If you’re a bit confused about the H1N1 vaccine recommendations, you are in good company! They are a bit confusing because this year’s flu season is a bit confusing. To add insult to injury, the recommendations for H1N1 are just similar and dissimilar enough from “seasonal flu”, Influenza A&B, that sorting it out can make your head spin and your tongue get tied.
Kim Carrigan and I attempted to clear the air about this challenging topic recently on Fox News Boston…as you’ll see, I even got tripped up once, so don’t feel badly if you’re a bit confused!
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.
This week’s New England Journal of Medicine contained a very, very interesting proposal put forth by a few prominent physicians and researchers working on the obesity crisis in America.
They propose that beverages loaded with sugar should be considered a public health hazard (much like cigarettes) and should be taxes. The proposal calls for an excise tax of “a penny an ounce” for beverages like sugar sweetened soft drinks that have added sugars. They cite research that links obesity to heart disease, diabetes, cancers, and other health problems. They say sugar sweetened beverages should be taxed in order to curb consumption and help pay for the increasing health care costs of obesity.
They estimate that the tax would generate about $14.9 billion in the first year alone and would increase prices of soft drinks by about 15-20%. That is big money, but at what cost?
My personal opinion is that while the tax would generate a lot of money that could be put to good use on anti-obesity programs, it is singling out one industry when obesity has numerous contributing factors. Calories Americans are getting from beverages have actually gone down in the past decade, but obesity rates still climb. Soft drinks alone are not making us fatter.
Americans need to pay closer attention to portion sizes and overall calories coming into their bodies from all sources. We know that Americans also eat too much fried food, candy, ice cream, etc. Should we tax everything that is “bad” for us? Absolutely not! And these foods are not “bad” when consumed in reasonable quantities in reasonable frequency.
We also need to learn how to move our bodies more to burn off some of the sweet treats that we love to indulge in. Weight loss is a simple equation that I don’t get tired of explaining again and again: Move more and eat less.
Taxing soft drinks will not decrease heart disease risk…exercising more and losing body fat by consuming less calories definitely will!
There’s a case for killing Granny? I guess so, or at least according to Evan Thomas’ article in the most recent Newsweek. Thomas, after sharing the story of his mother’s last days, concludes that death is the key to health care reform:
Until Americans learn to contemplate death as more than a scientific challenge to be overcome, our health care system will remain unfixable.
Does everything need to have a political spin on it nowadays?
But let’s take Thomas’ advice and talk about death. Not “death panels,” not the politics or the cost of end-of-life care. Just plain old death.
I was reminded recently of how fragile life is. It made me remember something I read after our oldest child was born. I realized that one day she would learn the truth about death. And I thought how bad that was, and how I wanted to protect her from it. But then, by chance, I happened across this interesting little saying.
When your children are young, all you think about is that you don’t want them to die. But when they get older, all they think about is that they don’t want you to die.
It touched me, and it made me think about how my responsibility to protect my children extended even unto and beyond my own death.
It’s a nice philosophical point, but there are very practical things each of us can do to fulfill this responsibility. Here is my list of just a few of the very important things we all should do to plan for our deaths:
Buy life insurance
If you’re young and in reasonably good health you should be able to buy a term life insurance policy for a few hundred dollars a year. You should do this so your family can have your earning potential replaced in the event of your death. Find a good insurance broker and make sure you get coverage that suits your needs. Even if you have a pre-existing condition (like a chronic illness) a good broker should be able to find you some kind of coverage. You won’t be able to buy any coverage at all if you become acutely ill, so don’t wait until it’s too late.
Make a will
This is so much more than just planning for your family’s financial future. For example, if you have children, have you figured out who will take care of them if both you and your spouse die? There are many important and potentially difficult conversations that go along with this kind of planning – but you’re much better off having them now. After you die, those left behind will end up fighting out these issues not knowing your wishes. Find a good lawyer to help you.
Make an advance directive
You need to think about what kind of medical care you want if you become incapacitated and unable to decide on your own. Do you want to live for 30 years on a ventilator, unconscious? Do you want to undergo extensive and painful treatments if you don’t have much hope of a meaningful recovery? Don’t leave your family alone trying to make that decision for you, wondering what you would have wanted. Write down what your wishes are.
Appoint a health care proxy
Pick someone who you trust to make your medical decisions for you if you are unable to do so. Write it down and make clear what you want that person to do, so if the time comes there isn’t any dispute among your family as to who is in charge.
There are many other things you can do, but to me these are four of what I think are the most important things you can do to prepare for your death. Maybe some commenters can add some more that I missed.
Now, with all that said and done, I will still disappoint Mr. Thomas.
Why? Because I still prefer to think of death as a scientific challenge to be overcome. And you know, I’m glad that many other people feel that way, too.
Especially the people who make medical breakthroughs – I’m really glad they feel that way.
*This blog post was originally published at See First Blog*
This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was about trauma and orthopedics. It was delivered by Douglass Weiss, MD of Teton Orthopaedics in Jackson Hole, Wyoming.
Utilizing some fabulous images, including those of Lanny Johnson, Dr. Weiss made some important points. Many of these are familiar to seasoned medical practitioners, but they merit repeating. First, when approaching a victim, always attend to the “ABCs” first – airway, breathing, and circulation (including bleeding) – so that a life can be saved. Then, if possible, take into account other injuries, including those of bones – save the limb, save the joint, and restore function.
Here are two good pointers. First, your field evaluation of the victim may be the only complete one, so do your best to examine the entire victim, and also to document in writing what you discover. Examine and establish the airway, listen for breath sounds, observe chest movements, feel for pulses and observe skin color, etc. Within the constraints of the situation and environment, “expose” the victim in order to evaluate bony and other injuries. The, move on to the “secondary” survey, which will include examination of the neck, back, pelvis, arms and legs, looking for swelling, bruises, scrapes, cuts, bleeding and deformities. If you feel inappropriate motion (e.g., broken or dislocated bones or joints), be prepared to apply splints.
Always try to roll the patient (using a logroll technique if necessary) to examine the victim’s back.
For the benefit of doctors reading this post, remember that if a fracture is identified, suspect an injury to the joint above and below the fracture, and be sure to splint these for the comfort and protection of the victim.
The application of splints is an art form, so should be practiced prior to your expedition. Any limb that is obviously deformed or that demonstrates excess motion (where there should be none) should be immobilized immediately. If a helper(s) is available, use assistance. Be sure to pad all splints very well to avoid pressure injuries to the tissue underneath. Depending on the rescue, the splint may be in place longer than you anticipate.
If a broken bone (fracture) is “open” (the bone has poked through the skin), then apply a wet (preferably normal saline or disinfected water) dressing and apply a splint. If you have an all-purpose antibiotic (e.g., cephalexin, amoxicillin or ciprofloxacin) and the victim is capable of purposeful swallowing, administer a dose.
Fractures of the pelvis generally imply that a very significant force was applied, so they carry a high risk for associated life threatening injuries. The victim should be evacuated as soon as possible. It is commonly taught that a broken femur (the long bone of the thigh) can cause bleeding in excess of a liter into the limb. This can be dangerous, so these injuries should be promptly splinted, preferably with a pre-fashioned or improvised traction splint.
Compartment syndrome occurs when tissue pressures within inelastic soft tissue compartments of the limbs (commonly the forearm or lower leg exceed perfusion pressure, that is, the pressure necessary to allow blood to circulate freely through the tissues and provide energy and remove waste products. Symptoms include extreme pain, loss of pulses, pale skin color, weakness or paralysis of the muscle, and numbness and tingling. If the pain is severe and the skin feels tight, a compartment syndrome may be developing. If a compartment syndrome is felt to be impending or present, keep the limb elevated and seek immediate medical attention, because an operation may be required to open the compartment and release the pressure before the onset of permanent tissue damage.
Thanks to Dr. Weiss for his contribution to wilderness medicine education.
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