Did you sleep OK?

This is a really interesting news item that nicely sums up a lot of recent study on sleep.

In a nutshell, sleeping 8 hours without interruption may not be biologically normal, an expensive mattress may not be better than a good mattress, and sleeping pills may be over-rated.

Stomach Flu

Viral infections (like colds and flu) can cause symptoms like nausea, vomiting and diarrhea. Typically, these go away without any specific treatment in a few days. A few tips, since there's definitely one going around in the past couple of weeks!

Stay hydrated; the symptoms are only a major problem when they result in dehydration. Any thing you can keep down for over two hours is fine. Popsickles work nicely for this, especially in children.

It is okay to take medicines to relieve the symptoms; they don't make the illness last longer, they just make for less vomiting and diarrhea.

Benadryl works very nicely for relief of nausea or vomiting, and is available everywhere in liquid or capsule forms. Imodium/AD works very effectively for relieving diarrhea.

Warning signs, for which you should be seen:

• Pain
• Vomiting without diarrhea (may be appendicitis or other problem)
• Blood or pus in the diarrhea
  
• Signs of dehydration: decreased urination, dry eyes, dry mouth
  

Flu Season

Well, we're just starting to see flu in California. And I do mean just. There have so far been only a handful of cases in Northern California. More information on influenza is available at the CDC's site.

How not to get the flu? First, get a flu shot. Second, try to avoid touching your eyes, nose and mouth. Also, wash your hands frequently. Any ordinary soap will do, just wash for as long as it takes to sing Happy Birthday twice (to yourself, if you like) in order to clean off viruses and bacteria.

Disposable paper masks are useful if you are sick- they prevent your coughs and sneezes from ejecting viruses or bacteria into the air. Particulate N95 masks like you can buy at Home Depot will filter out 99% of bacteria and viruses (even bird flu, perish the thought).

Away for the Holidays

We'll be out of the office during the holidays on Christmas Eve and Christmas Day, and also on New Year's Eve and New Year's Day.

The on-call doctor's number will be on the message if you need help, but we hope you will be enjoying the holidays and not needing it!

Happy Holidays, and best wishes for a healthy, happy New Year.

Medicare Drug Plan Open Enrollment

November 15th to December 31st is the open enrollment period for Medicare! Medicare Part D covers prescription costs, and can be added or changed during this period.

Please note that premiums may go up or down starting in 2008, so even if you are happy with your present Part D you should double-check whether the cost is going to go up and whether it is still going to cover your medicines. You can find out by calling 1-800-MEDICARE. This article in the Sacramento Bee discusses this.

While the drug benefit affects people differently depending upon their incomes, their health and where they live, the standard benefit looks like this: Participants pay the first $275 in drug costs. Then, the plan pays 75 percent of the tab until total drug costs reach $2,510. That's when beneficiaries hit the so-called doughnut hole, where they pick up all cost until they've paid $4,050 out of pocket. After that point, they only have to pay 5 percent of the tab for their medicine.

Medicare's website is a useful on-line resource.

This link is to the site's menu of the plans for 2008 in El Dorado County that have prescription drug coverage. Clicking on the names in the left column will give you details on each plan's benefits. It also allows you to filter or pick out plans based on other choices including dollar limits on the premiums.

This link is to the site's prescription drug portal. It includes ways to check out plans based on your list of medicines and by preferences including costs.

You can enroll in a plan here.

I hope this is helpful if you are looking into this for yourself, your spouse or your parents!

Also, remember that many medicines can be changed to suit your plan coverage with no sacrifice in quality of your care. Let us know if we can help you with this.

How much should I weigh?

Well, that depends! A good weight is one that is healthy for you, and where you feel good and are happy with your fitness and appearance.

Ideal body weight is an arbitrary concept, and largely a construct of life insurers more than doctors.

The body mass index you hear about (BMI) is an attempt to use easily available information to factor in your height and not just your weight.

The calculation is:

Weight (pounds)/Height X Height (inches), then times 703.

"Normal" is 18.5- 25
"Overweight" is 25-30.
Underweight is less than 18.5
Obese is 35-40
Morbidly Obese is over 40.

Thing is, this is also somewhat arbitrary. The idea here is an index using height and weight only, since this information can be gotten easily from medical records or even drivers' licenses. It does not include important factors such as muscle mass, body fat content or exercise tolerance.

This article neatly summarizes findings of two years ago that show that the "Overweight" category is actually the healthiest, in terms of lower rates of cancers, heart attacks and strokes.
The Underweights and Obese categories have about equally bad health outcomes. The Obese from certain cancers and heart disease, and the Underweight especially from trauma and infections (or at least poor recovery from them). See this article, too.

Basically, being slightly "overweight" by modern standards may be based more on modern standards of physical appearance than on actual health and well-being. The number on the scale is probably less important within the middle range of body weights than your fitness and activity level.

Over 40 Handbook: Hair Loss

Gradual hair loss can affect both men and women as we age. Unfortunately, this can be really devastating for women since men can more easily "pass" with thinning hair or head shaving!

Signs that your hair loss may not be a natural (though undesired) consequence of aging would include:

• sudden occurrence after an illness or other major stress
• painful or itchy hair loss
• hair loss resulting in scarring
• hair loss in patches

Otherwise, if more scalp is showing through at the top or at the temples or your part is getting wider it may be a natural process. Arrggh...

Minoxidil (Rogaine) works well for both men and for women! For it to work, it has to be applied to your scalp twice a day. It is especially helpful if you start it within the first five or so years of noticing hair loss. About 70% of folks get a satisfying increase in hair growth and thickness with this.

Hair transplantation has gotten much better than years ago, but it still requires you to have plenty of hair on the back of your head and can run from $5,000- 15,000 for effective treatment. Ouch.

Flu Shots

'Tis the season!

Any time from the end of this month though end of November is fine for getting yearly flu shots. This will ensure that it will be effective for the flu season which is typically around January and February.

Sorry, but supply problems over the past two or three years have made them hard to get in time so we do not have them this year.

Flu shot clinics are available at community centers, senior centers and retailers such as Long's. Check your local papers for announcements on these, or check here.

My child has a cold...

Cold and flu season is here, and if you have a young child (6 years old, or younger) this can be especially hard since you may not be getting much sleep and having to miss work.

You may also be aware that the federal government is recommending that over the counter cough and cold medicines should not be given to children under six years old. A number of manufacturers are taking them off the shelves.

This is because they not only seem to be ineffective in young children, they can also cause serious side effects especially on the brain and heart.

What you can do to keep your child comfortable is use a cool-mist vaporizer, a bulb for suctioning out mucus and Tylenol for fever.

More here on details and affected brand names and suggestions for safe treatment of cold and flu symptoms.

The Over 40 Handbook: Do you get weaker when you get older?

Short answer: No, but it's use it or lose it.

Long answer:

Up to 80 years old, you don't lose speed, stamina or reflexes compared to 30 years old unless you stop being active.

A medical study looked at folks who stayed competitively active in bicycling, running and swimming between 30 and 80 years old. In competition athletes, there was no significant loss of performance between 30 and 80 years of age!

Now, agreed no one is comparing any of these folks to contact sports athletes or 16 year olds. But, it does show that you can keep your physical fitness and reflexes at 30 year old levels for the next half a century if you keep using your muscles.

Even if you don't perform at competition levels, exercising and walking regularly helps to maintain a healthy weight, prevents high blood pressure and diabetes, and also helps to maintain good bone density and prevent falls.

Use it or lose it!

The Over 40 Handbook

I've noticed there seems to be no shortage of books on your infant, toddler or teen, but none that I've seen that address being older in the same way. Plenty of stuff on specific issues such as medications, menopause, diabetes and so forth. However, no single book that talks about common issues, questions or concerns that arise after 40.

Why after 40?

• It's the second half of average life span.
• Concerns or problems come up that have less to do with poor decision making or impulse control (like accidents and injuries and bad choices in kids and teens) than they have to do with entering "elephant country": the time where you start to see chronic diseases like heart problems, cancer, diabetes and dementia affecting your parents, siblings and friends.

More importantly, there are also a lot of assumptions that get made that are not correct. Examples include assuming that as you get older you have to slow down, lose strength, lose your memory or enjoy sex less.

I get to ask people how old they'd like to be if they could start over quite a lot. How often do you suppose the remark "getting old's a b**ch" comes up?

In nearly every case (with one specific exception, and you know who you are), folks over 65 say 40 or 50 would be it. That was when the kids were grown up and on their own (or at least out of the house...), they were at the peak of their work, and before health problems really got going.

So, bottom line is enjoy over 40 while you're there, and focus on what you can do to be strong, happy and independent at 80. It can be done!

I'll be posting on this regularly, so feel free to comment or request specific topics.

The Appendix: what's it for anyway?

Finally, an answer!

Older Adult Resources

Our county has many resources available for older adults and their families with concerns that often come up around maintaining safety, quality of life, and independence as well as and for as long as possible.

El Dorado county is one of the fastest growing counties in California, and over 30,000 folks here are over 65. This is double compared to 1989.

The Older Adults Task Force has been publishing a Resource Directory of available services since 1989. The 2007 edition has been distributed by the good folks at Elder Options on 82 Main Street in Placerville. Their phone number is 530-626-6939, and single copies are available free to older adults and their families.

You can have one mailed by calling, or pick one up at their office. All 31 pages of the directory are available at their website, and can be viewed or downloaded here.

Vitamins & Supplements

There's lots of information available about the role of vitamins, minerals and supplements and also questions that frequently arise about them.

Part of the complexity stems from the fact that they are sold as dietary supplements and not as medicines or pharmaceuticals. This means that there is little requirement around them for large scale testing of effectiveness and safety, testing for side-effects and interactions with other agents or even for truth in advertising. Whatever may be said about prescription medications and pharmaceutical companies, they are sold under very cautious regulations. In other words, consider vitamins and supplements with the same care as you would for a prescription medicine.

Keeping my comments and recommendations here only to the findings of medical research and studies then:

• CALCIUM: Calcium improves bone density up to 35 years of age. It is especially important in the high school ages. After 35 years old, supplementing calcium does not increase bone density, but it does assure adequate dietary calcium which otherwise is found in dairy products.
• Calcium carbonate (such as TUMS) is the cheapest, and most bio-available. This means that it is not necessarily the fastest into bloodstream, but it is the fastest into bone.
• Dose should be 600 mg, twice a day (up to three times a day in high school aged women).
• I do not recommend oyster shell or coral calcium. If the oyster shell or coral happens to come from a polluted area of ocean, you may be eating the pollutants.

• VITAMIN D: Vitamin D is crucial for normal bone growth, and also nerve growth. Several medical studies link low vitamin D levels to osteoporosis, higher risk of falls and higher risks of all types of cancers. Because vitamin D is mainly found in sardines, mackeral and artificially in milk having low levels is not unusual. This may also be because folks are using more sunscreen and avoiding over-exposure to sun to avoid skin damage and skin cancers!
• Doses of 200-400 I.U. per day are beneficial.
  
• This can often be found combined with calcium, for convenience.

• MULTIVITAMINS WITH MINERALS: You know; like Centrum, One-a-Day, and the generic brands for these. If you have a well balanced diet, you are not likely to be low in vitamins and minerals. Vitamin B12 deficiency can occur in strict vegans, but it isn't common. The trace mineral supplements are helpful in maintaining normal bone health.
• One a day of any inexpensive vitamin supplement may be helpful and isn't harmful.

• ANTIOXIDANTS: In theory, anti-oxidants should prevent cancers and promote longevity since oxidant molecules (so-called oxygen radicals) are a key factor in chromosomal damage which is the underlying cause of cancers and aging. Unfortunately, many studies have been done looking for this effect and it doesn't seem to bear out. If anything, antioxidant supplements may increase risk of heart attacks!
• One exception to this is the use of antioxidant vitamins and minerals in preventing and treating macular degeneration, which is a serious vision problem.
• Over-the-counter preparations such as OcuVite are helpful.

• VITAMIN C AND ZINC:
• Sorry, they really don't seem to prevent or treat colds and flus.
• They do help to promote wound healing, so taking some after surgery, a wound repair or an injury can be helpful. 500 mg a day of Vitamin C plus 200 mg of zinc are common doses for this.

• ASPIRIN: Aspirin reduces the risk of having a stroke or heart attack by making it harder for clots to rapidly form at cholesterol plaques in your blood vessels.
• An 81 mg "baby" aspirin a day is just as good as higher doses, and causes less bleeding problems.

• GLUCOSAMINE: This a precursor to cartilage which buffers joint surfaces. Swallowing it might not necessarily increase cartilage in joints and treat arthritis pain, but it seems to do just that.
• 1,500 mg a day of glucosamine is the normal dose. It can be taken all at once, or in 2-3 smaller doses a day if it upsets your stomach.
• It is not a "pain pill" in the usual sense, so take it for 3-4 months before you decide whether it's helping you or not.
• Chondroitin, MSM and magnesium don't seem to be helpful or add anything so don't bother paying more for these.

There is a lot of exciting research and study on vitamins and supplements, and plenty of it is to be found on-line or on TV and in magazines. Just review it with a critical eye, the same way you would with prescription pills.

School Immunizations

Back in the day when there were school nurses and they actually were registered nurses, 11-12 year olds were offered shots and boosters for diseases like tetanus. That went by the wayside for reasons probably related to funding and concerns about liability.

Unfortunately, that meant a lot of middle schoolers weren't getting them at all (most middle schoolers are quite healthy, and not at all interested in coming to the doctor for some shots).

The El Dorado County Public Health Department has really stepped up to the plate, and is offering routine immunizations to 11 and 12 year olds free of charge and on a completely voluntary basis. I encourage everyone who has received the packet sent home from school to look it over thoroughly. The information is complete, accurate and helpful.

And yes, I signed up my middle schooler for all of them.

CalPERS Open Enrollment- The Short Answers

Those of you who are State of California employees, or public employees who use CalPERS for health insurance (such as City of Placerville, Garden Valley Fire Department, El Dorado Irrigation District) have by now received the thick stack of glossy paper presentations on your options for health insurance for 2008.

I've already posted on this several times, and have discussed this with lots of patients, many of whom I have known for up to 10 years. I'm definitely getting the idea that any lengthy discussion larded over with HMO-PPO-EPO-IPA-blah-blah-blah is simply confusing, and that the big package from CalPERS can be overwhelming.

So, in a nutshell, here are the Short Answers to the Frequently Asked Questions:

• How do I keep you as my doctor?
• Choose one of the Blue Cross administered PPO choices: PERS Care, PERS Select, or PERS Choice.

• Are you with PERS Select?
• Yes.

• What is PERS Select?
• It's basically the same benefits as the PERS Choice plan, but where the 20% tier of personal costs goes with seeing doctors who are PERS Select doctors.
• I think these are doctors who Blue Cross feels meet some selective criteria for higher quality of preventive care and treatment of chronic illnesses.

• What are PERS Care and PERS Choice?
• These are brand names for two PPO plans through Blue Cross.

• What's a PPO?
• This is health insurance where you can choose your own doctors and see specialists whenever you want.
  
• Annual physicals are covered.
  
• Coverage of medications is typically better.
  
• There is an annual $500 deductible (this is very low compared to most other people's insurance).
  
• After this, you pay 10% (for PERS Care) or 20% (for PERS Choice or PERS Select) up to the annual max. After that, Blue Cross picks up 100% of medical costs.
• Please notice the annual max: you won't be getting a bill for 10-20% of a million dollars in medical care for a medical catastrophe!
  
• This is basically like the insurance plans that employees of smaller employers (like Intel, Bank of America, Microsoft...) get to pick from only with lower deductibles and lower max. In other words, you are on the hook for less money than most folks.

• Will it be hard to see primary care doctors or specialists?
• No.
• Most doctors take Blue Cross.
• Referrals are not required by the insurance.
  

• Should I pick PERS Care or PERS Choice? What's the difference?
  
• PERS Care has higher premiums every month, but it pays for more of your medical care.
• Most folks with chronic medical problems pick this because they know they're going to fully use it.

• PERS Choice and PERS Select have lower premiums, but pay a lower percentage of costs.
• Most folks who pick these are pretty healthy and don't use their health insurance a lot.
• These can also be a good choice for folks who save money well and want to spend less a month on the premiums since they know that if there's a need, they can manage the annual cap, after which point the insurance picks up everything.

• Can I still be on Blue Shield?
• Yes, but only as an HMO which means all your medical care will be down the hill just like with Kaiser.

• I was told that the Blue Shield EPO will still be available in "certain parts of El Dorado county". Is that true?
• No.
• CalPERS press releases state that your EPO has been dropped completely.
• Blue Shield as an HMO may be available in areas close to the border with Sacramento County.

• What if my employer switches to some other insurance?
• Fine by me.
• Most local large employers are very upset with CalPERS, and looking for insurance that most doctors up here already take. They already have stated at meetings that they don't want people to go to Kaiser because it's far and will result in a lot more missed work because of the drive time involved just to get seen.
• For example, EID is looking at benefits through the Association of California Water Agencies which offers Blue Cross.

• What if I am retired or retiring soon?
• Look closely at what you want to have beyond Medicare Part A and Part B (these cover ER, hospital, doctor visits, labs and X-Rays).
• You could easily be better off choosing PERS Choice because it has the lowest premiums, or even dropping CalPERS altogether.
• Medicare Part D (the drug plan) has an average premium of about $40/month.
• The most expensive Medicare supplement (for additional coverage of things like long-term care) is about $80/month.
  

• I have decided to switch to Kaiser.
• I am very sorry to hear that. You will be missed!

Will you see my child, too?

Short answer: Why, sure!

Family physicians are specifically trained to see patients of all ages and this includes delivering babies, and caring for newborns, infants, toddlers, adolescents and teens. (I confess: I stopped doing pre-natal care and delivering babies after the first 500 or so deliveries, in the interest of sleeping all night from time to time.)

Mind you, if your child has a rare and complex chronic medical problem, I am very likely to want to share their care with pediatric sub-specialists (down the hill since there aren't any up here).

I also get asked this question a lot about children who already see a pediatrician. Most of the time the question comes up in the sense that the child is a teen or pre-teen who is feeling a bit old to be seeing a pediatrician. Changing to an "adult doctor" seems reasonable to me, assuming that there are no ongoing concerns or medical problems that might make that a bad idea. Feel free to ask!

CalPERS AND BLUE SHIELD EPO-THE FINAL DEAL

By this time (8/16/07) you have received written notification from CalPERS that the Blue Shield EPO is not an option and reviews your options for the upcoming open enrollment period for 2008.

We are now at the point CalPERS has been moving towards for the past half a decade- you have two HMO choices, and two PPO choices and you are in the unfortunate position of assigning a dollar value to being able to get any medical care outside of the Sacramento- Folsom area.

For those who are not insurance/medical industry professionals,

• HMO (Health Maintenance Organization)
• Usually, but not always, lower monthly cost.
• You have to pick a primary care doctor, whose name has to appear on your card.
• You cannot see a specialist unless your primary care doctor makes a referral to one.
• Medications largely covered, but formulary (list of covered drugs) can be very limited.
• Doctors are salaried (as with Kaiser), or paid a certain amount per patient per month (as with other HMO’s) whether they see you or not. This creates an incentive to avoid seeing you whenever possible, and as quickly as possible otherwise. This pressure in some ways relates to the method of doctor payment, and also because doctors have to take on a lot of patients to offset the costs of sick patients

• PPO (Preferred Provider Organization)
• Usually, but not always, higher monthly cost.
• You may see any doctor that accepts your insurance.
• Formulary of medicines usually less restrictive than HMO’s.

So, this is the deal: you can either choose an HMO (Kaiser or Blue Shield HMO) and go down the hill, or pick a PPO (Blue Cross PERS Choice or PERS Care) and keep your medical care here.

• Your HMO Choices:
• Kaiser
• Well, it’s Kaiser. ‘Nuf said.
• Blue Shield HMO
• I think there are two offices up here that take this HMO, but Lots of Luck.
• You still have to go down the hill for any X-Rays or specialists.
• If you have to go to Marshall ER, your doc will have to work very hard to get you sent down the hill as soon as you are stable.
• You still cannot use Sutter hospitals, which I suppose is fine as long as you never need spine or brain surgery, or never get cancer.
• Your PPO Choices:
• Blue Cross
• PERS offers two flavors called PERS Choice and PERS Care.
• They are pretty much the usual PPO type coverage, but vary between the two of them in premiums, deductibles and co-payments.
• We already have patients with these two insurances, and have had no problems with either.

The bottom line:

If you want to continue to be able to have a doctor where you and your family live, to have a choice about getting blood tests and x-rays (also CT scans, MRI and heart tests) done here and see specialists or use your local hospital it is going to cost more than Kaiser or another HMO. It may not be much more than your current Blue Shield.

We think it’s important to base your family’s medical care where you live, and we hope you will continue to do so since we enjoy having you as our patients. If you were ever unhappy with our care we would want to know about it, but we think it stinks if you have to change doctors because of insurance.

For retirees:

MediCare already covers doctor visits, ER visits, hospitalization labs and tests.

Look very carefully at what you want any secondary insurance to cover such as medicines, long-term care and so forth. It may be that PERS Choice or PERS Care may do this perfectly well, or you may want to investigate the various MediCare supplements such as Part D which covers drugs/medicines or other ones which cover long-term care and other aspects of medical care.

Travel Questions

Travel is an all year 'round opportunity for pleasure or business. Either way, it's a great way to see what the rest of the world is like and meet new people!

People often have questions from a medical standpoint about whether they need shots before leaving the country.

Really, the medical and health concerns about travel not only include shots to prevent certain types of infection, but also the treatment or prevention of foreseeable problems that may arise.

Specific travel recommendations can be found at the Traveler's Health site at the US Centers for Disease Control (CDC).

Also, you can check with the US Department of State for advise regarding political concerns involving your destinations.

Immunizations
These are also known as "shots", or "jabs" if you're from the U.K., and are administered to prevent you from getting certain bacterial or viral diseases such as tetanus or hepatitis.Shots for unusual infections (such as cholera or yellow fever) can be obtained at county public health departments and specific travel clinics.

Make sure you check for immunizations as entry requirements for other countries. If you have an immunization card or record, check it to see what immunizations you may need and which ones you may have already gotten.

Tetanus is a deadly bacterial infection that can occur from wounds. A tetanus booster within the 5-10 years before travel may be a good idea, especially if you are doing any hiking or trekking or other less usual travel. We can give this at the office.

Hepatitis A is a viral infection of the liver that can be gotten from eating contaminated food or drink. If you have had Hep A before, or had the shots for it you do not need to get shots for travel. Otherwise, getting a shot four weeks before you leave will protect you from getting Hep A for the following 6-12 months. A second shot 6-12 months after the first one is good for life. We can arrange to give you both shots. You probably want to get these shots for travel to any destination where you are instructed to avoid drinking the local water.

Hepatitis B is a viral liver infection that can be a permanent chronic infection. Most people under 30 got shots to prevent it before kindergarten as part of their routine baby shots, and would not need to worry about getting more shots. Hep B is gotten from blood transfusion, drug abuse and as a sexually transmitted disease. Getting immunization before travel would probably only be necessary if you feel you would be at risk to get exposed to it during travel, or you will be abroad for an unusually long time.

Preventive Medications
Prescription medications can be prescribe prior to departure to prevent you from getting malaria or altitude sickness. You can check with the link for CDC to find out whether you need to be concerned about malaria at your destination. Medicine to prevent altitude sickness may be helpful at destinations above 8,000 feet (2,500 meters) elevation.

Bring DEET based insect repellent!

Treatment Medications
Antibiotics (such as Bactrim or Cipro) to take in case you get diarrhea while travelling can be prescribed.
Sleeping pills (such as Ambien) for "jet-lag" can be helpful, and can be prescribed before you leave.

Prevention Overall
Staying out of trouble is better than dealing with trouble, so a few pointers:

• Take a supply of any regular medications with you.
• Bring commonly used items as well, such as band-aids, Motrin (for pain), eye drops (for eye irritation), Neosporin (topical antibiotic), Imodium/AD (for diarrhea), Lamasil/AT (topical for fungus), Benadryl (for allergy and also nausea or vomiting), meclizine (for sea-sickness) and so forth.
  
• Bring medicines in original containers or pill bottles, to avoid problems at customs.
• Don't forget spare glasses, sun glasses, micronized zinc-containing sunscreen, and mosquito repellent.
• Avoid tattoos, piercing, acupuncture, sharing razors, and casual relations while abroad.
• A flashlight is very handy.

Bottom Line

See me about 4 weeks before you are leaving the States to discuss any concerns or questions you may have, and to get any presciptions that will help you, and to receive shots that you need.

On a personal note:

Here are links to some helpful travel-related websites that I have found useful in my own travels.

TripAdvisor is a great website for general information, reviews and pictures. Igo Ugo is good, too.

This is a foreign exchange currency calculator. Also, here is a handy conversion calculator since only the US and UK don't use the metric system.

The National Weather Service website can link you to current weather conditions at any airport in the world.

The Transportation Security Administration regulates what you can bring on a plane. On the other hand, major airlines may also have their own regulations.

Bon Voyage!

Is Avandia safe?

Bottom Line: so far, appears to be safe.

So, what's the issue?

A recent study was done that lumped together a number of separate studies (this is called meta-analysis), and it suggested that people on Avandia may have more heart attacks or heart failure than people who don't take Avandia. (Bear in mind, that the manufacturer and the FDA are involved in looking at the safety of the drug, but are not felt to have been at fault in some way.)

Problem is, meta-analysis is kind of a forced apples-orange comparision and is known to produce conclusions that have to be carefully considered.

So far, investigations looking specifically at whether Avandia carries an increased risk of heart disease do not show an increased risk. Naturally, these findings will be made public as they are concluded.

In the mean time, it's worth bearing in mind that poorly controlled diabetes itself carries a very high risk of heart attack. Because the question of drug-related heart risks is inconclusive, it is probably better to use Avandia to keep your diabetes under good control.

[This posting is for general information, and is not a substitute for individual assessment or advice!]

NEWS: Hantavirus

An El Dorado County woman was recently diagnosed with a hantavirus infection, and has recovered. Local doctor's offices have been notified today by the Department of Public Health, and further information from the Centers for Disease Control (CDC) have been distributed by Marshall Medical Center.

Please bear in mind that this is a rare disease and an avoidable one.

This virus occurs in wild rodents such as mice and rats. It can be inhaled by humans because the rodents excrete it in their urine and droppings.

The most frequent symptoms are pretty non-specific: fever, chills and muscle aches. Shortness of breath, chest pain and cough are not common, but are serious as the virus can cause a serious lung infection.

Rashes, bloodshot eyes reddened throat, and fluid swelling are unlikely to be from hantavirus.

To prevent getting exposed to hantavirus:

• Avoid areas (especially indoors) where wild rodents are likely to have been present.
• Before cleaning an enclosed cabin, shed, trailer or similar area open the doors and windows and air it out for at least 30 minutes before entering.
• Don't touch live wild rodents.
• Wear disposable plastic gloves when handling dead rodents or cleaning areas.
• Spray diluted bleach on areas soiled by rodent droppings or urine and on dead rodents. Use one part household bleach to 10 parts water.
• Wear plastic gloves and a wet sponge or mop to clean the area. Do not sweep or vacuum.
• Place dead rodents and waste in double plastic bags. Seal each one tightly and discard in trash.
• Wash your hands thoroughly afterwards.
• Deter rodents by removing rubbish, discarded junk, stacked wood. Block mouseholes. Tightly seal food containers.
• If large numbers of rodents are present, contact a pest control service to remove them.
  

Blood Pressure

Your blood pressure is considered to be one of your "vital signs" because increases or decreases in it can give doctors and nurses clues to underlying problems like infections, injuries, heart attacks and so forth.

It is measured in the resulting rise in a column of mercury in millimeters, abbreviated as mm Hg. The first higher number is the systolic pressure, which is the pressure in your arteries when your heart is pumping. The second lower number is the diastolic pressure, which is the "standing" pressure in your arteries when your heart is filling. (There has to be some positive pressure then in order for blood to flow up against gravity to your brain, and against resistance to reach your hands and feet.)

On a chronic ongoing basis, your blood pressure should be lower than 130/85. We find that risk of heart attack and stroke starts to get higher above this. Specifically, there is a doubling in risk of heart attack and stroke for every 20/10 in chronic blood pressure over 120/80. Lower than 110/60 (again, assuming you are not on heart medications) is not healthier.

By chronic, I mean at rest on a day to day basis and not with exercise or on heart medications. Your blood pressure normally changes throughout the day and may vary with activity, exercise, time of day, diet, stress or illness.

We used to think that if your blood pressure went up just in the ER or the doctor's office that this was just due to understandable anxiety. However, we now know that this lability or rapid changability in your blood pressure is just as dangerous to you as sustained high blood pressure.

Keeping your blood pressure under control is important because high blood pressure almost never causes symptoms. Therefore, you may only find out that your blood pressure is high through having a heart attack or stroke unless you are having it checked.

Fortunately, the benefits of having or getting your blood pressure to less than 130/85 are just as good with medications as without them. More on that...

Long-term care insurance

I'm posting about this because I get questions about this regularly, and it's a complicated matter.

Long-term care insurance is a kind of medical or health insurance you can buy that covers medical equipment, care or therapy for long-term conditions such as a stroke, dementia or cancer. It particularly covers care you might need at your own home, and not at a doctor's office, in the hospital or in a nursing facility. Most people consider buying it in addition to their health insurance in order to be able to receive medical care for a long period of time in their home, and to avoid having to go to a nursing home to receive such care. (What may be covered by this insurance is coming right up.)

In other words, this kind of insurance is very helpful in situations where you could be ill enough to need help at home or in recovering further, but could not otherwise afford it and are then left with no choice but a nursing home.

When to buy it is a judgement call. You want to already have it before you need it, so you don't want to wait overly long. At the same time, it's a very expensive insurance so buying it too early can be needlessly expensive. Having pre-existing medical conditions can make it more expensive, while buying it at 40 years old could even mean the insurance company is no longer financially solvent by the time you are old enough to need it! Look at your age, whether or not you smoke, your health and also your family medical history. Also consider your personal finances and the credit-worthiness of any insurance company you are considering.

If you are already on MediCare, examine some of the supplement plans which include long-term care coverage. You may find the coverage to be worth any increase in costs to you.

Read the fine print! Is skilled therapy (such as physical, occupational or speech therapy) covered? Is Durable Medical Equipment (DME such as hospital beds, wheel chairs, etc.) covered? When and for how long is coverage provided? Does it cover unskilled caregivers (someone to come in regularly to help you dress, have a bath, eat or just to be there to make sure you are okay)? How does it coordinate benefits with your other insurance(s)? Where does it provide coverage: hospitals, rehabilitation centers, your home?

Often, the need for coverage includes being unable to perform some of what are known as Activities of Daily Living (ADL's). There are six of them: bathing, toileting, dressing, feeding, continence and transferring (moving). You would like for coverage to start if you are unable to independently perform as few as 1-2 ADL's, especially transferring and continence. These two ADL's are the hardest for spouses, friends and family to manage for any length of time.

So, bottom line:

• Long-term care insurance can turn out to be extremely helpful to you should you be so unfortunate as to ever need it.
• It's usually very expensive.
• Comparison shop wisely with an eye to when you buy it, its affordability to you, the financial viability of the insurer, and whether it will help you as much as possible when you need it.
  

Preventing Heat-related Illnesses

It is definitely Summer now!

With all this sun and high temperatures, it can be easy to get sunburned or develop heat-related problems like heat exhaustion.

Avoid staying out in the sun too long; wear a hat, sunglasses and protective clothing.

Drink enough fluids to urinate every hour or two and to produce clear or light yellow urine.

Also, have a meal or some salty snack foods to replace salts you lose in your sweat. Do not use salt tablets: overly rapid changes in sodium or potassium levels can interrupt heart rhythm and can even be fatal.

Sunscreens that contain micronized zinc oxide are the best at preventing sunburn and also skin cancers. Remember to reapply sunscreen every 3-4 hours and after swimming.

If you don't have air conditioning, take advantage of air conditioning elsewhere by going to a movie or visiting the library. Or, enjoy a swim at the local pool!

CalPERS: the continuing saga

So far, press coverage (Sac Bee, Sac Business Journal, CalPERS press releases) consistently states CalPERS's withdrawl of Blue Shield EPO from four rural counties including El Dorado.

The pickings have become slimmer with their dropping of Western Health Advantage (WHA). This makes no difference to me, since WHA is another HMO option like Kaiser.

Happily, the plan rates for 2008 are a small increase when compared to every previous year and the rates for Blue Cross PPO PERSChoice and PERSCare are not much higher than for Kaiser.

Specifically, keeping your medical care local (my office, specialists, Marshall ER and Hospital, labs and XRay) can be done. Kaiser is not your only remaining choice. PPO's via Blue Cross allow you to get medical care where you want to (like with the Blue Shield EPO). They are a little more expensive than Kaiser, but not a lot.

If you decide that the extra buck is worth the extra bang, I am happy to continue to be your doc.

Back in the Saddle

Yes, I'm back from vacation which was absolutely great (except for the jet lag)!

Many thanks to Drs. Boston, Camisa, Ramos and Young and to Marshall's hospitalists who took care of everyone in my absence.

What about the side effects?

Yes, medicines can have effects on you that are not intended but that you may find obnoxious or may even be dangerous. These would be side-effects, and this is different from the actual desired effects of the medicine such as reducing pain, lowering blood pressure and so forth.

This can occur with prescription medicines, and also over-the-counter ones (OTC's) and also with vitamins, herbs and supplements.

In the case of prescription and OTC medicines (not herbs and supplements, though), the effectiveness and also the safety of the medicines is regulated by the federal government's Food and Drug Administration (FDA).

Believe it or don't, the FDA frowns on medicines that have side-effects that are dangerous. However, if a medicine causes a side-effect that is pretty rare (say, one in 10,000 people who take it), a lot of people are going to have to take it before a pattern of harm from the medication becomes apparent. Drug companies have to do incredible amounts of testing and trials before the FDA will even approve the drug for sale, but it's not realistic to expect them to test 100,000 people before FDA approval to uncover rare side-effects that affect 1 in 10,000 people.

This is not to say that once a drug goes on the open market that that's the end of the story. There is actually ongoing surveillance afterwards to be able to detect rare side-effects as people start to be prescribed the medication in offices by their doctors.

Even so, that's why being prescribed a medicine should involve discussion of what the benefits of taking it are balanced against the risks involved. In this less than perfect world, perfect benefit with absolutely zero side-effect is often not possible. However, as long as the probable good to you far outweighs the potential for serious harm taking a medicine is probably an overall good idea.

Sometimes, this is obvious and sometimes it's not.

For example, it's usually clear that taking an antibiotic for pneumonia is worth risking the antibiotic causing a rash or stomach upset versus letting the pneumonia kill you.

On the extreme opposite end of the spectrum, taking medicines for osteoporosis (low bone density) very clearly reduces your risk of falling and breaking a hip which in itself is known to have a 50% risk of being dead or in a nursing home within the following six months. However, with the TV coverage of jaw necrosis, you would scarcely know that the risk of having jaw necrosis happen to you is literally one in one million. Since the risk of dying in a fall is one in 281, taking the medicine is probably a safe bet. Just goes to show that TV finds bad/scary news sells ad time, but good/calming news doesn't: "if it bleeds, it leads" journalism at work.

So, bottom line:

• Medicines can have side effects, but dangerous ones are rare.
• Make sure that you understand and are comfortable with why you are being asked to take a medicine, what's in it for you, and what is the potential for any down side.
  

Away from the office

Just to let you all know, I'll be out of the office on vacation from the 14th through the 27th of this month.

Amy or Abbie will be in during usual office hours, and will be able to take care of any routine matters.

Otherwise, my colleagues in the community and at the hospital will be available should anything arise that cannot wait for my return!

Can I keep from becoming diabetic?

Short answer; yes.

This doesn't seem to get as much media airplay as it should, but then no one stands to profit much by extolling the virtues of moderate diet and exercise habits.

Becoming diabetic should concern you if you are overweight, and especially if diabetes runs in your family, you have high blood pressure or abnormal cholesterol tests. In fact, it's not so much what the scale says as your waist circumference (at the belly button, not at the hips). Over 40 inches in men and over 35 inches in women predicts folks who are likely to develop diabetes.

The good news?

Losing weight can reduce your odds of becoming diabetic by about 80% or more, and it doesn't take as much as you probably think. Losing 5-7% of your weight will do it. If you weigh 200 pounds, that means losing 10-14 pounds, not the usual 30-50 pounds that people often say if I ask them.

This can be done by limiting your calories to 1,800/day, avoiding any food over 30% calories as fat (check the Nutritional Fact labels) and getting a fast walk in for 30 minutes, 5 days a week. Just enough to break a little sweat will do. Sorry, "being on my feet all day" doesn't help. Yes, just eating smaller portions does help. The problem here is that many people eat up to 3,000 calories a day!

Most folks can lose about 4-6 pounds a month this way. 10 pounds off lowers your blood pressure by 8-10%, which is as good as starting doses of medicines for this. 7% weight loss, and you really cut down your odds of ever seeing me every 3 months for diabetes.

You get a taste for it and want to keep losing weight because you feel better and like what you see in the mirror, well the rest is gravy!

So, what about CalPERS Blue Shield EPO?

Well, that's a good question!

Between the newspapers, phone calls, and conversations with patients I think Blue Shield made real efforts to revise their way of running the EPO here to reduce costs. This was at CalPERS's request back around January. They were so far into this that they were mailing contract offers to doctors, and outlining the specific changes: mainly requiring authorization for CAT scans and more expensive tests, and requiring you to see me first before going to a specialist. The first requirement would have been a minor nuisance, the second not a problem. Heck, that's what we're for is to see you if you don't feel well!

However, I don't believe CalPERS had any intention of accepting any offer Blue Shield could reasonably make. I suspect they have a big wave of retirement coming in, and a lot of financial incentive to funnel people into cost-effective (read: cheap) HMO's. They would arouse too much complaint by simply doing away with everything but Kaiser, so they simply keep eliminating every other choice one at a time and jacking up the price on everything else.

Remember two years ago, when you could have brain or spine surgery and cancer treatment at Sutter? How about just before then when you could also choose HealthNet or PacifiCare?

So, now what?

You've got two choices; stay local, or go down the hill.

The two HMO's are Kaiser and Western Health Advantage. Kaiser is Kaiser, 'nuf said. WHA is an HMO based around UC Davis, which is a good place if you have acute leukemia or need a transplant, but otherwise is Big County in my book. I think there may still be one or two docs up here who take WHA, but maybe not.

In any event, WHA means down the hill for any X-Ray, surgery, or specialist. If you go to Marshall ER, a lot of effort will be taken to transfer you down the hill once you are medically stable because Marshall doesn't have a contract with WHA. WHA will therefore pressure them to send you to a hospital where they do have a contract.

HMO'S are cheaper, but you get what you pay for.

BTW, docs get paid by HMO's on what's called capitation. Meaning, the doc gets a dollar figure per patient per month (PMPM) whether any of them are seen or not. Problem is, that's what your insurance company is supposed to deal with; it's called managing risk. In an HMO, then the doc has to manage risk and decide whether you are too ill (expensive) to keep or take as a new patient, and whether to see you (expensive) or treat you by phone. You have to take on a lot of patients to make this risk a safe bet, which is where the stereotypic HMO experience of packed phone lines, impacted schedules, and "I'm Dr. Smith's patient, but I've never seen Dr. Smith" comes from. Do docs learn to game this system? Only if they want to live.

The remaining alternative would be with Blue Cross as a PPO: PERSChoice or PERSCare. Same as with any other cafeteria plan. The PPO means you can go just about anywhere you want (not many docs or hospitals that don't take Blue Cross), but it's more expensive. How much more? If you are a single employee not covering dependents, PERS Choice (less cost, higher deductibles than PERSCare) would cost you $1.80/day more than WHA. Naturally, it's more if you are covering dependents.

So, what to do?

If your employer is local (like City of Placerville, EID) then raise a stink! Being a local employer with local employees and sending them all down the hill every time they become ill, or need to take a sick child to the doctor is crazy and costly in terms of missed work to boot!

If you're retired, do the same! If you live over 30 miles from Sac, how can you be expected to go there for every medical need or problem?

Otherwise, it's all going to boil down to money- yours. You're going to have to look at the cost of a Blue Cross PPO compared to a cheaper down-hill HMO. I know my medical care is better than theirs, I hope you agree and find the additional cost worth the value.

Up and Running

Good Morning!

I plan to use this site to make information about the practice available on line, and to provide information that affects us. This might be changes in insurances, alerts about illness in our community or frequently asked questions.

The Link List is a list of websites I often mention to patients interested in general medical information, or on specific things like identifying their generic pills, or finding out whether their insurance covers them, or whether their supplements or herbs contain the labelled amount in each pill.

I don't intend, for now, to post absolutely every day (like, in my spare time). Still, come on by regularly and check it out!