Author Archives: meddyblogger

Update on the Earth’s Natural Sunscreen

It’s a good news/bad news story.

Most ozone is found in a layer that starts 6 -10 miles above earth and ends at about 30 miles up. (Photos by D. McNamara)

First, the good news: The ozone layer is recovering. The once-ominous news about depletion of the protective ozone surrounding the earth is now much sunnier, Drusilla Hufford of the U.S. Environmental Protection Agency said.

“It is likely we will have an ozone layer that recovers to what it was before human intervention by 2050 or 2065,” Ms. Hufford said at the Florida Society of Dermatology & Dermatologic Surgery (FSDDS) annual meeting.

The bad news is that is still at least 38 years away. “This is ultimately a self-righting system, but it will not happen

Drusilla Hufford

immediately,” said Ms. Hufford, director of the EPA’s Stratospheric Protection Division. Chlorofluorocarbons (CFCs) and other ozone-depleting substances last a long time. So even though levels are decreasing, we are still at risk of increased UV exposure in the meantime.

In fact, 2011 featured one of the largest holes in the ozone layer in the Southern hemisphere. NASA compiled a great video of daily satellite images from July to December 2011 that shows the ozone hole forming and dissipating as part of its normal seasonal fluctuation.

Despite the 2011 event, Ms. Hufford remains optimistic. “Global ozone was likely to get a lot worse in absence of the Montreal Protocol, and it has not.”

The EPA is going beyond the science to help physicians and others deliver effective sun protection messages. For example, if you are looking for a new angle on your sun protection message, consider pointing your patients to the EPA SunWise site. They can find a daily UV index forecast by city or zip code. Want help convincing patients to move outdoor activities earlier or later in the day to avoid peak sun exposure? The EPA service, provided in conjunction with the National Weather Service, also breaks down UV levels by hour of the day.

Courtesy Drusilla Hufford/EPA

If you have a patient who likes technology, they can get even more precise information. Have them scan this QR code from the SunWise program with their smartphone. It provides real-time UV exposure data for their precise location using the phone’s GPS technology.

The question remains: How bad would the future have been if we’d done nothing? NASA scientist Paul Newman and colleagues at NASA’s Goddard Space Flight Center developed ‘The World We Avoided’ simulation to answer that question. It shows what earth could have been like if 193 countries had not signed the Montreal Protocol and agreed to curtail production of ozone depleting chemicals starting about 25 years ago

Here is an excerpt: “The year is 2065. Nearly two-thirds of Earth’s ozone is gone — not just over the poles, but everywhere. The infamous ozone hole over Antarctica, first discovered in the 1980s, is a year-round fixture, with a twin over the North Pole. The ultraviolet (UV) radiation falling on mid-latitude cities like Washington, D.C., is strong enough to cause sunburn in just 5 minutes. DNA-mutating UV radiation is up 650%, with likely harmful effects on plants, animals, and human skin cancer rates.”

Ms. Hufford added, “Not only has the Montreal Protocol been enormously successful worldwide in preventing massive destructive of ozone layer, it is also likely helping with climate change.”

–Damian McNamara

@MedReporter on twitter

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Filed under Dermatology, IMNG, The Mole, Uncategorized

Lessons After the Storm: Joplin Surgeon Looks Back

Take emergency weather warnings seriously, prepare a plan to triage and treat mass casualties, and consider how you would work in a worst-case scenario following a major natural disaster. These are some lessons learned by a thoracic surgeon who survived a devastating EF 5 tornado that ripped through his hometown of Joplin, Mo.

The tornado was on the ground for 32 minutes and cut a 6-mile-wide swath through residential and downtown areas. (Photos courtesy Dr. Michael Phillips)

All normal communications were down when Dr. Michael Phillips arrived at his hospital, the Freeman Health System Heart and Vascular Institute. Staff figured out they could communicate via Facebook, Twitter, and texts. There was no water pressure or clean water.  “We were on generator power only, with no ability to identify any patient and no labs or x-rays,” Dr. Phillips said at the annual meeting of the American Association for Thoracic Surgery.

Nearby St. John’s Regional Medical Center, a 360-bed hospital, “was lifted off the ground and moved four inches off its foundation.” There were 183 inpatients at St. John’s when the tornado touched down

Cars were tossed about in front of St. John’s Regional Medical Center in Joplin.

with winds approaching 300 mph on May 22, 2011. More than 70 patients, including 11 on ventilator support, “came to our hospital needing a place to stay, and we were already full. We

have a 250 bed hospital – what do you do from there?”

More than 1,000 patients were treated in the first 24 hours. There were 11 deaths in the first six hours and “I pronounced seven of them,” said Dr. Phillips, a cardiothoracic surgeon at Freeman. There were 161 deaths overall, making the Joplin tornado the deadliest on record since 1950.

“We didn’t sleep. We operated nonstop. We performed 22 operations during that time, 13 of which I performed. It was almost 30 hours before I took a break, the same thing with all the people around me,” Dr. Phillips replied. “I was really blessed by having a wonderful staff around me.”

“There were so many challenges to overcome; it’s really hard to put into words. You have to overcome that initial shock. The layperson doesn’t understand the devastation around them; you do. You have to get your arms around it and move on and deal with the situation at hand.”

A transition zone of less than 100 yards separated “completely normal from complete and total devastation.”

“One can never train enough for such an event. We have to try to be prepared as much as possible. Preparation should include all levels within the health system,” Dr. Phillips said. “Mass triage plans are critical.”

Lessons learned include taking weather warnings seriously.  “We used to blow these off and we pay attention now,” Dr. Phillips said. Take shelter when a siren sounds and review your plans for worst case scenarios.  All this advice applies to other natural disasters – including tsunamis, typhoons, and hurricanes, he said.

“These are all natural disasters that not only take life and create mass casualties, but they also take away our basic essentials of communications, food, clothing, and shelter.”

–Damian McNamara (on Twitter @MedReporter )

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Filed under Cardiovascular Medicine, Emergency Medicine, IMNG, Internal Medicine, Surgery, Thoracic Surgery, Uncategorized

Adolescent Misuse of Prescription Pain Medicine Starts Early

In stark contrast to most research that suggests senior year in high school or later is the peak time for misuse of prescription pain relievers, it is younger 16-year-olds who are the mostly likely to report their first use of these agents outside their intended prescription within the previous year, a new study finds.

Courtesy Wikimedia Creative Commons/Kandy Talbot

The time for physicians to identify risk and intervene is the young to middle teenage years, Elizabeth A. Meier, Ph.D., and her associates at Michigan State University in East Lansing reported.

“With peak risk at age 16 years and a notable acceleration in risk between ages 13 and 14 years, any strict focus on college students or 12th graders might be an example of too little too late in the clinical practice sector and in public health work,” they wrote in the Archives of Pediatrics & Adolescent Medicine, published online May 7, 2012.

“We suspect that many physicians, other prescribing clinicians, and public health professionals will share our surprise that for youth in the United States, the peak risk of starting extramedical use of prescription pain relievers occurs before the final year of high school [and] not during the post-secondary school years,” the authors wrote.

Another reason to screen your young adolescent patients is the risk of hazardous consequences associated with prescription pain misuse, which is greatest during early adolescence, Dr. Meier and her colleagues noted.

They assessed self-reported extramedical prescription pain reliever use among 119,877 U.S. teens and young adults (ages 12-21 years) using 2004-2008 data from the National Survey on Drug Use and Health (NSDUH).

They calculated the highest risk estimate, 2.8%, at 16 years of age. This is an increase from 0.5% at 12 years; 0.7% at 13 years; 1.6% at 14 years; and 2.2% at 15 years. After the peak in mid-adolescence, risk dropped steadily by 0.3% or 0.4% each year, down to 1.1% among 21-year-olds.

Reliance on self-reported misuse of prescription pain killers is a limitation of the study. A strong point of the research, however, was including adolescents and young adults regardless of whether they were still in school.

Earlier and stronger school-based prevention and outreach programs are warranted, according to the researchers. There also is a distinct role and reason for pediatricians, dentists, and other clinicians to work toward misuse prevention in their practices, they added: roughly 15% of the youths surveyed were not in school during the peak time of risk.

–Damian McNamara

@MedReporter on twitter

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Filed under Anesthesia and Analgesia, Drug And Device Safety, Epidemiology, Family Medicine, IMNG, Internal Medicine News, Pediatrics, Uncategorized

‘Skinvestigator’ Author Describes His Dermatology Detective Series

A 22-year-old model with a distinct tattoo is murdered in Miami Beach. A dermatologist learns of the mysterious case while taking a skin cancer biopsy from a friend, a red-headed, fair-skinned policeman. “Doc, you know a lot about tattoos, don’t you?”

So starts “The Skinvestigator: Tramp Stamp,” the first in the Sunshine State Trilogy series of hard-boiled detective fiction written by Florida dermatologist Dr. Terry Cronin, Jr.

“It takes a lot of the knowledge I have about tattoos and feeds it into the mystery,” Dr. Cronin said in an interview. “But it also talks a lot about ‘scalpel tourism,’ where people go to foreign nations to get plastic surgery and cosmetic surgery at cut-rate prices, and a lot of times they get mutilated. That plays a big part in the murder mystery.”

Dr. Terry Cronin, Jr. (photo by D. McNamara)

Miami dermatologist Dr. Harry Poe delivers some important messages in the book as well. “He’s out there trying to promote prevention of skin cancer.” Like most dermatologists, he faces the challenge of warning people about the dangers of sun exposure in a culture that values tanning and looks above safety. When Dr. Poe goes to the beach, for example, everyone is lying out in the sun while he’s wearing long sleeves, a hat, sunglasses, and sunscreen. “And people make fun of him,” Dr. Cronin said.

A dermatologist as detective makes sense – because they use the same type of skills to diagnose skin conditions in their patients every day, explained Dr. Cronin, who is in private practice in Melbourne, Florida.

“I’ve always had a creative flair. I was involved in film making ‑ short films, going to independent film festivals. I ended up writing for comic books. Then I got the idea that I really wanted to tell a story that was pro-dermatologists.” Although Dr. Cronin had always kept his professional and creative sides separate, that was about to change.

The first book in the Sunshine State Trilogy (photo by D. McNamara)

“I wanted to tell a story in which the dermatologist was the hero. I love mysteries, like the Travis McGee series from John D. MacDonald and books byEd McBain and Ken Bruen. I thought ‘maybe I can make this hard-boiled dermatologist detective story, in which the dermatologist is pulled into an investigation. By using his expertise in diseases of the skin, he is able to help police solve a murder.”

Even though Dr. Cronin went through a “big process” of writing draft after draft, honing the story through multiple editors (including Michael Garrett, an editor for Stephen King), and encountering some challenges along the way, he encourages other physicians to pursue their outside passions as well.

“If a physician wants to be a writer, they should let their creative juices flow and do it. Don’t take ‘no’ for an answer,” Dr. Cronin said. “All doctors are pretty smart people, pretty motivated people, who have lots of talents. Some have those talents, but they tamp them down because of their professional needs. I think you have to have an outlet.”

Dr. Cronin initially self-published and sold copies of “Tramp Stamp” at Comic-Con and through Amazon.com. Then a friend at Barnes & Noble encouraged him to sell the bookstore management on ‘The Skinvestigator” series. They liked it and helped him find a publisher. (The store does not inventory self-published titles.) “Now it’s on the shelf in Barnes & Noble. That’s a thrill.”

Dermatologist colleagues have been very supportive, Dr. Cronin said. “That’s the thing I like the most. A lot of dermatologists have been reading it and giving me feedback that is good. I appreciate that.”

“The lay person will enjoy the book, but a dermatologist will get a kick out of it.  They know the language and they will laugh because so much of it is authentic.”

The second book in the series “The Skinvestigator: Rash Guard” is about surfers, syphilis, and the state department. The third installment, yet to be published, will be called “The Skinvestigator: Sun Burn.”

–Damian McNamara @MedReporter on twitter

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Miscarriages After ART Up Nationwide After Hurricane Katrina

Women in the United States who conceived through assisted reproductive technology were significantly more likely to spontaneously abort or deliver their babies preterm in the six months following Hurricane Katrina, compared with the same period before the natural disaster.

Hurricane Katrina from space August 28, 2005, courtesy U.S. National Oceanic and Atmospheric Administration

“Interestingly, this increase in preterm delivery and miscarriage was not associated with Hurricane Katrina sites. That is to say, the rates were not [significantly] different in directly affected counties, but they were different nationally,” Sangita K. Jindal, Ph.D. said.

Dr. Jindal looked at singleton live births conceived through assisted reproductive technology (ART) before and after the category 3 hurricane slammed the Gulf Coast on August 29, 2005.

“We had to double check our math, because we were shocked,” said Dr. Jindal, IVF Lab Director at Montefiore Medical Center in Hartsdale, N.Y. “The reported preterm delivery rate in the country is 10% to 12%. In this study, we found a preterm delivery rate of 19% ‑ much higher.”

She also compared pregnancy outcomes in five states with counties directly affected by Katrina (Texas, Louisiana, Mississippi, Alabama, and Florida) to outcomes at clinics elsewhere across the country.  “There was an 19% preterm delivery rate around the country and a 22% preterm delivery rate in Hurricane Katrina regions,” Dr. Jindal said at the annual meeting of the American Society for Reproductive Medicine.

The preterm delivery and miscarriage rates in regions affected by the hurricane already were elevated. Although they increased, the differences were not statistically significant, she explained.

Nationwide, however, “there was definitely a measurable increase in spontaneous abortions compared to pre-Katrina,”

Sangita K. Jindal, Ph.D. (photo by D. McNamara)

Dr. Jindal said. Compared to the ART cycles initiated before the hurricane, those started in the six months after Katrina hit were 87% more likely to end in a first trimester pregnancy loss and 63% more likely to be a miscarriage by 16 weeks.

So why did adverse outcomes rise significantly across the country? “I would suspect that nationally women suffered a trauma, and they imparted some sort of stress factor to the intrauterine environment, which impacted negatively and directly on the fetus,” she said.

More specific information on cortisol levels or epigenetic factors is outside the scope of the data of 104,724 ART cycles provided by the Society for Assisted Reproductive Technology.

Unlike previous researchers who have found more girls born after a natural disaster, Dr. Jindal found an equal birth rate of 49.5% for each gender.

In the future, Dr. Jindal would like to perform a state-by-state analysis. She also wants to assess pregnancy outcomes by maternal body mass index, because maternal weight “may be a confounding variable.”

–by Damian McNamara (on twitter @MedReporter)

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Help Is on the Way for Primary Care Doctors (Wink, Wink)

Help is on the way “very soon” for family physicians, internists, and pediatricians in the form of a final rule for accountable care organizations (ACOs).

Based on extensive feedback on the proposed ACO rule, changes are coming that primary care physicians are going to like, Dr. Nancy Nielsen said.

The preliminary  rule  “was met with – how shall I say? – an underwhelming response by the medical community,” said Dr. Nielsen, Senior Advisor of the Center for Medicare & Medicaid Innovation established as part of Centers for Medicare and Medicaid Services (CMS) by the Affordable Care Act.

“We have a few code words we have to work out here so I don’t get into trouble, but you get what I am trying to say,” Dr. Nielsen said at the American Academy of Family Physicians Congress of Delegates. For example, if I tell you ‘it has been suggested to us,’ that is REALLY important and it may be coming out, but I can’t announce anything yet,” said Dr. Nielsen, an internist and former president of the American Medical Association.

Regarding ACOs, Dr. Nielsen said, “Very soon the final rule will come out. Very soon. CMS has listened to the feedback:”

“It has been suggested to us that 65 quality measures are way too many.”

“It has been suggested to us that the mechanism for the shared savings ought to be done differently.”

“And it clearly has been suggested to us that hospitals have the ability to come up with the capital to start an ACO, but it’s really tough for doctors. So it has been suggested to us that we give advanced payment. I am here to say that very soon you will see that, and very soon you will like what you see.”

Although doctors have always been accountable for the care of patients, now they also will be accountable for resource expenditures, and the Center for Medicare & Medicaid Innovation plans to help, Dr. Nielsen said. There will be new expectations and new tools given to primary care physicians. “I will tell you that never once in my 23 years of practice did I see data showing me what it cost when I ordered an x-ray. Do you know what it costs when you write a prescription for an antibiotic? Do you get that data? No, you have never seen that.”

“But you must help us achieve this … when the [internal] warfare within the house of medicine begins,” Dr. Nielsen said. “I have a pet peeve. It really makes me crazy when people talk about people who do primary care as ‘primary care physicians’ and all the other docs as ‘specialists.’” She said that family physicians, internists, and pediatricians should stand together and say ‘We are specialists, just like you are specialists. We have a critical role to play and we need to have the tools to help us play that role.”

“Stay tuned. A lot of things you are going to, like, have been suggested to us.”

Dr. Nielsen’s comments were streamed live on the Internet during the congress and are available as archived video.

–Damian McNamara

@MedReporter on Twitter

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Filed under Blognosis, Family Medicine, IMNG, Internal Medicine, Pediatrics, Physician Reimbursement, Practice Trends

New Form of Headache Taking Off

The pilot announces your plane will be landing soon. Then it comes without warning: a severe, debilitating pain in your head that resolves ‑ spontaneously – only once you arrive at the terminal.

Dr. Frederico Mainardi first heard about such a sudden attack from a patient, and together with seven other case reports devised “Headache Attributed to Airplane Travel” criteria in 2007. Shortly thereafter, he started receiving e-mails from people around the world who described very similar headaches.

Source: Wikimedia/Creative Commons user Todd Neville

Dr. Mainardi sent a questionnaire to these 69 contacts, and answers returned from 63 people revealed some common, peculiar characteristics:

Strict unilaterality (occurs on only one side of the head).

Quality of the pain.

Severe intensity.

Short duration of attack.

Absence of companion symptoms (some headaches come with nausea, vomiting, sensitivity to light, etc.).

Appearance during landing phase (53 of the 63 reports)

The headaches are so bad that 44 people (69%) said their experience negatively influences their decisions to fly again, Dr. Mainardi said at a congress of the International Headache Society in Berlin.

Strangely, 46 people reported flying multiple times without incident before their in-flight attack.

The good news is acute pain medication such as sodium naproxen taken before (or during, if it’s a long flight) can prevent an attack in a patient with a history of this headache type, said Dr. Mainardi, a neurologist at the Headache Centre at the Giovanni e Paolo Hospital in Venice, Italy.

Importantly, only two people reported sinusitis at the time of their attack. MRI scans and sinus CT scans in a subset of patients ruled out any other physical explanations for the headaches, Dr. Mainardi said.

All patients denied drinking alcohol before their attack, and the duration of their flights was not a factor.

Dr. Mainardi proposes “Headache Attributed to Airplane Travel” be considered a new entity for the next edition of the International Classification of Headache Disorders or ICHD, the leading reference used by headache specialists worldwide.

In the meantime, Dr. Mainardi has collected 74 individual case reports so far.

–Damian McNamara

@MedReporter on twitter

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