House Calls – Syphilis & Blood Types

House Calls from the Carrboro Citizen 2.23.12

Dear HOUSE Calls, My brother was recently diagnosed with syphilis. He was treated at a free clinic and got a prescription but did not get any better. He went back and had to get another prescription. Is there any difference in the quality of care given at a free clinic versus a private practice?

We generally feel that the level of care given at free clinics is excellent. They often have an impressive staff of volunteers to help with pharmacy needs, care management and other types of therapy. The clinicians usually work in private practice or are retired from private practice and are generally very skilled. There are some downsides to free clinics. Because they are staffed by a rotation of fill-in doctors, it’s very hard to develop a relationship with a primary-care physician. They sometimes are not well set up for continuity care but offer excellent acute and episodic care. They may not have a full range of resources, such as medicines, and might have to settle for a second choice for a condition. The alternative might be filling a prescription at a drugstore, which many clients at a free clinic cannot afford. Specific to your brother’s condition, syphilis has different stages, and in later stages can be harder to treat. It is usually best treated with injectable penicillin, and the number of injections varies with the stage. The free clinic might not have had the injectable penicillin, or perhaps your brother is allergic to it. If things don’t seem right, the health department is another excellent resource for communicable diseases.

Dear HOUSE Calls, I give blood regularly. I’m told that I’m type O negative and the Red Cross loves it. What does that mean?

It is great that you give blood regularly, especially because you are O negative. This means you are a universal donor. Basically, anybody can accept your blood. Most people have to be cross-matched to a specific blood type to receive blood, but your blood can be received by anyone, and in an emergency we’ll use O negative to transfuse somebody we don’t have time to type. The bad news about your blood type is that you are the most restrictive receiver of blood. You can only get blood from other people with O negative blood. We should say that blood is needed from people with all types of blood. Consider giving blood if you are in good health. Your body will build that blood back up in no time, and you may be saving a life. Check with your local American Red Cross for upcoming blood drives.


House Calls – Radon & Gluten

House Calls from the Carrboro Citizen 2.16.12

Dear HOUSE Calls, Why is radon a problem? Should I get a house tested for radon before I buy it?

Radon is an odorless gas that can be produced from the decay of uranium products. It is somewhat more common in older homes. It can break down over time, and if you inhale it or ingest it, it may increase your risk of lung cancer. After smoking and second-hand smoke, radon is the third-leading cause of lung cancer. You can purchase inexpensive kits to measure radon, and this is probably a good idea before buying a house. Radon levels vary widely by location, so consider contacting your local health department for advice. Most of North Carolina has low levels of radon, including most of the counties in the central and eastern parts of the states. However, some counties in central North Carolina and most of the western part of the state have moderate to high levels of radon. You can find more information about radon and radon testing in North Carolina at the North Carolina Radon Program.

Dear HOUSE Calls, Gluten-free diets seem to be increasingly popular, even for people without gluten sensitivity. Is this a good idea?

Gluten is a protein found in wheat, barley and rye. The term “gluten” comes from the Latin word for glue, and this protein literally keeps our food sticky and chewy. Wheat is a very common part of our diet, and cutting it out can be difficult and expensive. Gluten is the protein that people with Celiac disease can not tolerate. These people should not eat gluten. Those without known or at least suspected Celiac disease have no reason to avoid gluten, but gluten-free diets are often very healthy diets. Most Americans eat far too much carbohydrate, especially simple carbohydrates like processed wheat flour. Cutting out some of the wheat in your diet and making most of your wheat intake whole wheat can make a big improvement in your diet and your health. As for us, we’ll continue to enjoy some whole-wheat gluten (preferably with pizza sauce and cheese on top). Exercise caution with extreme diets of any kind, and consider working with your physician or a nutritionist to make sure you are getting all the nutrients your body needs if you do decide to pursue a gluten-free diet.

House Calls – Computer Screens & Light; Lactose Intolerance

House Calls from the Carrboro Citizen 02.09.12

Dear HOUSE Calls, I spend a lot of time in front of the computer. Is it better to have the lights on or off?

We are all spending more and more time in front of the screen. Because of this there is more information than ever regarding eye strain and a number of ergonomic problems related to computer use. There is even a new syndrome called Computer Vision Syndrome, which gives people headaches, blurred vision and neck pain from being on the computer a lot. We do recommend that you keep the lights on while using the computer. The contrast between the bright screen and the dark room tends to place more of a strain on your eyes. Make sure you use a comfortable chair at the right height and a keyboard best designed for your needs. Elevating the screen off the desk will take tension off your neck. Take breaks for your eyes and your body.

Dear HOUSE Calls, I’d like to know more about lactose intolerance in adults, the best ways to get tested for it and the best products to help deal with it.

Lactose intolerance is when people get belly pain, bloating and sometimes gas or diarrhea that is related to dairy or lactose-containing foods because they are missing an enzyme that is needed to digest this lactose (called lactase). Lactose intolerance is something that is both relatively overdiagnosed and relatively common. It is especially common in people of African descent. The best treatment for lactose intolerance is reduction or avoidance of lactose-containing foods (dairy). That can be really difficult. Some people will use soy substitutes or lactose-free dairy products (such as those made by Lactaid). Many foods in restaurants will contain dairy, making it hard to avoid. There are lactase supplements (also known as Lactaid), which can be really helpful. Many people are diagnosed with lactase deficiency based on the results of a self- or doctor-imposed elimination diet.

One example is to eliminate all dairy for three days to see if symptoms improve, followed by three days with a lot of dairy. There are three tests we know of for lactose intolerance. There is a blood test for glucose after ingesting a lactose load (if you can’t digest lactose, your glucose should not rise) and there is a breath test after a lactose load that measures hydrogen. If you don’t metabolize lactose, it ferments and makes hydrogen. The last test, used for infants, measures stool acidity, which increases in a person who can’t digest lactose. Work with your primary-care provider to get more information and possibly testing before you restrict something from your diet.

House Calls – Prostate Enlargement; Stretching

House Calls from the Carrboro Citizen 02.02.12

Dear HOUSE Calls, How can you treat an enlarged prostate without drugs?
Many patients want to avoid “medicines.” Yet symptoms of an enlarged prostate (waking at night to urinate, weak stream, dribbling) can be a real nuisance. Just because a product is a natural herb that is available without a prescription does not mean that it is completely safe or effective. There are two natural products that we know of that people use for enlarged prostate – saw palmetto and pygeum. There has been plenty of controversy about the effectiveness of saw palmetto, but the bulk of evidence shows no treatment effect. We therefore don’t routinely recommend this to our patients. There is even less compelling data to support the use of pygeum. There are also behavior options, including decreased evening fluids, decreased caffeine and alcohol and so-called “double-voiding,” which means going to the bathroom twice to try to empty your bladder more fully. There are also surgeries to reduce the size of your prostate, but most people would proceed to that only if medicine were not working.
Dear HOUSE Calls, I’m a tennis player and I’ve been getting injured a lot. What is the best time to stretch– before or after?
The latest research says that it really does not matter. A recent systematic review of five studies found that stretching did not reduce soreness or injuries. another systematic review showed that warming up did not reduce injuries. We are not sure we believe this. There may be a couple of things going on here. With behaviors like warming up, cooling off and stretching, bodies just do what they do, and randomizing people can only minimize or maximize behaviors but not eliminate them. We think that in most sports, people warm up whether or not they identify the warm-up. The first few minutes of a run or a tennis match is always a little slower. The other thing is that not all stretching is alike. The latest we hear from coaches and personal trainers, as well as some physical therapists, is that stretching a “cold” muscle with a fixed or static stretch means you need to hold a position for 45 to 60 seconds. Dynamic stretches (stretching while moving) can be done more efficiently on cold muscles. Lastly, not all sports are alike. Jogging allows a slow warm-up period, while tennis is full-on impact with every move. So the study of joggers may not be suited to tennis players. We don’t know if any of this matters or when stretching is best. We like to stretch briefly before activity, warm up for a few minutes and stretch when done.

House Calls – Diabetes & Prostate Cancer

House Calls from the Carrboro Citizen 01.26.12

Dear HOUSE Calls, My brother takes insulin for his diabetes and drinks quite a bit of alcohol. Is that a problem?
It sounds like you may be concerned about your brother’s alcohol intake with or without the diabetes, so you should consider opening a dialogue, as this may be a problem for him. Specific to the diabetes and insulin, we have a few thoughts. First off, alcohol does not have much effect on the blood-sugar or insulin levels in and of itself. It is not a high-glycemic food like potatoes or candy bars. However, many types of alcoholic drinks are high in sugar and carbohydrates, which will increase blood sugar. Likewise, they all add substantial calories, which will make the weight control that is so important for diabetics more difficult. Also, drinking too much alcohol can lead to bad decisions regarding diet. Lastly, high levels of regular alcohol consumption over time can stress out the pancreas and make it less able to respond and contribute to the control of blood sugar. Drinking alcohol can affect your blood pressure levels, which is very important if you have diabetes. So there are a lot of downsides to drinking alcohol for your brother’s health and not much in the way of benefits. Hopefully you can share this information with him and start a conversation.

Dear HOUSE Calls, I am a 41-year-old black male. What do I need to know about prostate cancer?
There has been a lot in the media about prostate cancer screening, and it can be so confusing. Because you are black, your lifetime risk of developing prostate cancer is 16 percent, but your lifetime risk of dying from prostate cancer is only 2.9 percent, which is somewhat higher than the risk for white people. Genetics is the most important risk factor, and there is nothing you can do about it. Screening and early diagnosis seemed like a good idea for the past decade or so; however, the most recent and highest-quality studies show that men don’t live any longer if they get prostate-cancer screening, so we are by and large not recommending it anymore. We will give men older than 50 their choice about PSA testing and explain to them the pros and cons of testing. Symptoms of prostate cancer can be similar to enlarged prostate symptoms. If you are having trouble emptying your bladder, weak stream or dribbling, you should discuss this with your doctor.

Emailing your Doctor

House Calls from the Carrboro Citizen 01.19.12

Dear HOUSE Calls, I took a picture of my partner’s wound on his leg and emailed it to his doctor and asked what we should do. He prescribed an antibiotic. Is this the wave of the future? Can doctors bill for this type of consultation?
This is a hot topic. There are issues of billing, communication, correct diagnosis, liability and access. There are business models for this. There are insurance codes for telephone consultation. These are usually reimbursed at very low levels and by very few insurance companies. In our medical system, physicians make a living by seeing patients. There are capitated or single-payer systems where physicians make money for not seeing patients. Those systems have other challenges, but would make this sort of consultation quite reasonable from a financial perspective. This is no different from telephone medicine. We generally feel if a problem can be managed in about a minute or so, a telephone call is a reasonable approach. But if a patient needs 15 minutes of our time, a visit is important to us from a scheduling and financial perspective. Regarding communication, telephone medicine is generally preferable to email medicine for making a diagnosis. Two-way communication is much better this way, and we can detect discomfort or distress that is hard to pick up by email. For quick questions, email avoids phone tag. In this case, we would want to know: Is the wound warm? Is there any pus? Is the leg swollen, painful? Any fever? These questions help us to make the correct diagnosis. In this case, and many cases, a picture is worth a thousand words, but to see and touch the wound is worth 10,000 more. What if it is not infected? What if the antibiotic is unnecessary and your partner has a severe reaction? The treating physician has the same liability for delay in diagnosis or misdiagnosis in the event of a complication. On the upside, we all believe that access to care should be convenient and affordable but with careful attention to quality. This type of consultation is so easy in this day and age. We should note that we are especially fond of this type of consultation in conjunction with further dialogue and an office visit. Perhaps you get a picture of that rash at its worst and come in the next day for an office visit. Many of these issues are not new, and we have been dealing with the same issues in regards to the telephone for a long time. The challenges and opportunities are evolving.

Swimming & Weight; Technology & Medicine

House Calls from the Carrboro Citizen 01.12.12

Dear HOUSE Calls, I like to swim for exercise. A doctor told me that if I really want to lose weight, swimming is not the answer. Is this true?
What probably matters most is how hard you work – not what kind of exercise you do. It is easy to swim without pushing yourself and not as easy to jog without pushing yourself. In addition, when jogging, you have the added resistance of gravity, which is mostly eliminated in the water. To lose weight, we recommend 30-60 minutes of moderate to vigorous exercise six days per week. That means you need to elevate your heart rate to 70-80 percent of your maximum heart rate (220-age=maximum heart rate, so if you are 40, 80 percent of your maximum is 144 beats per minute). The other thing you can do in the pool is learn how to swim better, using more muscles and thereby increasing your workload. Depending on how good of a swimmer you are, you may want to consider a few lessons. Also, vary your workout routine. Try other strokes to improve the workout. Swimming is great for you and your muscles, but you might need to work a little harder and smarter to get the results you want. Also, consider cross training.
Dear HOUSE Calls, In what ways do you see the use of technology in your everyday practice as being a benefit or barrier to your ability to do your job?
The most important way technology facilitates medical practice is by enhancing communication. We have better access than ever before to new information and to records such as documents from hospitals and medical consultations. Our patients increasingly have better access to information about their health from their personal physicians and from the Internet. Technology opens up new channels of communication. This is mostly good. However, not all communication is good communication, and it is important not to use technology to supplant face-to-face communication, but rather to enhance it. Like wise, not all information that we read is good information, and the increased access to information has increased the importance of sorting good information from bad information. Some people also worry that doctors now bury their noses in computers during visits. We feel like those same doctors were likely to bury their noses in charts, so this is probably not a new issue, just a variation on an old issue.


Heart Attacks from Sex & Snake Bites

House Calls from the Carrboro Citizen 01.05.12

Dear HOUSE Calls, I read that there is an increased risk of heart attack with sex. People have sex more often when they are in a new relationship, so does this lead to an increased risk of heart attack?
This is a really interesting question, and thanks for raising the issue of sexual health. This is really important, and sometimes difficult to bring up. We read the report from the Journal of the American Medical Association too. Any increase in physical activity from what you are used to (jogging, gardening, sex, etc.) can increase the risk of heart attack. If you think of sex as exercise, the first few times you have sex after a period of abstinence may present an increased risk of heart attack. But as you “get back into shape,” your risk declines to average. Also remember that while the risk is real, it is small. According to this study, 10,000 people would have to have sex weekly for one year for one or two additional cases of sudden cardiac death. Also, there are a variety of things you can do to reduce your risk, such as quitting smoking; making sure your cholesterol, blood sugar and blood pressure are under control; and taking aspirin. Talk to your doctor about ways to reduce your risk of heart disease. Addressing sexual health is so important to your overall health; we hope you’ll consider talking about this with your doctor. One problem we have is effectively addressing sexual health in patients after a heart attack. Failure to talk about this can lead to fear and depression.
Dear HOUSE Calls, I do a lot of gardening and I hate wearing long, heavy jeans and boots, but I’m worried about snakes in the garden. What happens if I get bitten by a small snake? Do I need to kill the snake, or just be concerned with getting to the hospital?
First of all, wear the boots and pants. Snakes are important for our ecosystem and our gardens. Venomous snakes are rare in the Piedmont. Snakes are much more afraid of us than we are of them, so if you notice a snake, calmly step away. If you get bit, try to stay away from the snake and don’t try to catch it, because it’s likely to bite you again. Maybe snap a picture with your cell phone or have somebody else try to do so. But most importantly, get away. Make whatever observations you can about the snake’s pattern and head shape. Do not elevate the effected limb. Do not try to cut on the puncture sites and/or suck out the venom. Do not apply a tourniquet. Do get to the emergency room. In most cases, driving or being driven is fine. We hope you succeed at avoiding the snakes.

House Calls – Finding Medical Information on the Web & Nail Shellac

House Calls from the Carrboro Citizen 12.29.11

Dear HOUSE Calls, When I have a question about my health, I often type it into Google but so many results pop up. How do I know which ones to trust?
The first thing you should ask is, “Who is providing this information, and why?” There are many parties with commercial interest in health care. That does not mean information put on the web by a party with commercial interest is bad, but simply that you should understand that interest. Unfortunately, the absence of commercial interest does not mean the information is unbiased or high quality. One approach we like is to find long-standing patient-run chat rooms on major Internet search engines and observe, ask questions and find out where other patients have found reliable information. Don’t ever jump on the first piece of advice or information you get, but observe the dialogue for a bit. Another approach is to ask your doctor about recommended websites particular to the condition you are facing. Some doctors have regular websites they trust and send patients to, like their specialty’s organization website. The downside here is that because the information is high quality and reviewed, there may be less of it and it may not be updated often enough. The last advice we have on this is that if it seems too good to be true, it probably is. We live in a time of unprecedented information access, and we all must learn to be good consumers of information.
Dear HOUSE Calls, I’m wondering about this new shellac that is used in nail salons. Is there any health downside?
Shellac is a new type of manicure that lasts longer and requires lots of steps. It requires you to put your hands under UV light multiple times. Because this is new, we don’t know what the long-term health effects may be. We are cautious about this because of the repeated exposure to UV light. We know that increasing UV radiation increases a person’s risk of skin cancer. This stuff is very hard to remove (which is part of the allure), but that means that as your nails start to grow out or if you want to change color, you need to have your nails soaked in 99 percent acetone and wrapped. This process may be damaging to nails and nail beds. So, the jury is still out.

House Calls – Losing a Few Pounds & Hearing Aids with Pacemakers

House Calls from the Carrboro Citizien 12.22.11

Dear HOUSE Calls, I am a 60-year-old woman in good health; I eat well, exercise regularly and drink in moderation. How can I lose the five to 10 pounds I have picked up over the last few years? It is really frustrating.
You are already doing many good things for your health. As you age, your metabolism declines, so if you have the same diet and exercise habits now as you did 20 years ago, you will likely gain a little weight. You have two choices – eat less or move more. Portion control is key for eating less and is the great lesson of diet programs like Weight Watchers. You can also try writing down what you eat to see what you can learn from it and where you can cut calories. Also think about your glycemic load. Foods high in simple carbohydrates (processed flour, sugar, potatoes) will tend to make you hungrier than foods higher in protein, fat and fiber. Consider cutting beverages with calories (fruit juices, sweet tea, soda and alcohol). The other part of this equation is exercise. Can you add a workout or two each week or increase the duration of your workout? We encourage at least 30 minutes of moderate to vigorous exercise six times per week. Now if you are pressed for time, intensity is the other important part of this equation. Are you getting your heart rate up to 70-80 percent of your age-predicted maximum (112-128 beats per minute)? Can you add higher-intensity intervals to get as much as you can out of your workout? Consider a visit or two with a nutritionist and a personal trainer to tailor your diet and exercise program.
Dear HOUSE Calls, I have a hearing aid and was told that I have it too close to a pacemaker and it might be dangerous. Is this really a problem?
Hearing aids often have a warning that you are not supposed to use them with a pacemaker. This is probably pretty safe. Some studies show that with a remote-style pacemaker, if the transmitter is within 1 inch of the pacemaker, it may interfere with the hearing aid but not the pacemaker. Many manufacturers recommend that you keep the transmitter 4 or more inches from a pacemaker to avoid a theoretical risk of interfering with the pacemaker. Similarly, iPhones should be 6 inches from a pacemaker. Even though this is probably quite safe, it seems like a small inconvenience to keep the transmitter out of your shirt pocket.