Corns

Corns are basically calluses on your feet. Nothing more, nothing less. They result from pressure on your toes and feet from day to day activity, and are therefore treatable but not permanently curable. Or, at least no more curable than calluses on the palms of your hands.

Invasive or surgical treatment is rarely needed.

Home treatment is effective, but takes weeks to resolve a corn.

First, keep pressure off it by wearing a doughnut-shaped corn pad around it. It should be soft, but high enough so that when you walk you don't feel your other toes or the shoe against the corn. You may need to stack several pads to do this. You don't need to wear one at night, but you should wear one every day until the corn goes away.

Also, you can buff them off slowly. After every bath or shower, while the corn is still a little softer you can painlessly take a little off with a pumice stone, nail file or emery board.

Feel free to see me if you have one so large that you feel it needs to be pared down a bit. This is painless and does not bleed, since corns are dead skin and have no blood vessels or nerve endings!

MediCare coverage of lab tests

A number of folks (especially diabetics) have expressed concerns that Marshall Lab is saying that routine lab tests are not covered. I have discussed the matter with the Lab Services Director there, and have the following comments to make by way of clarification:

1. MediCare has always, and continues to cover medically needed lab tests.
2. Medically needed with respect to glyco-hemoglobin tests in diabetics (quarterly average blood sugar tests) are:
1. Every 90 days, if stable/well-controlled
2. As often as ordered by doctor if not well-controlled, doctor defines not well-controlled.

So, what's the to-do and what are all those threatening-sounding forms about?

1. Marshall got tired of being burned on lab tests.
2. They got a computer software program that automatically generates a form warning you that MediCare may not pay for a test for any and every test where MediCare defines a time limit.
3. This form is generated for the front-desk people at the lab, who will ask that you sign it whether you are at the time limit or not.
4. This is not meant to say that you will be billed, it is a CYA measure in case MediCare doesn't pay them.
5. The front-desk people have not been educated in the finer points of law and insurance regulations, they are "just following orders".

BOTTOM LINE:

If it concerns you, do "every 3 month" diabetes labs a 90 days or more apart.

If you have been asked to do labs at closer time intervals, don't worry about it. We are careful to complete the paperwork in such a way that it will be covered.

Sunscreen

Gardening season is definitely here, even for those who don't dare to plant before Mother's Day (which is this weekend!).

The active ingredient is the key factor in a good sunscreen, more so than the Solar Protection Factor (SPF).

Micronized zinc as the active ingredient (read the fine print on the container) is overall the best in preventing sunburns and also preventing skin cancer. It lasts longer and is less expensive than other agents, and goes on just like any other sunscreen.

Remember that any sunscreen will oxidize and will need to be replenished every 3-4 hours!

SPF 15 is good for most days, SPF 30 if you will be near snow or water (which reflect sunlight) or at higher elevations. SPF 45 is more expensive, but no more effective than SPF 30.

As an extra bonus, applying micronized zinc oxide once a day (even if you are not going outdoors) can reduce the number of age-related skin spots on your skin by half within a year.

Allergy Medicines

'Tis the season!

Prescription nasal steroid sprays such as fluticasone or Nasonex are the most effective single medication in relieving allergy symptoms. The absorption into bloodstream is so low (about 0.03%) that long-term adverse effects do not occur. However, they therefore have to be used every day during allergy season and can take a week or two to start working.

Antihistamine pills work by blocking allergy reactions. Benadryl works very well, but makes most people feel drowsy. As a rule, the more effectively an antihistamine works in relieving symptoms, the more likely it is to cause drowsiness. That being said, over-the-counter Zyrtec is stronger than Claritin.

Decongestants such as phenylephrine and pseudoephedrine may also help, and they are often added to over-the-counter remedies so check the labeling carefully! Some people have an elevation in blood pressure with them, so use with caution if you have heart disease.

Do not use decongestant nose sprays (Afrin, Neo-Synephrine, 4-Way, etc.) for over 3-5 days. Rebound is common with these, which means you can develop dependency on it because you get more congested every time you stop using it.

NasalCrom nose spray is very safe and effective if used 3-4 times a day every day for mild allergic nose symptoms.

Naphcon-A eye drops are a great anti-allergy eye drop for itchy watery eyes, and went over-the-counter a few years ago.

Allergy de-sensitization shots improve allergy in around 30% of folks who go through the every 2-4 week shots for about 2-3 years.

Using the Internet for Medical Questions

According to folks who study this sort of thing, up to 40% of internet searches are about medical or health questions or topics. That seems about right to me!

I get a lot of questions regarding the interface between medicine and net based information. I used to give patients a list of specific websites, but it became impossible for me to keep it up to date.

Generally, you should not feel abashed about researching on the internet or asking about your findings. There can't be anything wrong with being seriously interested in your own body and your own health!

At the same time, you should be just as critical or inquiring of internet based sources of information as you would for any other medium such as TV, books, magazines, newspaper or word of mouth. In other words, don't judge a book by its cover. Anyone with a modest level of computer skills can produce a very polished looking responsive website. Do not assume that a finished appearing website with a fast server is necessarily a good source of information.

Websites representing professional medical opinion should reflect this, while those representing personal opinions or chat rooms should be distinctly so. In other words, the Mayo Clinic's website very clearly represents a professional institution while the website of a person who has a specific condition such as M.S. will be representing their personal outlook and experiences. Both may be useful to you, but should be read with the author's background and point of view in mind.

It is difficult to use the internet deductively rather than inductively. That is, looking up a specific known diagnosis such as iron deficiency anemia will yield a wealth of information on that subject. Searching a collection of symptoms such as tiredness and fatigue and dizziness can lead to an overwhelming list of possible diagnoses which could include iron deficiency anemia, but also brain cancer, lupus, syphilis and diabetes.

In other words, trying to diagnose using the internet is difficult. But then, if it was easy medicine would not be defined as a profession!

Do I Have Arthur-itis?

Ahh, arthritis. A common lament.

Actually, arthritis is not a specific diagnosis. It is a symptom that describes pain in your joints.

Any initial evaluation of arthritis should consider uncommon but potentially disabling forms of arthritis in which your immune system is actually attacking your own joints. Yes this can happen, often runs in families and can be treated very well by a rheumatologist with medications that can alleviate pain and prevent crippling deformity. Examples of these kinds of arthritis include rheumatoid arthritis and systemic lupus erythematosus (lupus).

By far, the most common kind of arthritis is simply related to day-to-day, year-to-year wear and tear on the cartilage that lines your joints. Most folks call this age-related or wear-and-tear arthritis. It is technically called degenerative joint disease or osteoarthritis.

This will affect load-bearing joints such as shoulders, back, hips and knees and also frequently used joints such as the fingers. It differs from the nastier ones described earlier by typically being worse as the day goes on, and not being at its worst first thing in the morning.

What to do for it?

First, stay active. Avoiding absolutely everything that hurts can be worse in the long run because you can gain weight which will increase the load on joints, and lose muscle strength that supports your joints.

Exercise that is non-weight bearing is best: swimming, water aerobics, aqua running. If this is not practical, exercise that does not involve impact against the ground is good. This is referred to as closed-kinetic chain exercise and includes bicycling, stationary bike, elliptical trainer, Stair Master, etc.

Applying ice or a warm water bottle several times a day is also helpful.

Tylenol would be the best medication to use first. It relieves pain as well as any other over-the-counter or prescription medicine and has fewer side-effects. Kidney injury is rare, it cannot cause bleeding or stomach problems and it cannot hurt your liver (if you have hepatitis or drink over 2 drinks a day, cut the following doses by half or bring it up with your doctor).

The correct dose of Tylenol (or generic acetaminophen) is 1,000 mg at a time, 3-4 times a day. Yes, that's 8 extra-strength Tylenols a day.

If you take an aspirin a day for your heart or are on "blood thinners", it is okay to take Tylenol. It does not interfere with the aspirin's ability to prevent heart attacks and strokes, and cannot cause bleeding, and does not interfere with Coumadin/warfarin.

If that isn't enough, try adding topical capseicin (such as Zostrix). This is a topical ointment containing an oil-based extract of cayenne pepper. You apply it to your arthritic joints 3-4 times every day. It burns a bit for the first week or two, but after this it relieves arthritis pain by depleting a chemical that your nerves use to send pain signals to your brain. Native Americans in the Southwest have eaten cayenne for centuries as a treatment for pain. Applying it as an ointment works very well to relieve pain, though you should wash your hands thoroughly after rubbing it on!

If Tylenol and Zostrix are not adequate, then you may want to try anti-inflammatory pain relievers (NSAID's) such as Advil or Aleve instead. Tylenol is usually worth trying first since wear-and-tear arthritis doesn't cause joint inflammation.

Prescription level doses on these are double those on the label: 4 Advils 3 times a day, OR 2 Aleves 2 times a day.

• Do not take NSAID's along with Tylenol. You should only use them if Tylenol isn't working well enough, therefore you should then stop the Tylenol.
• Do not play mix-and-match. Use on or the other, not both.
• It's okay to take them with food or on an empty stomach.
  
• You cannot use NSAID's with Coumadin/warfarin or Plavix/clopidogrel which are prescription "blood thinners". Taking NSAID's along with these can cause fatal bleeding problems.
• If you have had a heart attack or have congestive heart failure, you should consider use of NSAID's with caution. They can keep aspirin from protecting your heart, and can cause fluid retention which could worsen your heart disease.
  
• If you take an aspirin a day to prevent heart attacks or strokes, you may as well stop taking it since the NSAID keeps the aspirin from doing its job. Yes, that does mean you are losing your heart attack and stroke protection!
• You can prevent these medicines from causing an ulcer, which is definitely worth doing, especially since 85% of these ulcers are totally painless.
• Take one 20-mg Prilosec OTC a day, and this will reduce the chance of an ulcer to nearly zero.
• Ignore the labeling on the package about not taking it for over 14 days. Or rather, do not suppose that this means it's not safe to use. The label is intended to keep folks from using it for stomach pain for over two weeks without seeing a doctor about it.

Narcotic pain pills may be appropriate for treating arthritis since the disease can really impact your quality of life. However, they have numerous side-effects and can be addictive so should be used with caution.

Mail Order Pharmacy

Mail order prescription services are known to your medical insurance companies as Pharmacy Benefit Managers (PBM's).

PBM's are middlemen that obtain contracts with pharmaceutical manufacturers ("drug companies") for discount prices on large sales volumes for the insurance companies. In theory, this is supposed to be a win-win situation for everyone. The insurance companies save money on cost of medications, they incentivize you to participate by lowering the out-of-pocket cost of your pills, and otherwise pass on the savings to you.

Of course, you could reasonable ask why your premiums keep going up, but that's a topic for another time. You might also ask what that's doing to your friendly and trustworthy local pharmacist, but I guess the idea is that it's a tough old world out there.

If you want to use your PBM, and would like our help in making it work for you as smoothly as possible,

• They will usually send you a renewal form for each of your medicines when your yearly prescription is up.
• Please let us use these for renewals. Using hand written prescriptions for renewing already existing prescriptions is very confusing to them.

• PLEASE, PLEASE USE YOUR LOCAL PHARMACY FIRST FOR NEW MEDICINES OR FOR CHANGES IN DOSES ON MEDICINES!
• It's not unusual to start or change a medicine, only to find that you have to switch to something else because of side-effects, or that you have to make another change in dose at the follow-up visit.
• Because of this, it's a good idea to make sure that the medicine and it's dosage is right for you before getting 3 months worth for a year!
• Yes, we know it's cheaper to do mail order.
• Yes, we know a few dollars is a lot of money these days, especially if you are on a fixed income.
• The problem is that serial mail-in prescriptions reflecting changes in medications and/or dose changes can lead to confusion as to your medications.
  

Do I Need Antibiotics Before I Get My Teeth Cleaned?

Short answer: For most patients, probably not.

Long answer:

The American Heart Association has been refining recommendations on who should take antibiotics before certain kinds of surgeries or procedures for about 50 years.

Revisions to prior recommendations were made last year. Factors that weighed into these new recommendations included existing evidence, recognition that bacteria entering the bloodstream occurs with normal daily activity, and the awareness that antibiotic use itself is not without risk.

Who may need antibiotics for dental visits? Those with conditions of highest risk for heart infections as a result. These would be folks who (1) have had heart infections before (Infectious Endocarditis), (2) those who have artificial heart valves or heart valve repairs using artificial materials, (3) those who had a heart transplant and then developed heart valve problems, and (4) those who were born with structural heart problems (Congenital Heart Disease) which were not repaired, or were repaired with artificial materials.

What kind of dental visit needs antibiotics? This would really depend on what your dentist plans to do.

What antibiotics should be used? Amoxicillin is the best choice, though there are several alternatives if you allergic to it. The antibiotics should be taken 30-60 minutes before hand, though could be taken for up to 2 hours after the work.


PLEASE NOTE:

We will work in conjunction with your dentist to identify whether you fit into one of the four high-risk groups described above.

However, only your dentist knows whether what they plan to do will make antibiotic treatment beforehand advisable or not. That decision needs to be made by them.

Peter Lockhart, DDS, Chair of Oral Medicine at Carolinas Medical Center is a member of the committee that wrote these new recommendations, and comments that:

"the primary care physician’s responsibility is to determine whether the patient has one of the four qualifying cardiac conditions. If the patient has one of those conditions, it’s the dentist’s responsibility — not the physician’s — to determine whether the upcoming dental procedure warrants prophylaxis."

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.