary.

A good supplement baseline to get started for the young to middle-aged adult includes a multivitamin daily; Vitamin C 500mg daily as immune support therapy, not a treatment for cold viruses; Calcium 500mg up to two times a day depending on dairy food intake; and Vitamin D 1000-2000IU daily. This may need to be adjusted depending on the patient’s diet and current levels which can best be determined in consultation with your primary care medical provider.

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Rita along with her husband, Dr. Frank established Eastside Family Health Center in 1999. She later joined EFHC in 2007 as a provider. In addition to caring for a wide range of patients, Rita’s special interest is Women’s Care and primary care for adults and adolescents. You can find out more about Rita at www.eastsidefamilyhealth.com

Hoarseness

noreply@blogger.com (Dr. Frank) — Wed, 25 May 2011 16:05:00 +0000

Sounding hoarse lately? This refers to any change of voice. It can be higher, lower, huskier, or even breathless. This blog is to help think about the potential causes.

Voice is the result of interaction between the nose, mouth and a structure called the larynx.

Hoarseness can be caused by a number of factors. If the hoarseness is persistent it needs to be evaluated especially if there are no acute symptoms of infection or if has gone longer than two weeks. Tobacco use and alcohol are two worrisome coexistent risks for head and neck cancer. Unexplained weight loss, painful swallowing, difficulty swallowing or one-sided throat pain or ear pain needs to be evaluated.

Other causes of hoarseness include: acute laryngitis, chronic laryngitis, benign growths, cancer, nerve dysfunction, neurologic disease, or stress.

Acute laryngitis is common and self-limited condition lasting less than three weeks. This is usually due to a virus although can be bacterial. Laryngitis can also be caused by strain such as yelling or coughing resulting in bleeding from microtrauma.

Chronic laryngitis is typically due to irritants over time. Things such as acid reflux, fumes, chemicals, chronic voice strain, chronic alcohol use, chronic sinusitis, chronic post-nasal drip, or tobacco smoke. Some symptoms include throat clearing, heartburn, change of voice, sore throat, feeling like a lump in throat, or choking sensation. Asthma type symptoms may also present this way.

Normal Vocal Chords

As noted, there are benign growths that can occur on the vocal cords. Smoking can cause swelling of the cords called Reinke's edema resulting a husky low-pitched voice( sounds like a man). Polyps and nodules can also occur due to smoking, acid reflux or chronic vocal cord irritation.

This is Reinke's edema. Note the soft swollen irregular appearances (this was due to reflux).

Some may know of singer's nodes. This can be true but usually occurs with screamers. This is more common in women and children.

Now to the possibility of cancer. The vast majority of cancer is squamous cell. Major risk factors include alcohol use and smoking. This is usually heavy alcohol use such as up to 4-5 drinks per day. There are many other potential causes that have not been fully proved such as viruses, genetics and diet.

Cancer. Note the irregular appearing mass from the right vocal cord.

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There's more to Psoriasis than meets the eye...

noreply@blogger.com (Dr. Frank) — Fri, 20 May 2011 18:01:00 +0000

What is Psoriasis? Psoriasis is a chronic skin disorder which typically is characterized by plaques (patches of red raised skin) with a silver coat or scale. Recently, this skin disease has been associated with heart disease and can also be associated with life-threatening presentations. It affects men and women the same and is seen in all races. It peaks in age between age 20-30 with a second peak between 50-60. It is also interesting to note that psoriasis is even now being seen in children.

Who is at risk? Risk factors include family history (the disease is 100x more likely to occur among family members than unrelated people) but there are also many triggers. These include infections, stress- both physical and emotional, and as well certain medications. Several drugs are associated with worsening psoriasis such as beta-blockers, lithium, or ant-malarial drugs. Ibuprofen may but has not been fully proven. Smoking increases one’s risk of getting this skin disease. The worst kind of psoriasis, called pustular psoriasis is strongly associated with smoking. It also associated with obesity. In fact the greater the obesity, the worse the skin. This is also true of alcohol consumption. The greater the consumption, the worse the condition of the skin. A number of people also have nail involvement called psoriatic arthritis. The sun helps with the UV exposure.

Some Types of Psoriasis

Plaque psoriasisSa

The most common form of psoriasis is called plaque psoriasis accounting for about 80%. This is characterized by plaque in the scalp, elbows, knees, and back. The plaques are red with sharply defined margins that are raised. A thick silvery scale is usually present. Other areas are the intergluteal cleft and belly button.

Pustular psoriasis

A severe form is called pustular psoriasis. This can be severe and life-threatening. In addition to the usual plaques, there are sheets of superficial pustules (small elevation of skin filled with fluid called pus). It can associated with fever, weakness and diarrhea. It can be caused by pregnancy or the withdrawl of oral steroids, such as prednisone.

What causes it? We do not know what causes psoriasis but it likely immune related. This link has triggered breakthrough treatments. This is especially true of the newer family of drugs called biologics. Some patients after having undergone bone marrow transplantation have had a complete resolution of this disease.

What are other potential concerns if I have psoriasis? Even though psoriasis is a skin disease, it is also an independent risk factor for the heart attacks. The worse the skin condition, the higher the heart risk. This also makes psoriasis a higher risk of death. Certainly, this can be more than just affected skin! See your doctor to discuss this. It is important to have normal cholesterol numbers as well as blood pressure. Not to mention stop smoking and lose weight. It all goes together.

Finally, there has been much discussion of an increased risk of cancer in individuals who have psoriasis. It is due to the immune process of the underlying disease or the treatment? Not known. But, if you have psoriasis it should mean getting it treated and seeing your doctor on a regular basis.

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Understanding Insurance

noreply@blogger.com (Dr. Frank) — Tue, 17 May 2011 00:35:00 +0000

What is an EOB? And More importantly, is it contagious?

Acronyms run freely about in the medical world. We have them for conditions, for procedures, for just about everything. So let’s throw one out there for discussion…

EOB… what is it? No, it is not a disease, body part or even some strange procedure with 30 letters if you were to write it out fully. EOB stands for Explanation of Benefits. It is simply a form you receive from your insurance company showing how they are processing a claim that your doctor submitted for the billing of your visit. It may also be referred to as EOMB.

What does it do? Simply put, an EOB takes the various codes used that tell what was done (procedure or visit) and the reason it was done (diagnosis) explains based on the benefits of your particular insurance policy what was paid by the insurance company, what part will be written off (or discounted) due to an agreement between the insurance company and physician, and what part the patient will be responsible to pay. Here are some terms you may see on an EOB.

What is a co-pay? A co-pay is usually a smaller payment that is paid at the time of service for office visits or tests by the patient. It is based on the insurance plan you select. The doctor is not able to waive or change the co-pay.

What is a deductible? A deductible is also part of the insurance plan agreement which a patient agrees to pay when they accept the plan. Deductibles are usually, but not always, the first amount to be paid. For instance, if the insurance processed $1000 in charges for a patient and the patient had a $500 deductible, the patient would pay the first $500 to fulfill their agreement of the deductible. More recently, there are some plans that allow for a certain amount of visits before the deductible is processed and expected to be paid.

What is co-insurance? Some plans have a certain percentage that when you accept that plan you are agreeing to pay that percentage as a patient. These percentages can vary from as much as 50% to 10%. They can also differ based on types of services, such as was it a skin biopsy or visit for a cold. Co-insurance is the amount the insurance sees as the patient’s portion of responsibility for that bill.

What is out of pocket? Most insurance plans have a maximum limit to the amount that a patient and/or family will pay each year. Every plan varies on what applies to that limit, but most typically it is the co-insurance amounts. For instance, when a patient’s coinsurance amounts for the year reach $10,000, the insurance plan will then pay the remaining bills at 100%.

What is an allowable? The allowable is the amount your insurance will pay for a visit or procedure. The physician services are billed off a fee schedule that is set for their office. The allowable amount for the insurance is typically lower than this amount as it is a discounted rate that the contract agreement between the physician and insurance plan . Per their contract, the physician will deduct the difference between the amount they billed and the allowable.

What are contractual adjustments? These are based on the allowable. Physicians are often in contract with insurance companies or networks and they agree to provide certain discounts to patients who are part of those plans. The contractual adjustments or discounts represent the amount of those discounts.

What is in network and out of network ? An In Network provider / facility is contracted with your health insurance. If you see someone NOT contracted, then they are Out of Network. Some insurance plans will allow you to see providers out of network but usually there is a higher portion that the patient is responsible to pay, in other words, you pay more co-insurance and/or deductible. Some plans, however, do not cover out of network providers. If you are unsure if a provider is in or out of network, check with the potential provider, or with your insurance plan.

What if something is denied or not covered? Contact your insurance company to find out why if it is not clear on the EOB. Typically they have a code that explains why. Sometimes the company is just waiting for a form or some additional information so they can process it. If that is not the case, you can always contact the physician’s office to see if they can assist you with it. There are some things that certain plans truly do not cover (these are called exclusions and can be found in your benefit booklet) and other times where is information that is needed. The physician’s office may be able to supply additional clinical information that will assist in seeing that you get the full coverage from your insurance that you are entitled to.

Denied for lack of prior authorization? What is prior authorization and why do I need one? A prior authorization is simply an approval from your insurance company to proceed with getting a certain test or procedure done before you get it done. A prior authorization must be obtained before certain services are covered to ensure medical necessity ( a fancy term that means according to the insurance plan guidelines they view the test and/or procedure as appropriate and needed for the symptoms and diagnosis that you have). If a service is performed without prior authorization, it may not be paid by your insurance plan. Common tests that usually require prior authorization are CT, MRI, Nuclear diagnostic studies and even some medications. Your physician’s office will take care of getting the prior authorization processed for you if they ordered the test, but you may have to wait to schedule your test. However, if you were referred to a specialist, make sure to clarify which physician (the specialist or your primary care doctor) will be obtain authorization and communicate with that office regarding the authorization.

So you have a received an EOB from your insurance company. What is next?

First, the EOB is not a bill. It is simply a statement showing how the insurance applied your plan to the bill. Your physician’s office will either send a statement if you owe a balance or you can contact them to pay any difference if you do not want to wait for the bill. Secondly, if something does not appear correct or make sense, call your physician’s office to get further explanation, or if you have a visit bring in a copy to review with someone.

Always check to see which provider the EOB is referring to. For instance, if you have an office visit where your blood is drawn, you will have an EOB from your medical doctor, and one from the lab. Your doctor cannot correct or modify the information on the EOB from the lab. If you have a question regarding your account with the lab, you should call them first.

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Rheumatoid Arthritis

noreply@blogger.com (Dr. Frank) — Wed, 11 May 2011 23:58:00 +0000

What is Rheumatoid Arthritis? There are many different types of arthritis. Certainly one of the most serious ones is rheumatoid arthritis. This is a chronic , systemic (thru the whole body), inflammatory (red, hot, tender joints) disorder of unclear cause. This arthritis is symmetrical. If the disease is not controlled, the joints may be destroyed and/or become disfigured which leads to disability.

How is it diagnosed? Here is a summary of the characteristic features used to make the diagnosis: morning stiffness for at least one hour and present for at least six weeks; swelling of three or more joints for at least six weeks; swelling of the wrist or hand joints for at least six weeks; hand x-rays that show erosions in a joint; nodules under the skin; or blood tests that are positive for rheumatoid factor or other markers of inflammation.

A real key is morning stiffness associated with fatigue, weight loss, low grade fever and depression. These are very common presentations. It can also be a cause of carpal tunnel syndrome.

What does it affect? At presentation, one joint (such as hand) or many may be involved. Key is how the arthritis has affected daily activities such as walking, doing stairs, dressing, use of the toilet, getting up from a chair, opening jars, opening doors, typing, or performing on the job. The feet may also be involved. A very potential and serious involvement would be the upper cervical neck. If you have been diagnosed with rheumatoid arthritis (RA), ask your doctor about getting x-rays of your upper neck.

It is important to know that rheumatoid arthritis may affect other systems outside of the joints. Anemia, skin, heart, nerves( neuropathy), eyes, spleen, blood vessels(vasculitis) may all be involved. These other systems almost always occur with the joints.

Most patients show a fluctuation of disease activity (changes in symptoms) over a period of months. The goal is remission (symptoms of disease subside) which is very rare without the use medication called disease modifying anti rheumatic drugs( DMARDS). We do see some remissions here in the clinic.

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Carpal Tunnel Syndrome

noreply@blogger.com (Dr. Frank) — Tue, 10 May 2011 18:58:00 +0000

What is carpal tunnel syndrome? Carpal tunnel syndrome (CTS) refers to the pain, numbness, and sometimes, but less commonly weakness which is caused by the compression of the median nerve as it travels through the wrist. Carpal tunnel syndrome is one of the most common causes of hand numbness seen.

What are the symptoms? The classic symptoms include numbness and tingling limited to the median nerve innervated fingers (or fingers that contain nerves that are supplied stimulation through the median nerve), but there is wide variability. The pain and numbness may be localized to the wrist or involve the entire hand. It is also not uncommon for the symptoms to radiate into the forearm, and as well, less frequently to radiate above the elbow to the shoulder. So, the hand symptoms described could be carpal tunnel or radiating pain from the neck.

These symptoms are often provoked by activities that involve extending the wrist, such as raising the arm while driving, reading, writing, typing, or holding a phone.

It is good to know that CTS often presents bilaterally (in both hands), up to 65% of the time.

Carpal tunnel may follow an alternating pattern with periods of remission and exacerbation. In some cases, there is progression from intermittent to persistent that may even advance to motor loss (strength). In the most severe cases, motor loss involves difficulty holding onto objects, turning keys or doorknobs, or buttoning clothes. One may even see atrophy.

How is it diagnosed? The diagnosis is a clinical one determined by a physician based on some testing and symptoms. The most important clue is nighttime pain or numbness. Standard symptoms include: dull, aching discomfort of the hand, forearm, or upper arm; numbness in the hand, weakness or clumsiness of the hand, any symptom in median distribution.

Some provoking factors include symptoms occurring in the sleep and repetitive actions of the hand. A test called an EMG which is a series of electrodiagnostic studies are needed to make the diagnosis. The EMG results in combination with the physical exam and the clinical history all lead to the diagnosis.

Who is at risk? Risk factors for CTS: obesity, female gender, pregnancy, diabetes, rheumatoid arthritis, diabetes, hypothyroidism, connective tissue disease( ex: lupus), pre-existing CTS, genetic predisposition, use of HIV meds, or workplace factors such as cold temperatures, vibrating tools, or repetitive hand use. As an interesting note, most studies do not support the association between computer usage and developing carpal tunnel.

What is the treatment? Treatment includes splinting, stretches, physical therapy, yoga, injections into the carpal tunnel and finally surgery. For sure there are many treatment options, the success of which usually depends on the severity of the compression. Ask your doctor to discuss the risk and benefits of each. Not all carpal tunnel needs necessarily end in surgery! As well, there are potentially other causes of it other than just overuse.

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Colon Polyps

noreply@blogger.com (Dr. Frank) — Mon, 09 May 2011 14:36:00 +0000

Colon cancer is one of the leading causes of death for both men and women. For the most part, death is avoidable with by using the very good screening tool we have called the colonoscopy. The colonoscopy is a procedure where a probe is inserted into the colon (commonly known as the large bowel) which allows the physician to view inside the colon for abnormalities as well as take samples of these to determine what the nature of these abnormalities are. This blog is about an announcing growth that needs investigation referred to as a precursor growth in the colon called the polyp.

Normal Colon Colon polyps

There are all different types of colon polyps, some pre-cancerous and some not. The most common polyps seen are called non-neoplastic polyps which include those called hyperplastic. Even though hyperplastic polyps are benign (or noncancerous), consideration must be given to their appearance, such as some (serrated forms) may have the potential for cancer. As well, there are some hyperplastic polyps which occur in large numbers together; a syndrome called Hyperplastic polyposis syndrome. This syndrome requires more intense screening due to increased risk of cancer development.

There are other polyps associated with other conditions such as Crohn’s disease or inflammatory bowel disease (IBS) which are both other diseases of the bowels. These types of polyps typically occur in multiples and need to followed closely by a physician.

Another important category of colon polyps are adenomatous polyps. These are by definition pre-cancerous. Nearly all colorectal cancers arise from adenomas, but only a small minority of adenomas actually progress to cancer( about 5 %). Risk factors for getting this type of polyp include older age( starts at age 50), obesity, and being a man. Adenomas can go through a process from low grade to high grade to cancer, or can present as high grade. You just don’t know where it is without looking under the microscope!

Adenomas have different shapes. Tubular adenomas account for about 80% of colon adenomas. Another type of adenoma is called villous adenoma. These polyps grow at variable rates, thus, when to repeat colonoscopy is based on size of the polyp. Adenomatous polyps bigger than 1 cm are a risk factor for containing cancer. If the adenomatous polyp is has a villous pathology( fingerlike under the microscope), the risk one whether one will develop cancer is also based on size( more than 1 cm, risk is up to 30% for that polyp to develop cancer).

So, it is very important to get screened for colon cancer. How often and when to begin depend on multiple factors including family history. This is a good topic to discuss with your doctor. There are some factors to prevent colorectal adenomatous polyps have been studied: diet—low in fat, high in fruits and vegetables as well as fiber. Maintaining normal body weight, regular exercise, dietary calcium intake, and avoidance of tobacco and excessive alcohol intake, especially beer are recommended.

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Melatonin for Sleep

noreply@blogger.com (Dr. Frank) — Tue, 03 May 2011 16:48:00 +0000

Melatonin is a hormone made by the pineal gland in the brain that controls the sleep/wake cycles. Our body has an internal clock that dependent on the time of day will control how much melatonin is produced. As insomnia can be a common symptom among patients, one of the recommended treatments for the often requested “natural” alternative is the dietary supplement melatonin.

Studies suggest that melatonin supplements may help people with disrupted circadian rhythms (such as people with jet lag or those who work the night shift) and those with low melatonin levels (such as some seniors and people with schizophrenia) to sleep better. Melatonin supplement doses can range from 0.3 mg to 80mg.

Melatonin is a dietary supplement and therefore it is not federally regulated. Thus the dose listed on the bottle may not be congruent to the dose contained inside. The timing of the dose can also be tricky as some sources recommend taking Melatonin up to 30 minutes before sleep while others suggest increasing the time by 30 minutes to as much as 6 hours to have an optimal effect on shifting the internal biological clock.

Melatonin has been found to be more effective on people that have already natural low levels of melatonin such as the elderly. Thus it is recommended that it be taken in the day time when low internal levels of melatonin already exist. It has also been found that the best method for delivery of melatonin is sub-lingual (under the tongue) or trans-dermal (through skin usually creams or patch) for better absorption.

All in all, the effectiveness of melatonin in treating insomnia is questionable and very individual. It is good to be aware that beta blockers and anti-depressants can suppress or reduce melatonin levels and thus may impact the effectiveness of the supplement as well. If insomnia becomes a chronic issue, it is recommended that you see your primary care provider for evaluation and treatment.

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Malignant Melanoma

noreply@blogger.com (Dr. Frank) — Sat, 30 Apr 2011 14:33:00 +0000

What is melanoma? Melanoma is the deadliest skin cancer. The incidence of melanoma has more than tripled in the white population in the past twenty years and with this increase, the number of deaths. This truly can be a deadly disease and great diligence is needed to avoid it as well as to discover it early. The good news is that melanoma is uncommon in children ( but it does exist!)

Who is at risk of getting it? The risk factors for developing melanoma are both environmental as well as genetic. There is an interplay between these two factors. Males are more at risk; lower extremity lesions (skin abnormalities found on the legs and/or feet) were more common in non-white groups. There is overwhelming evidence of the association between melanoma rates and UV exposure (mainly associated with being in the sun). This is more true for exposed areas of the skin to the sun (sorry sun lovers!). The bad news is that bad sunburns even in childhood or adolescence increase the risk of melanoma. The data leans more toward intermittent intense sun exposure, in other words the occasional weekend sunburn from all day at the beach. Also, geography plays a role. The farther from the equator and the farther south increases the risk. If one has had a diagnosis of melanoma already, reducing the sun exposure recreationally really does help decrease the odds of getting a second melanoma.

As noted, it is interesting that the pattern of sun exposure is unique to the risk of getting melanoma. This tends to be associated with intense, intermittent sun exposure and frequently occur in areas exposed only sporadically such as the back in men or the legs in women. Melanomas of the head and neck are more common in outdoor workers. Parents, it is REALLY important to know that five or more severe sunburns in childhood give an estimated twofold greater risk of developing melanoma.

Most sunscreens with sun protective factor( SPF) will protect against UV-B and far less against UV-A. Unfortunately, there is no good data to prove sunscreens really protect against getting melanoma or any other skin cancer.

What about tanning beds? The hot topic is tanning beds. Technically, melanoma is more highly associated with UV-B but there is also strong data linking this cancer to UV-A which means patients using tanning beds and those treated with puva light therapy for psoriasis at an increased risk. The risk seems worse with the newer high speed, high intensity units. So, like a good doctor, I discourage the use of tanning beds, no matter what! If you want a tan, perhaps the best idea is the self-tanning lotions with DHA. It will help you look brown without the UV damage to your DNA.

What about moles? There are studies from Australia showing that the number of moles(or nevi) may be associated with increased risk. Someone with 50-100 moles is more strongly associated with melanoma risk ( up to 5% increase). It is very important to understand that if you’ve had a melanoma, you are greater risk of getting a second one. Thus, get your skin checked!

Be on the outlook for atypical moles. What is atypical? These are larger than the common mole(4-12MM); different colors( shades of tan or brown and pink or dark); some notched borders. Atypical moles have a higher risk of developing melanoma. If you have a funny looking mole, a dark mole, a new mole, a mole that has changed in its appearance, a lot of moles, or a family history of skin cancer, get a skin check up.

Even if these risk factors don’t apply, it is still a good idea just to get a skin check, period.

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High Cholesterol and Risk of Heart Disease

noreply@blogger.com (Dr. Frank) — Thu, 28 Apr 2011 18:34:00 +0000

Hypercholesterolemia refers to increased levels of lipids (or fats) in the blood, which includes cholesterol and triglycerides. High cholesterol does not make you feel bad, but it can significantly increase your risk of developing heart disease, which is also called coronary heart disease. High cholesterol can lead to hardened arteries of the heart. These hardened arteries can be a cause of chest pain or heart attack or both. Because of the risk of this happening, treatment for high cholesterol or high triglycerides is usually recommended.

One type of cholesterol is LDL cholesterol, known as bad cholesterol, and it is the most accurate predictor of coronary disease, i.e. the higher the number, the more your risk of coronary disease. If you have had a heart attack or another significant vascular event, such as a stroke, your LDL goal should be less than 70. Otherwise anything less than 130 is optimal.

Other risk factors: Once you are aware of your cholesterol numbers, there are some other factors that also affect ones risk of coronary disease (heart disease). Other factors that can increase your risk for coronary disease include: cigarette smoking; high blood pressure; family history of heart disease( usually males younger than 55 or females than 65); males; and increasing age.

As well there are certain diseases that increase the risk of complications with coronary disease. Some of these are: Diabetes, type I and 2; symptomatic carotid artery disease—like stroke or TIA; peripheral artery disease; abdominal aortic aneurysm; and kidney disease.

Do I need treatment? The decision of who gets treatment for cholesterol and at what cholesterol number is treatment recommended is confusing at best for the public. This blog will give the ACP (American College of Physicians) guidelines and a table to determine your own level of risk. The ACP recommendations are based mostly upon the LDL cholesterol and the number of cardiac risk factors as noted above.

It is important to note that the ACP considers diabetes, carotid disease, aortic aneurysms and peripheral artery disease as heart disease equivalents (in other words equal to heart disease. The others such as smoking, high blood pressure and age are considered major risks, but not equivalents.

If two or more risk factors other than high LDL are present in a patient without heart disease (or an equivalent such as noted above), the ten year risk of developing heart disease is calculated by a risk table( see below).

NOTE: If you have 0-1 risk factors your 10 year risk is less than 10%.

Adapted from Adult Treatment Panel III at http://www.nhlbi.nih.gov/ The point total is determined in each category and the 10-year risk determined in the bottom row.

NOTE: These risk estimates for the development of coronary heart disease do not account for all important cardiovascular risk factors. Not included are diabetes mellitus (which is considered a CHD equivalent), family history of CHD, alcohol intake, and the serum C-reactive protein concentration.

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Estimate of 10-Year Risk for Coronary Heart Disease
Framingham Point Scores

Estimate of 10-Year Risk for Men

Framingham Point Scores by Age Group

Age	Points
20-34	-9
35-39	-4
40-44	0
45-49	3
50-54	6
55-59	8
60-64	10
65-69	11
70-74	12
75-79	13

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
<160	0	0	0	0	0
160-199	4	3	2	1	0
200-239	7	5	3	1	0
240-279	9	6	4	2	1
280+	11	8	5	3	1

Framingham Point Scores by Age and Smoking Status

	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
Nonsmoker	0	0	0	0	0
Smoker	8	5	3	1	1

Framingham Point Scores by HDL Level

HDL	Points
60+	-1
50-59	0
40-49	1
<40	2

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

Systolic BP	If Untreated	If Treated
<120	0	0
120-129	0	1
130-139	1	2
140-159	1	2
160+	2	3

10-Year Risk by Total Framingham Point Scores

Point Total	10-Year Risk
< 0	< 1%
0	1%
1	1%
2	1%
3	1%
4	1%
5	2%
6	2%
7	3%
8	4%
9	5%
10	6%
11	8%
12	10%
13	12%
14	16%
15	20%
16	25%
17 or more	30%

Estimate of 10-Year Risk for Women

Framingham Point Scores by Age Group

Age	Points
20-34	-7
35-39	-3
40-44	0
45-49	3
50-54	6
55-59	8
60-64	10
65-69	12
70-74	14
75-79	16

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
<160	0	0	0	0	0
160-199	4	3	2	1	1
200-239	8	6	4	2	1
240-279	11	8	5	3	2
280+	13	10	7	4	2

Framingham Point Scores by Age and Smoking Status

	Age 20-39	Age 40-49	Age 50-59	Age 60-69	Age 70-79
Nonsmoker	0	0	0	0	0
Smoker	9	7	4	2	1

Framingham Point Scores by HDL Level

HDL	Points
60+	-1
50-59	0
40-49	1
<40	2

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

Systolic BP	If Untreated	If Treated
<120	0	0
120-129	1	3
130-139	2	4
140-159	3	5
160+	4	6

10-Year Risk by Total Framingham Point Scores

Point Total	10-Year Risk
< 9	< 1%
9	1%
10	1%
11	1%
12	1%
13	2%
14	2%
15	3%
16	4%
17	5%
18	6%
19	8%
20	11%
21	14%
22	17%
23	22%
24	27%
25 or more	30%

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STROKE

noreply@blogger.com (Dr. Frank) — Sat, 23 Apr 2011 14:47:00 +0000

Just recently at Eastside Family Health Center we diagnosed a previously healthy man in his mid-fifties with a stroke. This has been a life-changing event for him and for his family. I thought it would be good to review the topic of stroke on this blog.

Stroke is the term doctors use when a part of the brain dies because it goes without blood for too long. There are two main types of strokes: those caused by a blockage in a vessel in the brain and those caused by a bleeding in the brain or surrounding area.

In the USA there are about 700,000 strokes per year. Most of these are caused by a blockage in a blood vessel. Early treatment of stroke can reduce brain damage that occurs for this reason time is of the essence. Here, time equals brain lost or gained.

The symptoms of a stroke may begin suddenly or develop over hours or days. The damage from a stroke may be temporary or permanent.

Ischemic strokes are those caused by a blockage in one of the blood vessels that supply oxygen to the brain. If the blockage is not relieved after just a few minutes, the brain fed by that artery will become damaged.
Embolic strokes occurs when a blood clot travels from one part such as the heart to a smaller blood vessel in the brain. This is called an embolus. One of the most common causes of an embolus is an irregular heart rhythm called atrial fibrillation.

Intracerebral hemorrhage is bleeding in the brain. The blood is an irritant to the brain and puts pressure on the surrounding tissue. Some common causes of hemorrhage include: high blood pressure, injury, bleeding disorders, and deformities of blood vessels such as an aneurysm.

A subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures. The blood pools in the space between two layers of tissue covering the brain (the subarachnoid space). The most common symptom of a subarachnoid hemorrhage is a severe headache called a thunderclap headache or the worst headache of one’s life.

There are a number of risk factors for ischemic stroke: age older than 40, heart disease, high blood pressure (defined as any blood pressure higher than 110/60 ) , smoking, diabetes, high cholesterol, illegal drug use, recent childbirth, TIAs( stroke symptoms but with no evidence via CT or MRI that resolve with 24 hours), obesity, or past history of blood clots.

Risks for hemorrhagic stroke include: high blood pressure, smoking, cocaine use or use of blood thinners such as warfarin.

As high blood pressure is a common risk factor here is an interesting graph showing the relationships between increasing blood pressures and age to stroke risk. You can’t slow down your aging but we all can watch our BP’s!

Classic symptoms of stroke can be remembered by the acronym FAST:

Face—sudden weakness or droopiness of the face or visual problems
Arm--- sudden weakness or numbness of one or both arms
Speech—difficulty speaking, slurred speech, or garbled speech or inability to speak
Time—Time is critical, the sooner the intervention the better the outcome.

A stroke is a medical emergency! Call 911. If it is an ischemic stroke and caught within a window of three hours, a medicine may be used to dissolve the clot. A brain scan will be done in the ER to help differentiate what type of stroke it is.

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Menopause: A Life Transition

noreply@blogger.com (Dr. Frank) — Wed, 20 Apr 2011 21:54:00 +0000

Menopause is a transition period in a women’s life where the ovaries stop producing eggs and less of the hormones progesterone and estrogen. This can translate to the menstral flow slowly stopping over time, sometimes becoming more closely or widely spaced, and heavier some months and lighter in others.

Menopause usually occurs between the ages of 45-55 years old; although symptoms of menopause can last as long as 5 years or more. Clinical postmenopause is when a women has not had a period for one year.

Menopause symptoms caused by decreased hormone production can be mild, moderate, or severe and vary depending on the individual. These include hot flashes, night sweats, skin flushing, heart pounding or racing, and insomnia. Other symptoms although not as common include forgetfulness, headaches, mood swings, urine leakage, vaginal dryness, vaginal infections, joint aches and pains, and irregular heartbeat.
Hormone therapy can be considered one of the more effective treatments for menopausal symptoms. Although due to recent research studies revealing an increase incidence of breast cancer or endometrial cancer with certain hormone formulations, new medical standards have been developed. These include prescription of very low dose transdermal estrogens with scheduled oral progesterone on an occasional basis.

Some effective alternatives to hormone therapy include antidepressants such as venlafaxine or paroxetine as well as natural over the counter black cohash creams or tablets and acupuncture treatment.

For less severe menopause, strategies to reduce symptoms can include avoiding caffeine, alcohol, and spicy foods; eating soy foods, taking calcium and vitamin D supplements, regular exercise, and relaxation techniques including deep breathing and/or yoga.

Although menopause is a normal transition in a woman’s life, the goal is that each woman navigate the symptoms whether mild, moderate, or severe while maintaining a quality of life and health. The primary care provider can be an advocate and assist in accomplishing such a goal.

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Rita, along with her husband, Dr. Frank established Eastside Family Health Center in 1999. She later joined EFHC in 2007 as a provider. In addition to caring for a wide range of patients, Rita’s special interest is Women’s Care and primary care for adults and adolescents. You can find out more about Rita at Eastside Family Health.

Gout...

noreply@blogger.com (Dr. Frank) — Wed, 13 Apr 2011 22:07:00 +0000

Even though gout has gotten a lot of publicity in the recent years, it actually has been around a couple of thousand years. There are reports that mummies in Egypt had evidence of gout when dug up in the pyramids. In the past, it was called rich man’s disease, as it has been related to foods the supposed wealthy eat, such as steaks.

What is gout? Gout is a painful and often debilitating condition that develops in people that have a high blood substance called urate which is the breakdown product of protein. Not everyone with high levels of urate (also called uric acid) develops gout and up to two-thirds of those with high levels never get gout. We do not know why some do and some don’t.

Joints are the main areas of involvement of gout, classically the big toe. Other parts of the body can be affected as well such as the kidney or urinary tract causing kidney stones (uric acid stones cause 15% of stones).

A gout attack can cause a sudden intense pain in the joint. This is usually associated with redness, swelling, and tenderness of the joint. An attack usually is in one joint, but some people develop a few inflamed joints at the same time. The pain peaks within several hours but can resolve spontaneously after a few days. I believe an attack should be treated, as gout may destroy a joint. Anti- inflammatory medications are the mainstay of treatment.

What are characteristics that increase risk? Those would be obesity, high blood pressure, a recent trauma, fasting, consuming excessive amounts of alcohol especially beer or spirits but not wine, eating meat or seafood, and taking certain medications such as diuretics.

There are three phases of gout: Acute -with the above noted symptoms of redness, swelling, pain; Inter-critical period- a second attack of gout that typically occurs within two years; and chronic phase. People who have recurrent attacks may develop tophaceous gout which are large number of urate crystals that collect in joints, bones, and cartilage. These tophi can cause the joint to become damaged and even deformed.

Do you need to treat? Yes! First, for the pain which can be severe; second,to help prevent chronic gout which may threaten the joint; third, to help prevent uric acid stones; and fourthly,to decrease the overall load of uric acid in the body which may be a cardiovascular risk factor.

After the acute treatment, prophylactic therapy is usually done to prevent or reduce recurrences. The most common therapy is allopurinol which is a medication that decreases the formation of uric acid in the body. It may take weeks or months to lower the total amount of uric acid in the body. During this time, it is important to drink plenty of water and adjust the diet to more fruits and vegetables, less red meat, less seafood, less beer and hard liquor, less high fructose containing foods with corn syrup( some diet sodas). You are encouraged to eat and drink low fat dairy products, eat foods made with complex carbohydrates( whole grains, brown rice, oats, beans), a moderate amount of wine( 1-2 five ounce servings per day), coffee( this may actually decrease the risk of a gout attack), and vitamin C( 500 mg. per day) which increases the release of uric acid in the urine. Please note that a change in diet alone without the use of some preventive medication is not likely to work very well as diet alone lowers blood urate levels only by 15-20%.

Finally, do not be surprised if your doctor wants to aspirate the fluid in your involved joint. This is the best way to be sure of the diagnosis of gout. The fluid once tapped would then be sent for analysis of crystals.

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Gluten Free...Why?

noreply@blogger.com (Dr. Frank) — Tue, 12 Apr 2011 14:21:00 +0000

You have probably seen the labels in the grocery store “Gluten Free”, but why? If you have heard the word gluten or wheat insensitivity, you are on the track of celiac disease. Celiac disease, like Vitamin D deficiency is coming into its own on the medical front lately. This disease indeed is not new at all but spans all the way back to the second century! It used to be thought of only as a bowel mal-absorption issue and not all that common but now has been linked to numerous other diseases.

During World War II during periods of food shortages, the symptoms of patients improved once bread was replaced by non-cereal containing foods. There was less diarrhea and abdominal cramping. A doctor by the name of Dicke found that wheat, barely, and rye all could trigger the abdominal pain and foul stool.

Later it was found that the primary problem occurred in the small intestine with inflammation and flattened villie (the fingers of the bowel that are responsible for absorption). There was found to be a genetic factor as well. Celiac disease is genetic disorder (Hla-DQ20) that is triggered by an environmental agent (gluten) in a predisposed individual. There is a strong association between the genetics of celiac disease and type I diabetes.

What are the symptoms? Some common symptoms of the disease include: bulky, foul smelling floating stools, a lot of gas, weight loss, anemia, deficiencies of vitamins such as vitamin D, osteoporosis. These are classic findings. Many, however, are without symptoms at diagnosis.

How do you know if you have it? The best way to make the diagnosis is a biopsy of your small bowel. There are blood tests also that are available. Ask your doctor for an endomyseal antibody test. There is an antibody called IgA that is especially associated with Celiacs.

This disease as noted is much more common than once thought. It was originally thought to be only related to mal-absorption of the bowels. It may be as high as one person in 250 affected. The question arises should everyone be tested even if no symptoms? Possibly.

So, should you be tested? There are four reasons to consider it: 1) the danger of cancer—the risk of cancer associated with Celiacs is not fully known but there is some association 2) the presence of unsuspected nutritional deficiencies (i.e. body not able to absorb nutrients) 3) to association with low-birth weight babies 4) the occurrence of autoimmune diseases such as diabetes and thyroid diseases.

As well, there is a ton data coming in now for associations with this disease with other things such as: arthritis (osteo), iron deficiency (high association), osteopenia/osteoporosis( due to vitamin D and calcium deficiency), kidney disease, risk of cancer-this is under active study, rash:, liver disease including hepatitis, menstrual issues, and perhaps even heart disease.

It is amazing to see the possible links of this disease with all the above! What is just as amazing is to think that all or most of it is treated or even avoided by simply a strict adherence to a gluten-free diet! Even the rash goes away with this diet! That is why I think you should ask your doctor if it makes sense for you to be screened for this disease.

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Eastside Family Health Center

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The Case of the Jumping Legs: Restless Legs Syndrome

Abnormal Uterine Bleeding

Tic, Tac Twitch

Prostatitis

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Rheumatoid Arthritis

Carpal Tunnel Syndrome

Colon Polyps

Melatonin for Sleep

Malignant Melanoma

High Cholesterol and Risk of Heart Disease

Estimate of 10-Year Risk for Coronary Heart Disease Framingham Point Scores

Estimate of 10-Year Risk for Men

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

Estimate of 10-Year Risk for Women

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

STROKE

Menopause: A Life Transition

Gout...

Gluten Free...Why?

Estimate of 10-Year Risk for Coronary Heart Disease
Framingham Point Scores