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A Surprising Discovery And The Value Of The Physical Exam

I’ve remarked in the past how rarely I ever learn anything useful from physical exam. It’s one of those irritating things about medicine — we spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing’s sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don’t do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don’t often learn much from it. But I always do it.

The other day, for example, I saw this elderly lady who was sent in for altered mental status. There wasn’t much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn’t clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. “Uh-oh. She don’t look so good,” I commented to a nurse. As an aside, this “she don’t look so good” is maybe 90% of my job — the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed “sick” to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash. Read more »

*This blog post was originally published at Movin' Meat*

Hard Water: Is It Hard On Your Skin?

Hard water is tap water that’s high in minerals such as calcium and magnesium. Hard water isn’t harmful, except the minerals prevent your soap from sudsing. Some people think that hard water is more likely to cause a rash than soft water.

Take a recent patient of mine: He moved his family to San Diego from the East Coast (good move this winter, no?) After they moved here, they noticed their skin became dry and itchy. He blamed San Diego’s notoriously hard water and installed a water softener in the main water line. It was costly, but did it improve their skin?

A recent study from the UK looked at this question: Does hard water worsen eczema? The answer was no, it doesn’t. Water hardness did not seem to have any impact on eczema, the most common skin rash.

What’s more important than the hardness of the water is the type of soap you use. True soap tends to strip the skin of its natural oils, leaving it exposed and irritated. Non-soap cleansers, of which Dove is the prototype, leave more oils on your skin, keeping it hydrated and protected.

My patient and his family didn’t get any better after installing a water softener (although he said they could drink our tap water without gagging now.) I advised him to change to a moisturizing soap and to apply moisturizer daily.

San Diego is drier than most of the country, and the low humidity can be a shock to skin accustomed to humid air. Many people who move here find they have to moisturize more often than they did back home.  When they complain, I suggest they could alternatively move back to the East Coast this winter — no takers so far.

*This blog post was originally published at The Dermatology Blog*

Bioadhesives For Repair Of Childbirth Lacerations

Bioadhesives are a reasonable alternative to sutures for repair of perineal lacerations sustained during childbirth, according to a poster presentation at last week’s annual meeting of the Society for Maternal-Fetal Medicine.

Researchers at the Hadassah Hebrew University Medical Center in Jerusalem randomized women with first degree perineal tears to either 2-octyl cyanoacrylate (Dermabond) adhesive glue or suture for wound closure. While healing and incisional pain was similar, women who received the adhesive closure were more satisfied than those who were sutured.

In Portugal, bioadhesives have been studied for closure of the top skin layer of an episiotomy repair, and found to shorten the duration of the procedure with similar outcomes to suture in terms of pain, healing, and infection.

Biologic adhesives are chemically related to Super Glue, which is ethyl-cyanoacrylate. Midwives have been using Super Glue for perineal wound repair for some time, according to Anne Frye, who has authored a book on wound closure for midwives, and who gives instructions for its use in repair of perineal lacerations. Apparently Super Glue was also used by the military during Vietnam for wound closure.

A PubMed search on Dermabond finds multiple studies of its use, from plastic surgery to mastectomy, surgical wound closure, retinal surgery, lung and gastric leak closure, and even on esophageal varices. RL Bates mentions Dermabond as an option to repair skin tears in elderly patients. This stuff is turning into the duct tape of the medical profession.

It’s important to remember that adhesives are only for superficial skin closure, as use in deeper layers can cause irritation and burning of tissues. Side effects of their use include irritation and allergic reactions and of course wound infections, and pain can always occur no matter how one closes a wound.

*This blog post was originally published at The Blog That Ate Manhattan*

Fungus: An Unwanted Yoga Partner

Yoga is good for your mind and body, including your skin. Yoga mats, on the other hand, might not be. Using someone else’s yoga mat for an hour could lead to an infection.

Fungal infections are common and appear as athlete’s foot, toenail fungus, and ringworm. Unfortunately, the fungus can survive on surfaces like mats long after the infected person has left. Although most people blame the gym locker room when they develop athlete’s foot, you can catch the fungus from a variety of places anytime you walk barefoot.

Fortunately, even if the fungus comes into contact with your skin, it doesn’t always lead to infection. Dry, cracked skin, or soft, wet skin disrupt your primary defense against the fungus — the densely packed barrier of skin cells, oils and proteins on your healthy skin’s surface. Here are five ways to prevent taking a fungus home with you from your next yoga class:

1. Bring your own mat. At least you know what you have.

2. Use an alcohol sanitizer on your hands and feet after your class. Sanitizers with at least 60 percent alcohol are excellent at drying up the fungus and killing it long before it has a chance to infect you. Read more »

*This blog post was originally published at The Dermatology Blog*

Winterize Your Mind And Body

This is a guest post from Dr. Jennifer Wider.

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Winterize Your Mind And Body

During the winter months, certain health issues may arise that women should have on their radar. From mental health issues like stress, depression and seasonal affective disorder (SAD), to physical concerns like skin care, the winter can certainly pack an extra punch.

Depression peaks during the holiday season, affecting more than 17 million Americans, according to the National Mental Health Association. On average, women are more vulnerable to stress-related illnesses like depression and anxiety than men. One study, conducted by Pacific Health Laboratories, revealed that 44 percent of American women report feeling sad through the holidays compared to 34 percent of American men.

“Depression of any kind is more common in females than males,” explains Greg Murray, M.D., lecturer and clinical psychologist at Swinburne University of Technology in Australia. “A pattern of elevated depression in the winter months is more marked in women than in men.”

There are a host of different reasons why women may be more susceptible to stress during the winter than men. Women tend to be the primary caretakers of the family and often take on the extra burden of the holidays with gift buying, entertaining, and coordinating visits with extended family. For working women, the added responsibilities can be difficult to balance, especially if they are already balancing a family, job, childcare and eldercare duties. Read more »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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