Last night in the ICU

We brought his family into a separate room with plenty of chairs. Sitting to the right of his father and mother, our attending uttered the first words in the room.

“I think you know what I am about to say.”

His mother took in a deep sigh, her eyes already swollen from inconsolable tears.

“I think he is dead.”

The whole room sank. We were all punched in the gut by those words.

“Oh my God….” his mother cried out, sinking her face in her husband’s shoulder as she was being told that her worst nightmare was her current reality—her 29 year old son was dead.

His girlfriend stared blankly and silently at the wall with glassy eyes, kneading the hands of those next to her with her fingers, not moving or crying or saying a word. She had found him last night on the floor, blue, without a pulse. His parents said that “she kept him alive” for the past two years, “loving him unconditionally” as he struggled with addiction to narcotic pain pills (opioids).

His father was the first to try to address and tackle the death, asking about the logistics of where and when and what now. As we got up he buried his face in his hands and sobbed.

I stood against the wall next to my co-residents, on the 14th hour of a night shift in the intensive care unit, using all my inner strength to not cry.

Amidst a night of putting in central lines, diuresing patients to goal, and repleting patients’ electrolytes, the only moment I will likely remember vividly in 20 years is the moment my stomach sank when his mother learned that he was dead.

Earlier that night my intern and I met his parents and siblings as they sat around his hospital bed praying that he would return to them. Intubated and mechanically ventilated, his heart was still beating because it was receiving oxygen, and his body was still warm. His youthful skin and handsome face belied his morbid condition. His parents hugged and kissed his body and asked us what his chances were of recovery.

“His brain injury was very serious because his brain was without oxygen for a long time. In the morning we will do a test of whether he can breathe on his own, which will tell us if his brainstem is functioning.”

There was no mention of death. We left it at “we need to gather more information.” But all the while I felt that he was already gone.

“He’s a good boy” they said, “my protector,” said his sister. They described him as bright and caring. “But he had an unhappiness inside the past couple years” his mother said. “He got sick.” He had just gone to rehab and was looking forward to his 60 days sober milestone—which would have been today.

His parents found comfort in the idea that he would live on in others by donating his organs. Yet the only time his girlfriend spoke was to say, “I told him not to put that on his license.” “He would have loved to help someone else,” his brother replied.

There is no moral to this story. A man was alive yesterday and today he is dead, and I was there when his family heard the news. This happens somewhere in some way to someone every moment of every day.

The last time I wrote in this blog I wrote a long, dense post about what it means to be brain dead. I chose to play it safe by writing about what I know. About objective facts, things that are written somewhere, that are backed up by evidence. I have not written in a while because I have been busy being a medical resident; but also because I do not really want to write about objective facts. I want to write about my experiences in medicine, what I have seen and what has become ingrained in my mind and in my soul.

Every day in the hospital, I invariably walk through someone’s personal hell on earth. For the most part, nothing I do will pull them out of their inferno. At most I can crawl into that hole with them and, just for a moment, keep them company.

 

Brain Death and Basketball

In reference to the recent unfortunate events regarding basketball player Lamar Odom, I have heard many inconsistent reports, from declarations that he is “brain dead” to reports that he woke up and spoke. This got me to thinking about how brain death, death, cardiac arrest, and altered levels of consciousness are often inaccurately portrayed in the media, and I wanted to clarify a few misconceptions 

First of all, when someone is brain dead, they are, for all intents and purposes, dead. Death is defined as brain death and/or cardiopulmonary death. If Odom were brain dead, he could not wake up. If he really woke up, he was never brain dead. Brain death = legal and biological death. Brain death means that the person has no function in their cortex (upper brain, which produces consciousness) OR in their brainstem (the “rudimentary” brain, so to speak, which controls functions such as breathing). When someone is brain dead, their entire brain is permanently functionally damaged and can never return to a functioning state in any way.

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The way that we as doctors assess for brain function is first by clinical exam. First, we make sure to minimize factors confounding the exam (for example, turning off medications, or warming someone who had been hypothermic).

If someone is awake, alert, and conscious, they are demonstrating that they have at least some cortical (upper brain) function. When someone has altered levels of consciousness (for example, they are somnolent) The exam then aims to answer “how good is their cortical function?” — can they speak? Can they interact or express themselves in some way? Can they visually track? Can they follow simple commands?

People who are unconscious can sometimes have spontaneous movements (such as abnormal posturing), but they will not have purposeful movements or meaningful interaction with their surroundings.
When someone is unconscious, we want to see if they have some “lower brain,” or brainstem function. We start by examining cranial nerve reflexes. Cranial nerves are peripheral nerves that have their roots in the brainstem, and they control head and neck functions such as facial expressions, facial sensation, and pupil dilation and constriction. Reflexes mediated by cranial nerves include pupil constriction upon stimulation with light, blinking upon touching the cornea, and gagging when the back of the throat is stimulated (such as with a q-tip). Someone without brainstem function (i.e. a brain dead person, or equivalently a dead person) has fixed dilated pupils, will not react to stimulation of their corneas or throat, and cannot breath on their own, as the brainstem controls the respiratory drive.
What does it mean to “pull the plug” or remove “life support” from a brain dead person? Often, brain death is declared on a person who is intubated and on a ventilator—they have a tube (an endotracheal tube, named because of its position within the trachea) down their throats, and this tube is connected to a machine called a ventilator that moves air in and out of the lungs using positive pressure. The drive to breathe is located in the brainstem, so a brain dead person will not breathe on their own if the breathing tube is removed (if they are extubated). Once they experience respiratory arrest, their heart will soon stop beating and pumping because it is not being supplied with oxygen (the heart’s drive to beat is actually independent of the brain, but without oxygen the cardiac muscle will stop functioning). So, someone who has experience brain death will, inevitably, if left untouched by medical devices, swiftly experience cardiopulmonary death.

ventilator

Keeping a brain dead person on a ventilator is not “keeping someone alive”—it is oxygenating and perfusing a corpse. The medically appropriate next step after someone is declared brain dead is to extubate them within a reasonable amount of time (eg. sometimes a few hours to a day, to give the family time to process). There are situations, however, where a person is  NOT brain dead, but they are breathing with the help of a ventilator. Sometimes, based on the patient’s prior wishes, his or her durable power of attorney (often a spouse, a parent, an adult child) makes the decision to extubate them and let nature take its course.

Why does the heart keep pumping if the brain is dead? That is because the heart beats independently of the brain. The heart has its own pacemaker, and the heart will continue to function (if it is a viable organ) for as long as it continues to receive oxygen. A viable heart removed from the body would continue to pump if it received adequate tissue oxygenation. When a person dies naturally (i.e., when they are not intubated and on a ventilator), however, both brain death and cardiopulmonary death occur (the heart stops once breathing stops, and breathing stops once the brain dies. Sometimes, the heart dies first, and then the brain dies because it is not getting oxygenated blood flow).

Cardiac arrest occurs when your heart suddenly stops. Cardiac arrest is not the same as a “heart attack,” or myocardial infarction, which is when a coronary artery (vessel that brings oxygenated blood to the heart) gets blocked, such as by a clot that gets stuck in a plaque (plaques often form on vessels, narrowing of the vessel). A heart attack COULD lead to cardiac arrest, but there are several other events that can also cause a cardiac arrest. Also, the majority of heart attacks do not cause cardiac arrest.

Coronary artery anatomy
Coronary artery anatomy

Sometimes, however, a person can have serious brain damage and can be in a coma for days, but can still have brain function and a chance for some sort of meaningful recovery. I recently saw two patients around the same time who had experienced cardiac arrests. One died, and one is alive and interactive. Both received CPR at the scene, and both were brought to the hospital and their bodies were cooled (therapeutic hypothermia). Both were intubated and on ventilators, and unresponsive for several days. Bill had his eyes open, was at first not visually tracking, but was withdrawing to pain, and was moving his arms on the bed spontaneously. Tim was completely unawake, with eyes closed, not moving, not responding to pain; however, he did have cranial nerve reflexes. We did a test called somatosensory evoked potentials (SSEPs), which showed that Bill had some cortical activity, while Tim had only brainstem function. Neither was brain dead, but Tim had a very poor prognosis based on clinical exam and SSEP; Bill’s prognosis was at that point unclear. After a few days, however, Bill started tracking our faces with his eyes. He started following simple commands (at first, he would blink and shut his eyes on command. Next, he would squeeze hands on command. Then he became able to give a thumbs up, lift his legs). Soon Bill passed spontaneous breathing trials and he was extubated. He was very disoriented, not knowing where he was or what year it was, but he could verbalize, and he could tell me his name, his wife’s name, his hometown. Day after day, he continued to get better. He still has serious neurologic deficits, but he is awake and alive. Tim, on the other hand, did not get better. Each day, he looked the same as the day before. His family decided to extubate him, and he eventually passed.

Cardiac arrest is a serious event, and most who experience it die. However, like my patient Bill, there are some who do survive. However, most who survive a cardiac arrest are left with serious permanent neurologic deficits. Only a very small fraction, however, return to their baseline functioning. Someone might return to baseline–for example, if he or she were were young and healthy at baseline and received effective CPR right away.

How Your “Natural” Supplements Could Kill You.

Today during our “morbidity and mortality” lecture, we discussed a case of a woman who suffered a devastating stroke because she was taking naturopathic dietary supplements. She had a list of 70 different homeopathic supplements that she was taking, one of which contained thyroid hormone from animal organs. She presented to the hospital with a heart arrhythmia called atrial fibrillation as a result of the off the charts thyroid hormone levels in her body. Soon after arriving to the hospital she suffered a major stroke which left her permanently disabled (new-onset atrial fibrillation can put patients at risk of forming clots in the heart which can travel to the brain and cause ischemia, or inadequate blood supply, leading to cerebral infarction–commonly known as stroke).

Earlier this month I took care of a patient who died of metastatic breast cancer because she refused conventional treatment. She was diagnosed with breast cancer in her 40s, 7 years prior to her death. At that time, she had a very good chance of being cured with surgery and local radiation alone. However, she was a firm believer in naturopathic medicine, which essentially teaches that the body can heal itself, and she refused conventional or allopathic treatment. She was an educated person, and she had received a doctorate in a branch of alternative medicine. Eventually, her cancer became metastatic, infiltrating her liver, her bones, a diffusely throughout her tissues (known as “carcinomatosis”). She did agree to some chemotherapy towards the end of her life, but by that point it was too late. When I met her, she was bed bound, in severe pain all over her body, with chest tubes in place draining up to 2 liters per day of pleural fluid (fluid from around her lungs). The morning I met her I assisted her husband in draining her chest tubes, a task he meticulously completed every day. They were a very loving couple, speaking gently and kindly to each other in the most frustrating of circumstances, and she was a very sweet lady. After she died, after I left her room, I went somewhere private to cry. I had bonded with her. After some time passed, I also felt ashamed that she had died a preventable death. Somehow, we as allopathic doctors had failed her by not doing a good enough job of convincing her to allow us to treat her with evidence-based medicine. Maybe we hadn’t pushed hard enough, because we thought it was a losing battle.

Last week I met a patient with gastroesophageal reflux disease (GERD) who did not believe in taking medications and refused to take her Nexium (omeprazole, a proton pump inhibitor which decreases the acid content of the stomach). She experienced an uncomfortable feeling in the back of her throat after eating, and she was convinced that she had food allergies. A naturopathic doctor had diagnosed her with a whole slew of food allergies. In clinic, skin testing to the common food allergies, including the ones diagnosed by the naturopath, were all negative. The one treatment that would make her feel better was the proton pump inhibitor; however, due to misinformation and her mistrust of conventional or allopathic medicine, she would continue to feel lousy.

In medical school I took care of a patient who went into liver failure because she was taking Herbalife. Here, a local police officer lost his job because he was taking a weight loss supplement that contained amphetamines.

There are countless stories like this. In the US, about half of the adult population uses dietary supplements. The US Food and Drug Administration (FDA) defines dietary supplements as “vitamins, minerals, herbs or other botanicals… amino acids, enzymes, organ tissues, glandulars, and metabolites… extracts or concentrates” and may be found in many forms such as “tablets, capsules, softgels, gelcaps, liquids, or powders.” Dietary supplements are a $34 billion per year industry. These supplements are marketed as “natural” and they are sold at “health food stores,” GNC, Whole Foods, etc.

The reality is that dietary supplements are not categorized by the FDA in the same way that drugs made by pharmaceutical companies are, and thus they are not held to the same rigid standards and regulations. Dietary supplements do not even need approval from the FDA before they are marketed to consumers. Under current law, the responsibility of monitoring safety and effectiveness falls not on the government, but on the manufacturer. In other words, I can bottle a concoction of sugar and rosehips and write on the label that my product cures cancer, diabetes, and heart disease, and the government will not stop me.

Though regulations were created in 2007 to “ensure the identity, purity, quality, strength and composition” of supplement products (in other words, to make it more likely that the bottle labeled as Vitamin C actually contains Vitamin C), the government does NOT enforce these regulations. Straight from FDA.gov: “Unlike drug products that must be proven safe and effective for their intended use before marketing, there are no provisions in the law for FDA to ‘approve’ dietary supplements for safety or effectiveness before they reach the consumer.” Under the DSHEA law signed in 1994 by President Clinton, dietary supplements are regulated retroactively; manufacturers are supposed to report adverse effects of their products to the FDA. In other words, the onus of regulating supplements falls on the manufacturers of these products, who have a vested interest in selling them and making money.

Furthermore, the dosing is completely unregulated. As mentioned on FDA.gov’s Q&A section, “Other than the manufacturer’s responsibility to ensure safety, there are no rules that limit a serving size or the amount of a nutrient in any form of dietary supplements. This decision is made by the manufacturer and does not require FDA review or approval.” A supplement may contain very high levels of a compound, or they can contain such a minimal amount that a person would have to take thousands of pills to have any kind of effect.

Many supplements are manufactured abroad, and often contain dangerous contaminants, including lead.

There is one reason alone to take vitamins or supplements: when your allopathic healthcare provider (board-certified MD or DO, or ARNP/PA working under the supervision of one) prescribes it. Notable examples include

  • When you have certain types of anemia that require supplementation with Vitamin B12, Folic acid, and/or iron.
  • When you have been diagnosed with Vitamin D insufficiency or deficiency
  • When you are trying to become pregnant, and prenatal vitamins are prescribed.
  • Or when studies have otherwise shown that taking that supplement is 1) safe and 2) effective in treating your problem.

Why is there a demand for dietary supplements? Now, this is just my personal conjecture… But perhaps we buy supplements because, in spite of the best evidence-based conventional medicine, people still get sick and die every day. The big bad pharmaceutical companies have big bad reputations, and conventional doctors make mistakes every day that hurt and kill people (“iatrogenic” events). We place unreasonably high expectations on medicine, and by proxy on doctors, to be perfect and Godly, Almighty Fathers and Mothers who keep us safe and take away our ailments. And conventional medicine very often fails to accomplish either. So, in rebellion, or perhaps with our last ounce of hope, we buy magical potions sold with impossible promises. Because we need to believe that something will fix us. Because illness is scary. Because death is scary.

My suggestions to the reader are:

  1. Know what you are ingesting.
  2. Do not waste money on products that are at best ineffective, and at worst dangerous.
  3. Put your faith in scientific evidence, not in false promises.

[PS This post is in no way implying that all alternative and complementary practices are harmful. The stipulation is that they be evidence-based–meditation and other stress-relieving techniques, for example, have some proven benefits. Otherwise, that they be low-risk and have subjective benefits–for example, massage therapy makes me feel great. In any case, alternative and complementary practices are not adequate substitutes for conventional medical therapy. The purpose of this post is to make the point that certain active compounds found in dietary supplements can be very harmful.]

PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology

Hello, blogosphere. In light of changes with Marketplace insurance plans (i.e. Affordable Care Act, or “Obamacare,” plans), the purpose of today’s post will be to define all of the terminology commonly used regarding health insurance.

I will be using a fictional family, the Waytes, for illustration purposes. The Waytes family consists of husband Bill, wife Sandra, and young children Timmy and Susie.

Healthcare Provider (or Provider): your physician (medical doctor, MD or DO), nurse practitioner (NP), physician assistant (PA), podiatrist (DPM), or other similar professional who provides you with medical care.

Primary Care Provider (PCP) vs. Specialist: A PCP is a physician or other provider who is your “main” doctor or provider. He or she is a generalist and can evaluate and address most of your healthcare needs. When you have a more complex health issue, your PCP will refer you to a specialist, who is more extensively trained in a particular field.

  • Sandra and Bill regularly go to see their PCP, Dr. Garcia, an MD who is board-certified in family practice. She performs their annual wellness exams, coordinates immunizations, manages Bill’s hypertension, and prescribes antibiotics for Sandra when she has a UTI. Sometimes, however, Dr. Garcia consults specialist providers for the Waytes’ care, for example referring Sandra to dermatologist for a funny-looking mole.

Referral: the directing of a patient to a medical specialist by a PCP or other provider, usually requiring documentation of such (eg. a paper slip signed by the provider). Some plans require you to have a referral from your PCP to see a specialist, while others do not.

Inpatient vs. Outpatient: you become an inpatient when you are admitted to the hospital. You are an outpatient at any other point, including while being seen in the emergency room before admission, and while having outpatient surgery (i.e. not spending the night in the hospital). If you go to see your PCP and then go home, you are an outpatient.

Coverage: when a bill is “covered” by the insurance, that means that it will be paid for by the insurance, after your deductible is met (see below for “deductible”).

Claim: a bill for medical services. The provider usually sends the claim directly to the insurance company.

Subscriber vs. Member: a subscriber is the policyholder (can be a person or an organization) whereas a member is anyone who is covered under the plan.

  • Sandra receives great insurance benefits from her job, so she signs up for a health insurance plan through her employer that will cover her spouse, Bill, and their dependent children. So Sandra would be the subscriber, and Sandra, Bill, and the kids would all be members. Alternatively, Sandra’s employer may be the subscriber, and she, Bill, and the kids still members.

In-Network vs. Out-of-Network: insurance plans make contracts with a wide range of providers, hospitals, labs, radiology facilities, and pharmacies in which they agree on special rates and assure a certain quality of care—these providers, hospitals, etc. are “in-network” with those insurance plans. All others are “out-of-network” and may charge higher rates. The member will have to pay whatever the difference with out-of-network costs (or, in the case of an HMO, the entire cost. See below).

PPO or an HMO? A preferred provider organization (PPO) plan allows more flexibility in choosing providers. With a PPO, a member can visit an out-of-network provider and still receive coverage. Staying in-network, however, provides more consistent coverage. A health maintenance organization (HMO) plan, on the other hand, is more restrictive and will only cover in-network providers.

  • Sandra thinks her insurance benefits are “really great,” so they are more likely a PPO than an HMO. She and Bill appreciate being able to see a wider range of providers.
  • PPOs are also known as Point-of-Service (POS) plans
  • HMOs are also known as Exclusive Provider Networks (EPOs)
  • HMOs will generally cover out-of-network care in the case of an emergency

Private vs. Hospital-based: when a provider has a private practice, claims will be sent to the insurance from his or her office (eg. The Office of Dr. Patel). When a provider is a hospital-employee and is seeing a patient at that hospital’s clinic, claims will usually be sent from that hospital (eg. Baxter Memorial Hospital).

  • This is relevant especially for HMO plans were the hospital might be in-network, but providers are not, so you can go see Dr. Patel when he staffs Baxter Memorial Hospital’s diabetes clinic, but you cannot see him in his private office.

What is a premium? This is what you pay every month in order to maintain your insurance coverage.

What is cost sharing? These are costs, other than your premium, that you will have to pay in order to use medical services. These cost sharing methods include deductibles, copays, and coinsurances (see below).

What is a deductible? This is the dollar amount of out-of-pocket expenses that your insurance requires that you pay before they will begin to pay for claims.

  • Sandra and Bill’s deductible is $500. That means that they will have to pay the first $500 of medical bills before their insurance will begin its regular coverage. So when Timmy falls and breaks his arm at the beginning of the year and goes to see an orthopedist in his private office for diagnosis (involving a consult, x-rays) and treatment (a cast), Sandra and Bill will have to pay the first $500 of bills before their insurance company starts to pay.

What is a copay? A copay is a fixed dollar amount that you pay every time you use a particular type of healthcare service.

  • Sandra has a $10 copay to see her PCP and a $25 copay to see a specialist. She has a $10 copay to fill a prescription for a generic drug and a $30 or $50 copay for a brand-name drug (depending on it’s “tier,” which is a category of price difference determined by the insurance company for drug coverage).

What is a coinsurance? This is the percentage of a medical bill that you will have to pay. Usually, an insurance company does not bill both a copay and a coinsurance for the same service, so it would apply to services outside of outpatient physician consults and drugs.

  • Sandra and Bill have a 20% coinsurance for lab tests, diagnostic imaging (i.e. x-rays, MRIs, CTs), and inpatient services. If little Susie is hospitalized for an asthma exacerbation, Bill and Sandra will have to pay for 20% of the bills, up to a certain maximum level.

What is an out-of-pocket maximum? The most you will ever have to pay out of pocket for deductible and coinsurance in a given year. Once this maximum is reached, the insurance company will pay 100% of the covered costs. This maximum does not include premiums, copays, or services that are not covered (eg. out-of-network services with an HMO plan).

The Patient Protection and Affordable Care Act (aka “Obamacare”, abbreviated here as ACA): a federal statue signed into law by President Obama in March 2010. The law expanded public and private insurance coverage and introduced mandates, subsidies, and health exchanges. The Supreme Court upheld the constitutionality of the ACA in June 2012, but held that states cannot be forced to participate in the ACA’s Medicaid expansion. As a result, changes vary by state.

  • Click for the full law
  • Nice video summarizing the ACA by the Kaiser Family Foundation

Some changes proposed by the ACA include: Read more “PCPs, PPOs, and Premiums: De-coding Health Insurance Terminology”

What is ALS?

Over the last few weeks, many of us have seen video after video of friends and celebrities taking on the “Ice Bucket Challenge” to benefit ALS research. So, what is ALS? And why does it need to be researched?

In a sentence: Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease for which there is currently no cure.

What it looks like clinically, and what’s causing it to look that way:

–ALS is “neurodegenerative” because “motor neurons,” or nerve cells that control movement, are damaged. Motor neurons are damaged because they accumulate a build-up of “inclusions,” or clumps of dysfunctional proteins, which cause the cell harm. These damaged neurons then cannot signal muscles to contract and release as they normally would. As a result, patients with ALS develop muscle weakness and, eventually, paralysis.

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–Loss of motor neurons eventually impairs the function of limbs, head and neck muscles, spinal muscles, and respiratory muscles. That means that, eventually, people with ALS will not be able to walk, speak, eat, or breathe.

–In ALS, the motor neurons in both the brain (“upper motor neurons”) and the brainstem and spinal cord (“lower motor neurons”) are affected. Signs of upper motor neuron involvement include increased reflexes, “spasticity” (increased muscle tone leading to muscle tightening), and lack of coordination. Signs of lower motor neuron include muscle atrophy and “fasciculations,” or muscle twitches.

8355_Lou-Gehrigs-Disease-Amyotrophic-lateral-sclerosis

–There are different variations of ALS where the initial symptoms and areas affected differ, and where additional symptoms such as dementia are present.

Who gets it? ALS most often affects people between ages 40 and 70, but can affect individuals in their 20s and 30s. Sometimes it runs in families, but most often people with ALS have no known affected family member. There are about 2 cases per 100,000 in the US population newly diagnosed each year (about 5,600 new cases per year). About 30,000 people in the US are currently living with ALS.

HawkingWWE

Left: baseball player Lou Gehrig (right) after whom the disease was named. Right: Professor Stephen Hawking, living with a form of ALS.

Is it life-threatening? Yes. Respiratory failure is the most common cause of death in ALS. The median survival from the time of diagnosis is three to five years.

What are the currently available treatment options? Though there is no cure, some treatment options modestly modify the disease. A drug called Riluzole which targets the pathway of the neurotransmitter glutamate is the only drug shown to impact survival, and even so only increases lifespan by months. Otherwise, patients must be given supportive care to assist them with functions of daily living.

What could we use in the future? There are several therapies being tested in animals and humans, and there are therapies that have been proposed for future trials including drugs, stem cell treatments, and gene therapy.

The aim of the ice bucket challenge is to raise money for ALS research by encouraging donations to the ALS organization.

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Benign Skin Growths and Spots

During my dermatology elective, I encountered countless patients who were concerned about growths on their skin that were, in fact, harmless and very common. There are thousands of lesions that can appear on the skin, but here I will discuss a few of of the most commonly seen benign skin spots and growths. I will also discuss what kind of changes to be cautious of when examining growths and moles. When in doubt, consult with your dermatologist.

Brown Spots

1.freckles-boy-flickr-NoSpareTime Freckles (“Ephelides”): these small, flat light-brown spots are small, multiple, and irregularly shaped. They appear in childhood, darken during the summer months, and lighten during the winter months (waxing and waning in response to sun exposure). They are due to a local, superficial accumulation of melanin, the protein the gives pigment to our skin and protects us from the sun. They are more common in lighter-skinned individuals who sunburn more easily. Sometimes these fade with age. The best way to avoid new freckles is by good sunprotection.

2. “Solar lentigos” (aka liver spots, age spots, or sun spots): these brown spots appear similar to freckles, but have sharper margins and sometimes stand alone. They can be found on the backs of hands, the shoulders, and the head and neck of adults. They are caused by sun damage acquired over time, but their appearance is persistent (they do not darken or lighten with the sun, or with time). They are due not only to a local accumulation of melanin, but also to a local increase in the cells that produce melanin (“melanocytes”). Some consider them to be flat versions of seborrheic keratoses (see below). Though not harmful, they can be treated for cosmetic reasons with freezing (“cryosurgery”), chemical peels, or certain lasers.

solar lentigos facesolarLentigo_53672_lg

3. Café-au-lait spots: these light-brown “macules” (flat, smaller than 0.5cm) and “patches” (flat, greater than 0.5cm) appear within the first year of life. They are due to a local increase in melanin. If a child has greater than 5 café-au-lait spots >1.5cm, they should be tested for syndromes such as neurofibromatosis.

cafe au lait infantcafe au lait

3. Junctional nevi: these darker brown, sharply bordered, flat lesions are a type of mole (“nevi” = mole). Moles have specific features under the microscope. They do not need to be removed unless there are features concerning for melanoma (see the ABCDE rules below). Removal is by cutting them out (“excision”); be mindful that excisions leave scars.

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*There are many types of flat and elevated moles. Some have more pigment, and some are skin-colored. We will discuss at the end how to monitor moles.

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Signs of Wisdom – seen more commonly in people age 30+

1. Seborrheic Keratoses (SKs): sometimes referred to as barnacles, these light tan to dark brown waxy growths appear to be “stuck on” to the skin, as if they could be peeled off with your fingernail. They have a rough, warty surface, and they can grow up to 1” (2.5cm) in width. SKs are caused by skin cells from the top layer of the epidermis (“keratinocytes” in the “stratum corneum”) sticking together. Some think they may be related to sun exposure. There is no need to remove these growths, as they are completely harmless, but if they become irritated or cosmetically undesirable, they can be removed by freezing (“cryotherapy”), burning with an electric current (“electrocautery”), or scraping.

seb kerseborrheic_keratoses_2_high

2. Skin Tags: these smooth, fleshy growths hang on to the skin by a little stalk. These are commonly acquired in areas of friction. Though they are harmless, if irritated or undesired they can be removed by snipping with scissors or freezing.

skin tag neckskin-tags-polyps-33

3. Cherry angiomas: the cherry-red raised round bumps (“papules”). They often start out flat and become dome-shaped. They are caused by an abnormal growth within capillaries, the smallest blood vessels. In the rare case that the patient desires removal, they can be burned off with electrocautery or zapped with a laser.

cherriescherry angiomas

Monitoring moles and other growths and spots:

One of the most important rules of thumb in screening for melanoma is the ugly duckling sign: spotting the mole or growth that does not look like the others. A lesion is often not concerning if you have others that look like it on your body.

Monitor your moles by following the ABCDEs. The most important of these is E – EVOLVING—if you notice any change in your moles, or any appearance of new moles, mention this to your dermatologist during your check-up. [*Make note that even benign moles can grow. Not all change is melanoma.]

A – ASYMMETRY: if your mole has become uneven or asymmetric, have it looked it.
B – BORDER: benign moles have nice, regular borders. Dangerous moles have irregular borders.
C – COLOR: benign moles usually have only one color. Dangerous moles can have two or more.
D – DIAMETER: benign moles are usually smaller than a pencil eraser (<6mm).
E – EVOLVING: changes in your moles or the appearance of new moles should prompt examination.

ABCDEs-1

Sunprotection

Summer is upon us, and that means fun in the sun!  Let’s remember to be safe and smart, taking measures to prevent sunburn in the short-term, and skin cancer, premature aging, and unsightly discoloration in the long-term.

AA sublocksunsmarties_cabana_tent

Everyone, regardless of skin tone, is susceptible to the harmful effects of the sun’s rays. People with lighter skin types who burn easily should be especially cautious.

Ultraviolent (UV) radiation (290 to 400 nm) causes skin damage. Within that spectrum, UVB (290 to 320 nm) is responsible for sunburn (“B” for “burn”), inflammation, skin discoloration, and cancer formation. UVA (320 to 400 nm) is responsible for photoaging (“A” for “aging”), skin darkening, and possibly cancer formation.

The UV Index, on a scale of 0-11, is a forecast of how risky the sun exposure is that day, and is calculated by zipcode here or here. Read this or this to learn how to interpret the UV index.

beach hat

To protect your skin against UV radiation:

A)   Avoid the sun during peak hours: stay inside or seek shade between 11 am and 3pm. This is especially important at latitudes closer to the equator.

B)   Wear sun protective clothing:

  1. Sunglasses: Look for lenses that block 99-100% of UV rays. UV rays can lead to eye damage including cataracts, macular degeneration, photokeratitis (“sunburn of the eye”). For more: Mayo Clinic, All About Vision.
  2. Hats: especially wide-brimmed.
  3. Long-sleeve garments: Fabrics are rated on their ultraviolent protection factor (UPF).

C)   Apply sunscreen: these contain filters that reflect or absorb UV rays. They fall into two categories: organic (aka chemical), or inorganic (aka physical).

kids under tent

Here are some tips for finding and using sunscreen:

1)   Look for “broad-spectrum” on the label: these protect against both UVB and UVA. Make sure it contains at least one of the following in the ingredients list: avobenzone, zinc oxide, or titanium dioxide.

2)   Look for SPF 15 or above, per the FDA (but better 30 or higher). When enough sunscreen is applied, SPF 15 will absorb about 93% of UV radiation; SP 30 will absorb 97%, and SPF 50 98%.

3)   Apply daily, even on a cloudy day. Keep your sunscreen of choice next to your toothbrush so you apply it as part of your morning routine.

4)   Look for cosmetics or lotions with SPF15+. Choosing a moisturizer or a foundation with SPF to use as your daily sunprotective product may help you stick with your sunscreen routine.

5)   Apply 15-30 minutes before going out in the sun. This allows a protective film to form on the skin.

6)   Apply sunscreen liberally before outdoor activities to all sun-exposed areas. For the average adult, this means applying 1 oz (30mL), or one shot glass full.

7)   Reapply often: at least every two hours when out in the sun. Reapply after swimming, water sports, or sweating.

8)   Look for water-resistant sunscreens for days you will be in the water. Continue to reapply, however, after each swim.

9)   If you have sensitive skin, inorganic or physical sunscreens may be best for you, as they are less irritating. These contain mineral compounds such as zinc oxide and/or titanium dioxide. These products are also preferred for use in children.

10) Find the form you are most likely to use. Sunscreens come in a variety of forms: creams (greasier, thicker), lotions (thinner), liquids, sprays, gels, roll-on sticks. Find the vehicle that works for you. The best sunscreen is the one that you will use.

Vitamin D: Some people are concerned that they will not produce enough 25-hydroxyvitamin D if they do not get enough sun. Vitamin D, however, is readily available in certain foods (milk, fortified juices, salmon) or in supplement form. Vitamin D insufficiency is a common problem, but the safest way to combat it is by taking a daily supplement.

Thanks for reading, and enjoy your summer!

-Alex

 More links: Consumer info on Sunscreens, Teacher Resources, SunSmart Australia

References:

Baron ED, Elmets CA, Corona R. Selection of sunscreen and sun-protective measures. UpToDate April 01, 2014. Accessed May 13, 2014.

Young AR, Tewari A, Dellavalle RP, Danzl DF, Corona R. Sunburn. UpToDate May 01, 2014. Accessed May 13, 2014.

HPV: Could It Happen To You?

This article was originally published by The Cornell Daily Sun on February 14, 2014. Some changes have been made to this version.

A 25 year-old woman comes to clinic for her routine Papanicolau (Pap) smear during my ob-gyn rotation. A few days later she receives a phone call from the gynecology resident. “Your Pap smear results were abnormal,” the doctor told her, “and we would like to take a biopsy of your cervix, which we do under an exam called a colposcopy.” She is told that this abnormality was caused by a strain of the human papillomavirus (HPV), the same virus family that causes common warts.

“HPV?” she asks, “isn’t that a sexually transmitted infection?”

“It is, in fact it is the most common STI in the US.”

“I didn’t think that I was at risk for HPV… I have not had many partners… and we almost always use protection… and I think maybe I was vaccinated… Does this mean I’m going to get cancer?”

The patient expressed a flurry of questions. She was quite surprised and distressed. She did not know that she could be among the 20 million Americans, male and female, aged 15-49 currently infected with HPV. Seventy-four percent of those infections occur in the 15-24 age group.

Nearly all sexually active people will become infected with one of the many strains of HPV at some point in their lives; half become infected within three years of becoming sexually active. Some strains are high-risk, or potentially cancer-causing, and some are low-risk, or wart-causing. Most HPV infections will not cause symptoms or problems, and they will become undetectable within 6-24 months. Among women with high-risk HPV infection of the cervix, the infection will be persistent in 10%, putting the patient at risk of developing dysplasia, or precancer, that, if left untreated, could progress to cancer. Cervical cancer is currently the third most common cancer in women, and 99.7% of cervical cancer is caused by HPV. Both males and females, regardless of sexual orientation, are susceptible to developing dysplasias and cancers of the anogenital region. HPV has also been associated with head and neck cancers and some skin cancers. Looking at cancer as a whole, approximately 5% of all cancers in men and 10% of all cancers in women are caused by HPV.

There is no cure for HPV infection. The best strategies are prevention and early detection. Vaccination with Gardasil or Cervarix can prevent infection with HPV types 16 and 18, which are responsible for 70% of cervical cancer. Gardasil also provides protection against HPV types 6 and 11 which cause anogenital warts. Gardasil has been approved for use in both females and males ages 9 to 26, and is ideally given before the start of sexual activity (i.e. before exposure to HPV), so it is commonly administered prepubertally (eg. age 11-12). Even if you are already sexually active, vaccination is recommended. On the other hand, even if you plan to abstain and become monogamous for life, if your partner has ever had another sexual partner, you could still be at risk for acquiring HPV. Furthermore, HPV can be transmitted by genital contact besides intercourse. Vaccination should be a consideration for all young people, because everyone who will eventually become sexually active will most likely be exposed to at least one strain of this ubiquitous virus.

Because vaccination does not cover all strains of HPV, regular Pap smears are recommended in women aged 21 and over regardless of vaccination status. With a Pap smear your doctor can collect a sample of cells from the cervix and upper vagina to analyze under the microscope. This test can detect precancerous cells, prompting further intervention in order to diagnose dysplasia and prevent the progression to cancer.

So, what are some ways to protect yourself against HPV?

1. Get vaccinated if you are under 26, regardless of gender, sexual orientation, and sexual activity. Then,

2. Get Pap smears regularly if you are a female, starting at age 21. Your doctor will let you know how frequently you should be screened. Currently most women with a negative Pap smear at age 21 only need screening once every three years.

3. Use condoms consistently. Condom use reduces the risk of HPV infection and disease progression. Condoms are not, however, a perfect protection against HPV. Condom use is important to prevent against other STIs including HIV and chlamydia, two infections that have serious consequences in their own right, and that make HPV more likely to remain persistent.

4. Consider your number of partners: HPV prevalence increases nearly linearly with increasing number of lifetime partners, despite condom use. Furthermore, infection with multiple high-risk HPV types increases the risk of high-grade precancerous lesions.

5. Don’t smoke: Smoking is a risk factor for persistent infections.

If, after taking appropriate precautions, you find yourself with an HPV-related concern as the patient described did, remember that:

1) You are not alone. The volume of patients seeking care for HPV-related concerns, particularly cervical dysplasia, is quite large. On my ob-gyn rotation, four afternoons per week were dedicated to cervical dysplasia: one to Pap smears and three to colposcopy. I have also seen patients presenting to dermatology for genital warts and for HPV-related skin cancers and precancers of the penis.

2) About 90% of infections become undetectable without further intervention. Therefore, your infection will most likely not remain persistent, and you will most likely not develop an HPV-related cancer. Make healthy choices for your body and mind, and live your life.

References:

 

Welcome!

Welcome to Medicine Simply, a blog that addresses your health questions. During my clinical rotations, I often observed a disconnect between what doctors understood about patients’ conditions and what knowledge patients took home with them. Doctors are fluent in “Medicalese,” or the specialized terminology of medicine, and they know where to find authoritative information. Patients, on the other hand, are not usually fluent in Medicalese, nor do they have access to those authoritative sources. During the time-limited patient encounter, medical professionals relay the most important information to patients in “Layspeak,” or layman’s terms. Often, however, patients seek more. Having accurate background information is helpful in equipping patients with the tools to participate fully in their care.  The intent of this blog is to help close the knowledge gap by providing information on health topics that affect a wide audience. The next post, for example, will be about the ever-prevalent HPV virus.

As a medical student, I have one foot in the land of Layspeak and another in the land of Medicalese. I would like to use my predicament to best suit you, the reader. If I traveled to a country whose language I did not speak fluently and whose system I was unfamiliar with, I would appreciate having a guide by my side assisting me on my voyage. In this blog, I will be your guide and translator on a number of health topics. 

I would like to hear what you are most interested in reading about. Please email me at medicinesimply@gmail.com, or leave comments on this post, with suggestions. To get updates on the blog, please “like” the Facebook page.

Disclaimer: These posts are my personal interpretation of the primary sources. My views do not represent those of any institution of higher learning or of any group. This blog is not in any way a substitute for your physician or other healthcare provider’s advice, diagnosis, treatment, or care and it does not intend to provide those. If you believe that you have a medical problem, contact your healthcare provider. If you believe that you have a medical emergency, call 911.

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