Back Pain

Back pain is the most common problem people see a doctor for, and runs to about $6,000 per person per year in terms of U.S. medical care expenses. So, it's not just you...

Sudden back pain certainly gets your attention, and should also raise some concern especially if a cause is not evident.

Alarm bells should go off if back pain comes with fever, chest pain, shortness of breath, vomiting, loss of normal bowel or bladder function or tingling or weakness in your legs. These may be signs of infection, heart attack, aneurysm rupture, or spinal cord injury and should prompt urgent medical care.

However, most back pain that comes on for no memorable reason or after a hard day brush clearing or gardening is the result of muscle strain.

When this happens, muscle and other connective tissues are torn and your body responds through inflammation which tries to limit the damage by causing swelling and pain. This limits further use of the inflamed strained muscle until it can heal.

Unfortunately, this inflammatory response can be counter-productive as anyone who has "pulled a back muscle" can agree!

So, best treatment at the outset is a cold pack for 15-20 minutes 3-4 times a day for the first day or two to decrease inflammation to the area. Do not put ice right to the skin as this can cause frostbite injury. Use a chilled rice bag or other cold pack.

After the first day or two, use warm packs if this feels better. Do not overuse heat as this can cause burns or worsened muscle spasm.

Anti-inflammatory pain relievers are helpful for both relieving pain and also reducing the inflammatory response. Examples include aspirin, ibuprofen (Motrin, Advil) and naproxen (Aleve). These should be safe to use for brief periods of time assuming that you do not have any pre-existing stomach, liver or kidney problems.

If you smoke or drink or have ever had an ulcer (or if you are simply interested in keeping these medicines from being able to cause an ulcer while you take them), take one 20-mg Prilosec/OTC a day while you are using these medications. This medication is not dangerous to take for over 14 days. The warning on the box is to prevent people who take it and overlook dangerous symptoms from suing the manufacturer.

Please note that normal adult prescription level doses of Aleve would equal two pills twice a day, and Motrin at four pills three times a day.

Normal daily activities can be continued. Just pay attention to your body, and avoid activity that starts to worsen pain.

Back pain can actually take a surprisingly long time to go away. Half of people with simple back muscle strain have pain that lasts over one month; one quarter for over three months and ten percent of folks take over six months to heal up!

If your back is taking longer than seems right, physical therapy can be very helpful in alleviating some of the pain and in strengthening underused muscles that can add support to your back and help you heal more quickly and also prevent re-injury.

Cheap Drugs (Inexpensive Prescription Medications)

Times are, as they say, tight.

While I'm no particular fan of Wal-Mart, they are offering $4/30 days on over 360 commonly prescribed medications. That's mighty tough to beat. Yes, that's $4.00 for up to 30 days on normal dosages which is 13 cents a day.

Cash paying patients should compare this to other large operations such as Rite-Aid and Long's where the average mark-up on medications is 5-6 times the Manufacturer Suggested Retail Price (MSRP).

If you have prescription drug coverage including "mail-in" pharmacies (Phamacy Benefit Managers, or PBM's) this still might beat the co-pays.

Furthermore, these are real every day widely used medicines and not oddball rarely used ones.

Check it out.

Cholesterol Medicines in the News

If you are taking Vytorin or Zetia, there is no urgent need to change or stop these medicines. For a nice round-up on this news story, check this out.

In a nutshell, a study was sponsored by the manufacturer of these drugs involving a relatively small number of people with genetically extremely high cholesterols. It found:

• Neither of these medicines worked better than generic simvastatin (which is one of the medicines in Vytorin) in preventing cholesterol plaque build-up.
  
• There was no harm in taking Vytorin or Zetia, either.

The controversy is around why the drug manufacturer waited for over a year to announce these results, and speculation that they did so because the results did not favor these two brand-name drugs.

It is still important for your health to keep your cholesterol low. If you are on either of these medicines, they are not harming you, but you may be able to do just as well or better with less expensive generic medicines.

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!