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Friday, November 24, 2017

  • Monday, November 20, 2017 4:00 AM
    Winter cold & flu season is starting to gear up. This week, I’d like to talk about a different kid of flu, “stomach flu.” I have to start by dispelling a common misconception that all flu is the same. “Stomach flu” is not caused by the same viruses as “respiratory flu.” Flu shots, given to prevent respiratory influenza, will not protect you against viruses affecting the gastrointestinal tract that causes an infection known as viral gastroenteritis.
    Noroviruses are the number one cause of acute viral gastroenteritis in America, with an estimated 21 million cases per year with about 70,000 hospitalizations and 800 deaths. The name norovirus is derived from a virus that was first identified as the cause of an outbreak of illness in a school in Norwalk, Ohio in 1968. They are a very sturdy group of viruses, able to withstand freezing and temperatures as high as 140 degrees. They can survive steaming when cooking shellfish and are even resistant to the levels of chlorine found in our municipal drinking water.
    Typical symptoms of norovirus infection include the sudden onset of nausea, vomiting, diarrhea and abdominal pain/cramping. Diarrhea is particularly common in children. These symptoms can lead to dehydration, especially in the young and elderly. 
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  • My head is spinning – what’s wrong, Doc?
    Monday, November 13, 2017 4:00 AM
    This week I want to address a specific variant of a condition that I’ve been seeing a fair amount of lately – dizziness. Primary Care doctors in the U.S. see about six million patients a year with dizziness.
    Dizziness means different things to different people and can be a symptom of many different medical conditions. People usually describe being dizzy when they either feel faint or lightheaded or when they feel like their environment is spinning. This latter sensation is called vertigo, from the Latin vertere meaning, “to turn.” 
    I want to touch on the most common cause of vertigo, known as benign paroxysmal positional vertigo or BPPV. Benign means the condition is not dangerous, paroxysmal indicates it occurs in a recurring pattern for short periods of time, and positional refers to the vertigo being brought on by changes in position.
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  • Monday, November 6, 2017 4:00 AM
    This week I’d like to write about a problem that costs taxpayers billions of dollars each year – Medicare fraud and abuse. Medicare paid out $591 billion in payments for services and medications in 2016, accounting for 14.8 percent of the federal budget. The Office of Management and Budget (OMB) reports that 11 percent of those payments were “improper,” meaning the services were not necessary, did not meet Medicare guidelines, or were downright fraudulent (a decrease from 2015).
    Medicare fraud refers to individuals or companies who obtain payments from Medicare under false or illegal pretenses. The OMB has been making a concerted effort to limit Medicare fraud, but Medicare is an easy target since it is such a complex program. It’s like playing the lottery for those who are intent on defrauding the government, but with a much higher chance of a payoff.
    There are three major categories of Medicare fraud: phantom billing, false patient billing, and upcoding, also known as upbilling.
    Phantom billing involves a provider billing Medicare for services or procedures that were not necessary or were never provided. Billing for medical equipment falls under this category. I see this type of fraud frequently when companies bill Medicare for equipment or services for my patients that they never requested or that I did not prescribe.
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  • Monday, October 30, 2017 4:00 AM
    Someone told me the other day that they thought “restless leg syndrome” (RLS) was a condition made up by pharmaceutical companies to sell more medications. You may have seen the commercials for Requip® and Mirapex®, both drugs used to treat this malady.
    People have described symptoms suggestive of restless legs since the 17th Century. The Swedish neurologist Erik Ekborn initially coined the term in the 1940’s. It is estimated that between 10 to 15 percent of Americans suffer from restless leg syndrome to some degree. The incidence in women is about twice that of men. About 40 percent of people develop symptoms prior to age 20. Since symptoms tend to be mild initially and worsen with age, most sufferers are not diagnosed for 10 to 20 years after they start having symptoms.
    The symptoms of RLS are highly variable, but most people describe a bothersome, irresistible urge to move their legs (and sometimes the arms). This urge to move the legs is worse during periods of inactivity and often interferes with sleep. About 85 percent of sufferers have difficulty falling asleep. Stress and fatigue can also exacerbate the symptoms.
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  • Monday, October 23, 2017 4:00 AM
    I’m frequently asked by patients to comment on the use of “non-traditional” treatments or remedies they have heard or read about. I usually have to respond that I have limited knowledge about the product, but I will sometimes try to help the patient research the product or its ingredients.
    The business of complementary and alternative medicine or “CAM” is booming. This is largely an outgrowth of patient frustration with traditional medical practice in America. People are fed up with the high cost of medications and other treatments as well as the perceived lack of caring by medical professionals. Many are looking for less expensive “natural” ways to deal with illness and health promotion. A government survey in 2007 revealed that 83 million Americans spent $33.9 billion on CAM treatments over the preceding 12-month period. This accounted for 11.2 percent of total health care spending that year. This number has no doubt increased since that study was reported.
    Traditionally, physicians trained in the U.S. have received little or no education in CAM treatments in medical school or afterwards. This is beginning to change as more medical centers are starting to integrate CAM into their treatment programs.
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  • Monday, October 16, 2017 4:00 AM
    I’m starting to see a few cases of head lice now that kids are back in school. Head lice are white, and about the size of a sesame seed. They are known as "obligate ectoparasites." Obligate means they require a placental mammal host to survive (i.e. humans) and ectoparasites means they live outside the human body. They must feed on the host’s blood to survive, and can't live off of a body for more than a day or so. Lice are spread by direct contact of a person's head or hair with an infested individual or through sharing personal items such as hats, towels, brushes, helmets, hair ties or even car seat headrests. They do not jump or fly and are not transmitted by pets.
    Adult lice survive on a person for about one to three months. A female louse lays about three to five eggs, known as "nits," each day and glues them to the hair shafts of the host, close to the scalp. The eggs require the warmth of the scalp to incubate. A louse may lay up to 300 eggs in her adult life. The eggs take about ten days to hatch and the new lice need an immediate blood meal to survive. They then take another seven to ten days to mature to the point they can start laying eggs.
    Lice typically are not harmful to their human host. There is recent evidence that the head louse is genetically identical to the body louse that is known to carry the organisms causing typhus, trench fever, and relapsing fever. There is some concern that as lice become more resistant to chemical treatments that they will become more prone to spreading disease, but this is currently not a concern in the U.S.
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  • Monday, October 2, 2017 4:00 AM
    The title of this column, a quote from comedian W.C. Fields, refers to his penchant for drinking alcohol. So what does alcohol and W.C. Fields have to do with my topic of rosacea? Read on. 
    Rosacea is a common skin condition usually found on the face, which can be a great source of consternation. It is a disease with various clinical signs. These can include redness (flushing), coarse skin, and bumps and pustules resembling acne. It may also present with visible superficial blood vessels called telangiectasias. 
    The condition is found three times more often in women and usually presents between 30 and 60 years of age. It is also more common in fair-skinned people of European and Celtic origin. One of its nicknames is the “curse of the Celts.”
    The diagnosis of rosacea is made on clinical grounds (i.e. signs and symptoms). There has to be a persistent rash on the central part of the face for at least three months to qualify as rosacea. Classifying rosacea is important in determining the best treatment. 
    The exact cause of rosacea is not well understood, though there are numerous factors that likely play a role. The flushing associated with rosacea is thought to be due to the increased number of blood vessels that are close to the surface as well as the increased sensitivity of the vessels to heat. Sun exposure may play a role based on the location of the rash, though some studies refute this.
    Skin inflammation is a major finding in rosacea. Demodex, a species of skin mite, may also play a role in the development of an inflammatory reaction though studies are somewhat conflicting. Free radicals in the skin produced by various biochemical reactions can also cause damage.
    There are four different subtypes of rosacea based on clinical findings. The types are likely the result of how a particular patient responds to various biologic factors and triggers. The first is the erythematotelangiectatic type. The main signs and symptoms are central facial flushing, often with burning or stinging. The redness usually is not found around the eyes. The red part of the skin can be rough with some scaling.
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  • Dr. Roberts revisits discussion of Shingles
    Monday, September 25, 2017 4:00 AM
    I’ve had requests to re-run my column on shingles. I think the increased interest has been brought on by the television ads for the vaccine to help prevent shingles, which are quite accurate and compelling. I’ve had quite a few patients who have recently been suffering from this malady, two quite severely.
    Shingles is caused by the Varicella-zoster virus (VZV). The virus is also known as chickenpox virus, varicella virus, and zoster virus. It is a member of the herpes virus family, of which eight strains are known to infect humans. 
    The biology of herpes viruses is very interesting. They infect humans through the skin and mucus membranes that line body openings. The initial or “primary” infection results shortly after exposure to the virus. This usually causes itching and redness of the skin followed by development of small fluid-filled blisters or “vesicles.” Some readers may have seen chicken pox, though it is becoming a very rare disease since the advent of childhood vaccination to prevent the disease.
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  • Carpal Tunnel Syndrome common repetitive injury condition
    Monday, September 18, 2017 4:00 AM
    I see a number of people who suffer from carpal tunnel syndrome. Carpal tunnel is a very common condition, often related to repetitive injury at home or in the workplace. It is one of a number of repetitive strain injuries or “RSIs.” 
    Carpal tunnel symptoms usually include numbness and/or pain in the hand and wrist that may extend up into the arm, shoulder or even neck. The numbness, tingling or pain frequently wakes people during sleep.
    To understand the condition, it’s helpful to have a lesson in wrist anatomy (see accompanying diagram). There are eight carpal bones that make up the wrist. When you hold your wrist with your palm facing up, these bones form a U-shaped valley. The top of the valley is enclosed by a piece of connective tissue called the transverse carpal ligament. These structures form the carpal tunnel.
    The tunnel is a very cramped space and some very important structures are packed into it. There are nine flexor tendons and the median nerve. The tendons that run through the tunnel connect the muscles in the palm side of the forearm to the bones in the fingers. When the muscles in your forearm contract, the flexor tendons slide through the tunnel and pull on your finger bones, allowing you to make a fist (finger flexion). 
    The median nerve runs directly under the transverse carpal ligament. This nerve is responsible for the feeling in the thumb, index, middle, and the thumb side of the ring finger. It also controls the muscles in the thumb that allow you to pinch your thumb and index finger together.
    Now that you know the anatomy, hopefully it will be easy for you to understand what causes the symptoms of carpal tunnel syndrome. People who have occupations or hobbies that require either repetitive or forced finger flexion (requiring use of the flexor tendons) are at risk for developing carpal tunnel. 
    Manual laborers and people who operate keyboards are the most common sufferers of the condition. Heavy vibration when operating machinery like a chain saw or jackhammer can also cause problems. Keyboard operators typing 60 words per minute will move their flexor tendons in and out of the tunnel 18,000 times per hour!
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  • Monday, August 28, 2017 4:00 AM
    Health care at the end of life has been a popular discussion topic over the last couple of years. It has come up for discussion as we continue to search for ways to deliver compassionate, more cost effective care. Excellent books such as Dr. Atul Gwande’s book, Being Mortal: Medicine and What Matters in the End, have also popularized the topic. 
    As a family physician, I see it as my professional duty to discuss end of life planning and care with my patients. In fact, I would consider it negligent to not hold these discussions when appropriate.
    To put this discussion in financial perspective, about 30 percent of Medicare expenditures are paid out in the last six months of Medicare recipients’ lives. This equates to about $6 billion a year. This would be money well spent if it went to improving health or quality of life, but most of it does not.
    However, this should not be a simple dollars and cents discussion. Determining a patient’s wishes regarding end of life treatment is both sensible and humane. Forcing treatments on patients to keep them alive against their stated wishes is irrational and degrading.
    I suppose I have served on numerous “death panels.” I am guilty of having guided my patients and their families to help them recognize the importance of advance planning as well as carrying out those plans when the time came. It can be heart-wrenching for patients, families and their doctors. Allowing someone to die with dignity is aptly described in the modern Hippocratic Oath: “I will keep them [the sick] from harm and injustice.” 
    To assist patients in discussing and putting their wishes on paper, I want to briefly describe the advance directives that are available in the State of Indiana. Everyone should draft one or more of these documents when they feel the time is appropriate. I like to start the discussion when my patients turn 50 or even younger, particularly if they have other chronic diseases.
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  • Monday, August 21, 2017 4:00 AM
    I recently had to remove some of a patient’s toenails. Why on earth would someone want that done? Because they were infected with fungus. The medical term for a fungal infection of the toenails or fingernails is onychomycosis (OM).
    This condition is generally more of a nuisance than a real health threat. However, infected nails can become quite enlarged and painful. Diabetics and people who have poor immune function need to be concerned about OM. Infected nails in these folks can lead to inflammation of the skin around the nails and entry of skin bacteria that can lead to serious skin infections.
    Most people visit their doctors for OM because of the ugly nails. It is the most common nail disorder in adults and affects up to 13 percent of North Americans. It is 30 times more common in adults than children.
    OM is caused by three types of fungi. The vast majority of these infections are caused by fungi that invade and feed on hair, skin and nails. These organisms are called dermatophytes and account for 90 percent of OM. Trichophyton rubrum (70 percent) and Trichophyton mentagropytes (20 percent) are the most common dermatophytes. 
    Yeasts and molds cause the remaining cases. It’s often difficult to tell what organism is causing the infection without doing a culture in the lab which is usually recommended prior to starting treatment.
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  • Get a better understanding of Lyme Disease
    Monday, August 14, 2017 4:00 AM
    The arrival of warm weather each year means we have to start worrying more about Lyme Disease. Most people are aware of the association between tick bites and Lyme disease, but few know exactly what Lyme disease is or what causes it. Indiana has seen an increasing number of confirmed cases of Lyme disease, particularly since 2013. The most recent statistics showed 102 cases in Indiana in 2015.
    Lyme disease received its name in the late 1970s when a number of children around Lyme, Connecticut developed arthritis. The actual disease has been described since the early 1900s. It is mostly found in New England as well as Wisconsin and Minnesota. When a case does occur in Indiana, the news spreads rapidly, sometimes inciting panic. Most infections (85 percent) are seen in the spring and summer with the remainder in the fall. 
    Ticks do not actually cause the disease, though they do carry the organism that does cause it, the spirochete Borrelia burgdorferi. Spirochetes are bacteria that have a spiral shape. Another common misconception is that any tick can spread B. burgdorferi infection, when in fact only Ixodes (deer) ticks carry the organism. The accompanying photo shows a deer tick on a fingernail – they are very small.
    The B. burgdorferi organism, during its various life stages, mainly infects field mice and white tailed deer. Humans are innocent bystanders when we wander into deer habitat. The ticks lie in wait on the tips of grasses and shrubs and crawl onto us as we brush by. They then crawl about until they find a nice tender spot where they attach and begin to feed.
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  • It’s that time of year: Leaflets three . . . let it be!
    Monday, August 7, 2017 4:00 AM
    We are in the middle of summer and people are still out puttering in their yards. Predictably, this has resulted in a lot more cases of contact dermatitis showing up in my office, most of which were likely caused by poison ivy. Poison ivy is one of three plants in Indiana in the genus Toxicodendron. This genus also includes poison sumac, commonly found in central Indiana, and poison oak that is an infrequent offender.
    The physical appearance of the poison ivy plant is highly variable, though it always has leaves in sets of three (see illustration). Boy Scouts learn a little mnemonic to recall what it looks like – “leaflets three let it be, berries white a poisonous sight.” The white berries can sometimes be seen in wintertime. The plant is small and low to the ground when young. As it grows, it can be found in various sizes all the way up to a thick vine attached by small red roots to trees or other structures.
    The rash of poison ivy, like most contact rashes, results from the immune reaction to a foreign compound on the skin. The compound binds to skin cells, is recognized by the immune system, and attacked. When dealing with poison ivy, sumac or oak, it causes a typical rash, known as “rhus dermatitis.” 
    In the case of poison ivy, oak and sumac, the offending chemical is the plant resin or oil urushiol. Interestingly, urushiol is also found in mangos and the shells of cashew nuts. This oil can remain active for years after a plant dies. 
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  • Monday, July 31, 2017 4:00 AM
    The joy of summer sports and yard work has resulted in a number of patients coming to see me complaining of sore shoulders, elbows, hips and knees. Many of these folks have been suffering from bursitis. Most people have heard of bursitis, but what is it really? 
    Any time a medical term ends in “itis,” it indicates inflammation of the tissue or organ involved. In this case, bursitis is an inflammation of a bursa (pleural bursae or bursas). Bursa is Latin for purse, a very good descriptor of what it looks like – a small sac made of connective tissue. 
    A bursa is lined with a synovial membrane that secretes fluid, filling the sac. This turns the bursa in to a little pillow filled with a slippery liquid that helps cushion structures around it. It also allows these structures to glide more easily over each other. Here’s a fun activity for the kids; make your own bursa by putting just a little water in a small balloon. Then put an object like a book on top of it and roll it around on the table to get an idea of how bursae work. 
    There are many bursae in the body. The ones that cause the most problems are found in the shoulder, elbow, hip, and knee. These joints are fairly complex and have many bones, tendons and ligaments that intersect and move over each other. Without the aid of bursae, these structures would rub together, causing a lot of pain as well as wear and tear.
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  • Monday, July 24, 2017 4:00 AM
    I continue to be amazed that, when asked what the number one killer of women is, the majority of women respond, “breast cancer.” While breast cancer is the number one cancer killer of women, and is estimated to have claimed about 40,000 women last year, it is not the biggest threat women face. It’s estimated that ten times that many women - 400,000 died of heart disease in the same year.
    Cardiovascular disease is arguably the most important women’s health issue that is largely preventable. How can women be so unaware that they have a one in 31 chance of dying from breast cancer but a much higher one in three chance of dying from heart disease? Could it be that breast cancer gets so much more coverage in the popular media? Is breast cancer generally more frightening & potentially disfiguring? Is heart disease just plain boring to talk about?
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