If you’re from a Western country, there’s a 10-20 percent chance that you suffer from classic symptoms of acid reflux: chronic heartburn and/or acid regurgitation.
But if you don’t have those classic symptoms you may still have acid bubbling up from the stomach into the esophagus, a condition called “gastro-esophageal reflux disease” (GERD). Over the past decade, research has suggested that acid reflux can cause atypical symptoms such as cough, hoarseness, sore throat, asthma, and even chronic sinusitis. GERD can also cause chest pain, especially if the acid causes the muscle in the esophagus to go into spasm.
As an internist and gastroenterologist, I’ve seen patients who have suffered for years with atypical symptoms of GERD get better with treatment. Although I usually prescribe acid-reducing medication, I try to avoid an approach that relies exclusively on “better living through chemistry.” In fact, my goal is to treat the symptoms with life-style adjustments alone if possible. Smoking and obesity both increase acid reflux and must be addressed. I tell my patients to limit alcohol, caffeine, chocolate, peppermint, and fatty foods (I know, basically anything that gives them even an iota of pleasure in life). I also suggest keeping a food diary to try to identify culprits such as tomato-based products or certain spicy foods. If their symptoms resolve then they can try to reintroduce the things they miss the most. Elevating the head of the bed can sometimes help.
The most serious consequence of chronic acid reflux is esophageal cancer. About ten percent of patients with long-standing acid reflux develop changes in the swallowing tube that increase the risk of developing adenocarcinoma, a deadly cancer with a 5-year survival rate of less than fifteen percent. The condition is called “Barrett’s esophagus. “Fortunately, only about one in 200 patients with Barrett’s esophagus develops cancer each year. And over the last year a treatment called “radiofrequency ablation” has been found to be extremely effective in treating Barrett’s esophagus that is starting to show signs that it may turn into cancer.
It’s estimated that almost 15,000 Americans will die from esophageal cancer this year. Fifty years ago, more than 95% of esophageal cancers were “squamous cell” – the kind caused by smoking and excess alcohol use. As smoking has declined, the incidence of squamous cell carcinoma has dropped. But for reasons that are not clear, esophageal adenocarcinoma – the kind linked to acid reflux (and smoking) – has dramatically increased over the past forty years and now accounts for about half the cases of esophageal cancer. From 1975 to 2001 there was a 600 percent rise in esophageal adenocarcinoma. The obesity epidemic may well be playing a role by increasing the number of adults with acid reflux.
Gastroenterologists can diagnose acid reflux by slipping a thin, flexible instrument (endoscope) through the mouth and down the esophagus. It’s a lot easier than it sounds. Patients are usually given sedation and the back of the throat is sprayed with numbing medicine to avoid gagging. There’s no problem breathing because the tube doesn’t go into the breathing tube (the trachea). Biopsies can be taken from the last part of the esophagus to look for microscopic evidence of Barrett’s and inflammation (esophagitis) caused by acid reflux.
There is currently a controversy about who should be endoscopically screened to look for evidence of Barrett’s esophagus. Only a fraction of the millions of patients with chronic reflux will ever develop Barrett’s. And many patients with Barrett’s have no symptoms at all. In a study in Sweden, 1.6% of the population had Barrett’s but only about 40% had heartburn. And only about half of esophageal adenocarcinoma is estimated to be a result of reflux.
The American College of Gastroenterology recommends against screening the entire population but says it may be appropriate in certain populations at higher risk – such as Caucasian males over 50 with longstanding heartburn. That would be me. So for this week’s episode of CBS Doc Dot Com, I underwent an upper endoscopy, explained and performed expertly by Dr. Mark B. Pochapin, director of The Jay Monahan Center for Gastrointestinal Health at New York-Presbyterian Hospital/Weill Cornell Medical Center. For more information about the Jay Monahan Center, click here.
For information about GERD from the American Society for Gastrointestinal Endoscopy, click here.
Over the last several weeks I have received numerous emails dictating the enforcement of work place rules regarding eating and drinking in nursing areas and other areas with patient charts. It seems everyone, from the Chief of Staff to the CEO to the Head Nurse In Charge has been making it very clear that drinking in work areas won’t be tolerated. I have at times been confronted by dutiful staff doing their jobs with a robust sense of confidence to enforce this potentially dangerous patient safety issue.
Or so I thought. Whilst speaking with one of Happy’s friendly colleagues, I learned that the issue of food and drink in the work place has nothing to do with patient safety. Like my colleague stated so eloquently, if there is data that can be presented to me that shows my action of drinking coffee at the work stations would some how harm my patient, I will gladly stop immediately. Discussion finished.
But as I learned from my colleague, the issue of food and drink at the nurse’s station or anywhere near patient charts has nothing to do with patient safety. In fact, the regulations are in place to protect ME from myself.
That’s right, the coffee Nazis are cruising the halls with reckless abandonment searching for violators of the hospital wide coffee ban on rounds not because patients could be harmed, but because I could harm myself.
You see, it turns out my distinguished colleague was told these regulations were not CMS or JCAHO regulations, but rather OSHA regulations.
“OSHA does not have a general prohibition against the consumption of beverages at hospital nursing stations. However, OSHA’s bloodborne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination of work surfaces exists 29 CFR 1910.1030(d)(2)(ix). Also, under 29 CFR 1910.141(g)(2), employees shall not be allowed to consume food or beverages in any area exposed to a toxic material. While you state that beverages at the nursing station might have a lid or cover, the container may also become contaminated, resulting in unsuspected contamination of the hands.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Eating and drinking areas. No employee shall be allowed to consume food or beverages in a toilet room nor in any area exposed to a toxic material.
In other words this is not a patient safety issue, but rather an employee safety issue. The Joint Commission has no specific standard on the issue other than for hospitals to comply with OSHA regulations.
So with that in mind, I have two comments regarding the issue:
As a private practice physician who is not employed by the hospital, I would suggest that these OSHA rules do not apply to me and therefore the hospital risks no retribution for noncompliance from the accreditation arm of the Joint Commission, which is why I suspect the issue comes center stage for hospitals everywhere. If necessary, I will gladly sign a waiver to relinquish my rights to compensation should I ever contract a blood born pathogen or other communicable disease from drinking my coffee.
If the hospital believes this is a patient safety issue and wishes to make their regulations stronger than those of OSHA and apply them to ALL people in areas with patient pathogens, I will gladly relinquish my daily fluids when I am shown the data regarding patient harm AND the hospital also bans all patient guests from bringing food or drink into the patient’s room. If this is a patient safety issue, it must apply to everyone should they wish to make their rules stronger than OSHA guidelines.
Until this is resolved with rational thought, perhaps over a round of coffee, I’m going to carry one of these around:
That’s a sensitive topic that progressive reformers often bring up as one way to control health spending.
Over at Slate, Christopher Beam takes a balanced look at the issue. He acknowledges that, yes, American physicians get paid proportionally more than the average employee when compared to other countries.
But that should always come with the caveat that other countries, like Great Britain and France, heavily subsidize medical education, while the average American medical student graduates with debt in excess of $150,000. Furthermore, the cost of medical malpractice insurance is significantly more fiscally burdensome for doctors Stateside.
Listen to Princeton’s Uwe Reinhardt, a favorite economist of health reformers, who says, “doctors’ take-home pay (that is, income minus expenses) amounts to only about 1 percent of overall health care spending, or about $26 billion. That’s a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors’ offices, and advertising for drug companies. The real savings in health care will come from these expenses.”
Indeed.
By the way, thanks to Mr. Beam for including a quote and link from yours truly.
*This blog post was originally published at KevinMD.com*
Cotton in its raw state has very little absorbent power because of the oil and gum with which its fibers are covered. When the cotton has been bleaches by chemicals, and the oil extracted, its absorbent power is very great. This fact, together with its cheapness and lightness, the toughness of its fiber, and its ready sterilization by steam or dry heat make it almost the ideal material for surgical dressings.
Unbleached Cotton
This is cotton in its natural state, freed from dirt, combed, and put up in pound rolls. It is non-absorbent and has a greater elasticity than the absorbent cotton. It is therefore preferable as a padding for splints, and to diffuse the pressure of a non-elastic bandage….It costs about thirty five cents a pound…..
Absorbent Cotton
as supplied by the manufactures of surgical dressings, is freed from dirt, gum, and oil, combed and sterilized, and so wrapped in tissue-paper that with a little care it remains aseptic until it is all used. It is furnished in packages of various sizes, from a half ounce to one pound, costing thirty-five cents a pound in pound packages. On account of its lack of elasticity, it is inferior to unbleached cotton as a padding for splints, etc.
Dry cotton is not a suitable material to bring into contact with a wound either during operation or afterward. In the former case its fibers are likely to stick to the wound, and also to the fingers of the operator. In the latter case, if the discharge is small, it is likely to evaporate and seal the cotton to the wound or to the surrounding skin with a scab which is difficult of removal. If cotton is used for sponging, during an operation, balls of suitable size should first be saturated with saline or some antiseptic solution, and then squeezed dry.
Substitutes for Cotton
Lamb’s Wool
Lamb’s wool has great elasticity, does not become soggy when exposed to moisture, and absorbs readily oily substances and glycerids. When cleaned and sterilized it is therefore an excellent material for vaginal tampons.
[So very different from today!]
Gauze
Bleached absorbent gauze is the most important item in surgical dressings. The firmness of the material varies according to the number of threads to the inch. The quality should be selected according to the purpose for which it is desired. Thus a gauze which has 24 X 32 threads to the square inch is suitable for sponges or for dressings, but has not sufficient firmness to make a good bandage. On the other hand, a gauze with 40 X 44 threads to the square inch, used for bandages, is unnecessarily expensive when used for sponges or dressings. It is, however, an unwise economy to select for sponges and dressings a gauze with too large a mesh. Such a gauze absorbs so little that an additional quantity is required in every case, so that the total expense is very likely increased.
Gauze suitable for sponges and dressings, have 26 X 32 threads to the four to five cents a yard, by the piece of 100 yards. This price is increased to eight or even ten cents a yard when the gauze is purchased in small pieces, previously sterilized and hermetically sealed.
From today’s article by the always-interesting Sarah Avery at the News & Observer:
After several failed attempts to extract the item, Manley was referred to another doctor, who suggested removing the entire left lung. “I said, no, I wouldn’t be doing that,” Manley says.
That’s when he decided to seek a second opinion at Duke University Medical Center.
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