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Abnormal Mammograms Often Terrify Women Unneccesarily

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A dear friend of mine sent me a panicked, cryptic email late on a Friday night: “call me immediately” (followed by her cell phone). As a doctor, I usually know that these kinds of requests are triggered my medical emergencies, so I anxiously picked up the phone and called my friend, hoping that I wasn’t going to hear some alarming story about a tragic accident.

And low and behold the story was this: “I got home from work late and picked up the mail. There was a letter in there from the radiologist’s office. It said that my mammogram was abnormal. Do you think I have breast cancer? Am I going to die?”

Remaining calm, I asked what sort of abnormality was described. She read the letter to me over the phone:

“Dear [patient],

Your recent mammogram and/or breast ultrasound examination showed a finding that requires additional studies. This does not mean that you have cancer, but that an area needs further evaluation. Your doctor has received the report of your examination. Please call us at XXX to schedule the additional examinations.”

I knew immediately that this was a form letter (heck the letter didn’t even distinguish between whether or not my friend had had a mammogram or an ultrasound) and it made me angry that it had frightened her unnecessarily. I knew that as many as 40% of women who have mammograms have some sort of “finding” that requires further testing. Usually it’s because the films are too dark or too light, the breasts are particularly large or dense, or there is some cyst, calcification, lymph node, or shadow that the radiologist picks up. And in a litigious society, a hint of anything out of the ordinary must be reported as an abnormal “finding” until proven otherwise.

I did my very best to reassure my friend – to tell her that if the radiologist were truly concerned about what he or she saw on the mammogram s/he would have called the physician who ordered the test right away. Receiving a vague letter like this is reassuring, because it’s an indication of a low index of suspicion for a malignancy. I also told my friend that if a true mass were found on the mammogram, that a biopsy of that mass still has an 80% chance of being normal tissue.

But even though I did my very best to reassure her, my poor friend didn’t sleep well that night, and worried all weekend until she could speak to her physician on Monday. As I thought about her experience, and the unnecessary fright that she was given… I began to wonder about how common this experience must be. How many other women out there have lived through such anxiety?

Personally, I think that women who get mammograms should be warned up front that there is a high chance that the radiologist will find something “abnormal” on the test, and that these abnormalities usually turn out to be any number of typical breast characteristics. They should be told not to worry when they receive a letter about the abnormality, but come back for further testing in the rare event that the finding is concerning.

I decided to do a little research about this phenomenon (women receiving scary letters out of the blue about their mammogram results) and interviewed Dr. Iffath Hoskins (Senior Vice President, Chairman and Residency Director in the Department of Obstetrics and Gynecology at Lutheran Medical Center in Brooklyn, N.Y.) about her experiences.

Please listen to the audio file for the full conversation. I will summarize her opinions here:

Q:  How common are abnormal mammograms?

Mammograms are considered “abnormal” in some way in up to 40% of cases.

Q:  What sorts of things are picked up as abnormal without being true pathology?

Overlapping tissues in women with larger or heavier breasts, fibrocystic breast tissue, calcium deposits or the radiologist doesn’t have the last mammogram to compare the new one to and sees some potential densities.

Q:  What happens next when a woman has an abnormal mammogram?

It may take a week or two for the patient to get scheduled for follow up tests. Usually the physician will choose to either repeat the mammogram with targeted views of the area in question, request a breast ultrasound, biopsy the mass, or remove the concerning portion of the breast tissue surgically.

Q:  When would a physician choose a biopsy?

A biopsy is indicated if the mammogram and follow up tests all are consistent with the appearance of a concerning lesion. Sometimes the physician will do a biopsy on a lump if a woman says that it’s unusual, new, or tender and the mammogram result is equivocal.

Q:  What percent of biopsies confirm a malignancy?

It varies from physician to physician because some have a lower threshold for performing biopsies (so therefore the percent of biopsies that are malignant is lower). But on average only 10% of biopsies pick up an actual cancer.

Q: What does a radiologist do when he or she finds an abnormality on a mammogram?

First of all, the patient must be notified of the abnormality. Secondly, the radiologist reports the abnormality to the referring physician, usually by fax. They do it either in batches, or one at a time. If the person reading the film has a serious concern about the breast tissue – or if it appears to have the characteristics of a malignancy, the radiologist will personally call the referring physician right away.

Q: What advice would you give to a woman who receives a letter in the mail indicating that she’s had an abnormal finding on her mammogram?

Please try not to be concerned yet. Wait for the doctor to fully evaluate the mammogram and do further testing before you make any assumptions about the diagnosis. Although it’s almost impossible not to feel anxious, you must understand that the vast majority of “abnormal findings” on a mammogram are NOT cancer.

Listen to the full interview here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Good Cholesterol (HDL) Is More Important Than You Think

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Heart disease is the number one killer of Americans, and high cholesterol levels are a primary contributor to heart disease. But the cholesterol story is a bit complicated – some of it is damaging to blood vessels (Low Density Lipoproteins or LDL is considered “bad” cholesterol) and some of it is restorative (High Density Lipoproteins or HDL is “good” cholesterol). Most medications are aimed at lowering the “bad” cholesterol, and this strategy has been very helpful in reducing heart disease and atherosclerosis. But what about raising the good cholesterol as part of a heart healthy strategy?

A new study in the New England Journal of Medicine suggests that having low levels of HDL can put people at risk for heart disease and heart attacks, even if the LDL is well controlled.  This is the first study to show that low LDL does not erase heart disease risk if the individual’s HDL is also low.  In fact, each increase of 1 mg in HDL cholesterol is associated with a decrease of 2 to 3% in the risk of future coronary heart disease.  So lowering LDL with statins (if lifestyle measures fail) is only half the battle for those who also have low HDL.So how do you increase your HDL levels?The most effective medicine for raising HDL is a type of Vitamin B called niacin.  Taken in the quantities required to have an effect on HDL, though, there are usually unpleasant side effects: flushing (redness or warmth of the face), itching, stomach upset, mild dizziness, and headache.

Perhaps the best way to increase HDL is to lose weight and exercise regularly.? In fact, the list of HDL-raising “to do’s” reads like a healthy living manual:

1.  Avoid trans fats

2. Drink alcohol in moderation

3.  Add fiber to your diet

4.  Use monounsaturated fats like olive oil where possible

5. Stop smoking

6. Lose weight

7. Engage in regular aerobic exercise

So next time you see your doctor, make sure you review your cholesterol levels, and discuss some strategies to get your levels of HDL and LDL in the optimal zones for a healthy heart.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Motion Sickness: What Can You Do About It?

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If you’re one of those unlucky souls who is easily nauseated by riding in planes, trains, and automobiles – and forget about boats, they’ll keep you hanging over the rail for hours – then welcome to the motion sickness club.  You’ve probably already read about your treatment options, but you may not find any of them completely satisfying.

Motion sickness (like car sickness, sea sickness, etc.) is caused by an uncoupling of input from the eyes, ears, and joint position-sensing nerves throughout your body.  In other words, your brain becomes confused by conflicting messages about where your body is in space.  If you’re sitting in a chair, your brain expects it to be fixed and not to move – but then if that chair is in a car or on a boat, the movement doesn’t make sense to it, and you become dizzy and nauseated.  The details of the science behind motion sickness is quite complex – and there are many different approaches to treating and preventing it.

In terms of medications – antihistamines such as Benadryl (diphenhydramine), Dramamine, Antivert (meclizine), and Phenergan and anticholinergics like Scopolamine may be the most commonly used.  They have varying sedative side effects which can be very inconvenient for those who need to be alert and active immediately after they get out of the car, train, boat, etc.

Some people have used Zofran (ondansetron) for motion sickness prevention – and although this drug is only approved for the treatment of nausea side effects caused by cancer chemo and radiation therapy, it has a unique mechanism of action for preventing nausea.  It works by blocking serotonin receptors in the brain (and perhaps in the gut) to head off motion sickness.   It does not produce drowsiness as a side effect, and is generally well tolerated.  Unfortunately, it is very expensive (about $50 per pill – without insurance).

Personally, I try to stay away from medications as much as I can (they always have the potential for unwanted side effects) – but if you’re really struggling with motion sickness and have exhausted all your options, you might want to ask your doctor about Zofran.  I must admit that for me (someone who gets ill just looking at amusement park rides), a little bit of Zofran has radically improved my traveling difficulties.  In fact, I’m writing this blog post from a seaside vacation spot in sunny California… and I have no worries about the flight home, choppy air or not.  Bring on the deep sea fishing, parasailing, and jet skiing – I have no fear, Zofran is here!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Bruised Finger Nails: How Do You Treat Them?

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A colleague slammed his thumb in a door recently and got a black and blue nail.  He told me that he searched for how to treat it on the Internet, and was advised to stick holes in the nail to relieve the pressure.  I gazed at his thumb nail, peppered with tiny little needle divots and cringed as I imagined bacteria being introduced into the soft fleshy part under his thumb nail.  His thumb otherwise looked good – no mallet finger, no swelling – no blood under pressure that I could see.

I decided to do a little research on this issue, since all I’d ever done for a black and blue finger nail before is let nature take its course – it’s painful for a few days, the nail eventually falls off, and a new one grows.

However, in many cases creating a hole in the nail to let the blood escape can significantly relieve pain in the acute phase.  Making the hole is tricky – it has to be large enough to let the blood out, and it has to be done with a sterile instrument so that bacteria are not introduced below the nail.  Most physicians recommend a local anesthetic to ease the pain prior to making the hole.  The hole can be made with a large bore needle (but you have to be careful not to place the needle in too deep) after swabbing with alcohol, or by burning through the nail with the tip of a paperclip that has been heated with a butane lighter.  Creating the nail hole (known as trephination) is best done by a medical professional.

Routine antibiotic coverage is unnecessary. If the nail is loose, split, or a cut extends past the edge of the nail, the nail should be removed,
the cut closed with stitches, and the nail reapplied as a
dressing.  It’s also important to make sure that the thumb bone is not fractured.

Bottom line: black and blue nails (subungual hematomas) are very painful and may be relieved by having a medical professional place a hole in the nail.  But don’t try this at home, folks.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Popcorn Lung: What Is It And What Should You Do About It?

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Is it safe to eat microwave popcorn?  In case you missed it, a surprising new case of diacetyl lung damage
(so-called popcorn lung) was discovered in a patient who is a popcorn fanatic.
He reported eating 2 bags of artificial butter flavored popcorn per day
for years on end and began to notice shortness of breath.

My bottom line: avoid diacetyl, don’t avoid popcorn.  Popcorn itself is
not harmful or dangerous (unless you’re under age 5 and are at risk of
choking or inhaling it) – just make sure it’s not laced with chemicals.

Five years ago the New England Journal of Medicine published a study linking a popcorn chemical (diacetyl) to a serious lung condition in 8 popcorn factory workers.
The lung condition, also known as bronchiolitis obliterans, is an
inflammatory reaction to diacetyl that can reduce lung capacity by as
much as 80%.  Certain people who inhale too much of the chemical form
scar tissue as a reaction, making the lungs stiff and causing cough and
shortness of breath.

In this week’s case, the astute pulmonologist examining the popcorn addict remembered the 2002 NEJM article, and thought to ask him about popcorn exposure as part of her work up for his breathing complaints.  As it turns out, his exposure to popcorn chemicals is the likely cause of his lung damage.  Sadly, though, once the scarring occurs there is no way to return the lungs to their original state of heath.  The only known treatment for popcorn lung is a lung transplant.

There has been incredible interest in this story because microwave popcorn is a part of most of our lives.  The United States is the single largest consumer of popcorn worldwide, and we purchase over 1 billion pounds of unpopped corn per year.  We naturally wonder: could this happen to me?  Am I (or my kids) at risk?

First of all, I think that diacetyl should be avoided by all consumers of popcorn.  ConAgra, the parent company for Orville Redenbacher and Act II, has agreed to immediately remove this chemical from its artificial butter flavored popcorn.  Nonetheless, we should scrutinize the labels of any popcorn that we intend to purchase to make sure that it doesn’t contain diacetyl.

Second, the good news is that not everyone’s body forms scar tissue in reaction to this chemical.  In the same way that we’re not all allergic to the same environmental agents, our bodies are not all going to respond to diacetyl by developing lung scarring.  That said, why tempt fate by inhaling fumes that have harmed a small number of people?

Third, it does seem that it requires prolonged and high exposure to diacetyl to be at risk for popcorn lung.  So if you’re not a buttered popcorn maniac (consuming several bags per day for years on end) your risk is extremely small, even if in the past you’ve eaten the occasional microwave popcorn containing the chemical.

If you are looking for alternative healthy snack options check out this link.

Hope this post allows some of you to breathe easier!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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