Wednesday, May 24, 2017

Weight loss surgery still problematic

Every year, 200,000 Americans undergo some sort of weight loss, or bariatric, surgery. This has been going on for 20 years.

University of Michigan researchers, however, took a look at outcomes and have published several papers on the high level of variability of outcomes from facility to facility and the incidence of complications. (Annals of Surgery)

--Nearly one in five Medicare patients with adjustable gastric band surgery (done laproscopically through small incisions) end up needing at least one more operation, either to remove or replace the band or switch to another approach.

--Nearly half of the money Medicare spends on bariatric surgery--47%--is to repair or replace the bands.

--This form of surgery has declined in popularity and constitutes only 5% of operations, but hundreds of thousands of people still have the bands installed.

--In addition--there is tremendous variation between surgery centers in terms of the rates of re-operation.

--Even accredited "centers of excellence" can vary widely as to complications. The worst to the best, even in such centers, varies 17 fold. That's a huge swing.

--Hospitals with the lowest complications rate before the operations cheaper, too.

The conclusion? Efforts to improve the quality of this surgery would affect not only patients, but also costs.

Anecdotally, I also know people who have "eaten" though this surgery and have not achieved close to the expected weight loss or it has not been lasting if it has been achieved.

Do your research!

Tuesday, May 23, 2017

The first visit to the gynecologist

I remember--waaay back in the Wayback--my first visit. The doctor said, "You will do this a million times in your life, so here is how to do it." Zip, zip, kind of embarrassing and gross--but fast.

Julie Jacobstein, a board-certified adolescent gyno with LifeBrige Health, has some tips you can pass on to your daughter:

--Explain why this visit is important, even though your daughter is not sick and has no complaint. This is a safe place to ask questions (without your mother being present). Often, the first time is just to establish a relationship--the "exam" part may not even take place.

--Tell your daughter this involves her medical history--including questions about whether she is sexually active. Also--bring your vaccination history.

--Explain the two parts of the exam. The breast exam and the pelvic exam. Emphasize that all this is over with quickly, which it is, although it can be a little uncomfortable--be honest.

--If your daughter wants to, discuss concerns beforehand--what if your child wants birth control--will she tell you or involve you in the types?

--After, ask her how it went. Your daughter may share a lot or gloss over it. Is she seems disturbed by the practitioner in any way--find a different doctor.

--Tell her this will be a regular part of her health care--get her used to it.

Those stirrups--every woman encounters them at some point.

Monday, May 22, 2017

ESAs versus service dogs

ESAs are Emotional Support Animals. These can be various species and have little or no specific training. They provide companionship, relieve loneliness and can help with anxiety or depression.

In contrast, Service Animals help owners do specific tasks, such as guiding the blind,  and have years of training in helping the disabled.

Certifying ESAs proves to be a problem.

Researchers at the University of Missouri are looking into this.

ESAs can be pets, but legally are not really pets--they can go places pets cannot go.

The laws---Federal and state--concerning ESAs are ever-changing and confusing.

---A landlord can bar a pet, but not an ESA (and often must waive pet deposits for them, too).

---ESAs can go in the main cabin of a plane or even a restaurant.

So mental health professionals must certify these animals somehow.

The researchers agreed that ESAs are appropriate for some patients. Also:

--Requests for ESAs should be met with the same thoroughness of any disability evaluation.

--Professional guidelines are needed.

--Local, state, and national policymakers should meet with mental health professionals to evaluate future legislation involving ESAs.

They also recommended the evaluators not be the owner's doctor or practitioner--this can lead to biased assessments.

So where does that leave us? Pretty much dependent on future actions, I would say. For now, a beloved "pet" could still get special privileges. But, at the same time, those special privileges could benefit the owner greatly and even save his or her life.

Google "emotional support animal"--there are many websites claiming to certify these animals. You will also find out more about the law as it stands now.

Friday, May 19, 2017

Patients of older doctors may be at slightly more risk

When I consider a physician, I wonder: Will just out of medical school with fresh information be better? Or will long experience substitute for recent training if the doctor keeps up?

My father was a doctor--he got medical journals every month--but hardly ever looked at them that I could see. I am not saying my dad was a bad physician, just observing.

Doctors are required to undertake Continuing Medical Education--is this enough?

Harvard recently examined more than 700,000 Medicare patients of 19,000 doctors from 2011 to 2014 (Ars Technica).

They found that mortality rates rose with the age of the doctor.

--Doctors under 40--the mortality rates for elderly patients within the first 30 days (of what?) was 10.8%.

--Doctors 40-49, 11.1%

--50-59, 11.3%

--Above age 60, 12.1%

In real terms, this means one more death per 77 patients for a 60-year-old doctor, compared with a 40-yr-old one.

A little over one-fourth of US doctors are over 60 years of age. Nine percent are over 70.

The researchers said this did not mean as doctors get older, their quality of care slips--it probably means there is a difference in training from before and now.

Medical technologies are evolving all the time. It might be harder for older doctors to keep up, the investigators said.

Also a cautionary note--the study involved only older patients. Would this apply to a cross section?

Still--let's keep up the Continuing Medical Ed. And not just that provided by drug companies, either.

Thursday, May 18, 2017

Treating the whole suffering person, not just the pain

I have chronic knee pain, ooo, ouch, I count every step, I talk myself through outings involving long limps, I mean, walks. But I don't want knee replacements. I have just had too bad luck with surgeries, it's as simple as that.

So I take Tylenol--carefully rationed. No more than four a day and only on bad pain days. Did you know pain can vary from day to day? It can.

I have a close relative who got into the pain med cycle--opiate dependence, if you will. It has not been good.

The American Pain Society has said for decades that you must treat the whole person, not just the pain.

Holistic medicine expert David Katz, MD, at Yale (a guy I have interviewed) urges multi-pronged approaches to pain.

Katz recommends medical, social, psychological and lifestyle factors be considered for each patient.

For instance, the doctor can look at your sleep habits. Pain can cause sleep problems. People who sleep less also have less energy, move around less, and gain weight--which can lead to more pain.

Just the exercise from sleeping more and better can improve pain.

What you are looking for is more vitality, a greater sense of well being. Sleep can be a start.

I have slept badly all my life. A few hours at a time. Now, with age making me need more pit stops in the night, this is emphasized. Even that is usually OK--but if I worry and can't sleep, mind racing, I will have terrible knee pain the next day.

So there is a link.

However, I think all this improvement of lifestyle is limited when it comes to pain. The nerves are wired to warn you when you do something the body does not "like"--each and every time you do it.

Those nerves will fire no matter how chirpy you feel.