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Yahoo Released Its Best Hospital...
Yahoo just released its current report: Best Hospitals (in the U.S.) 2010-11: the Honor Roll. There were no surprises although I believe I could find another 14 hospitals equally good. The list includes John Hopkins, Mayo Clinic- Rochester, Mass General, Cleveland Clinic and others; and much as I see the logic in this list I also see the perverse irrationality in its construction. For instance: why does Yahoo publish this? Is it an interesting item that sells advertising? Is it a public service? Since there are only 3 hospitals in the West (2 in Calfornia and 1 in seattle) and 2 in the Midwest, and the rest are on the east coast, am I to believe that people are going to travel coast to coast to go to a best hospital? More important, who takes these evaluations seriously? The reality is these hospitals are the site of origin of many of the clinical studies in the United States and cultivate much of the innovative brain power in medical care. Yet only 1 in 4 Americans with cancer will consent to enter a clinical study and less than 20% of women with breast cancer do so. The reality is these university health systems have partnerships with community hospitals that are laced with financial incentives and the university systems would not impugn the reputation of any clinical hospital for fear of economic reprisal. And another reality is that there is economic competition between community based physicians and university based physicians and it is not in the economic interest of community based physicians to promote the services of the university health system. Then there is the issue of unaffordable health care and a health care bill passed by the Obama administration that ignores the main causes of runaway health care costs and rewards the beneficiaries of the system. I am referring to the health insurance companies and the trial lawyers who lobby through the trial lawyer associations and its many euphemistic marketing organizations. It cannot go unnoticed that both Barack Obama and Hillary Clinton are attorneys and have supported the heavy contributors to their election campaigns (I bring in Clinton since she was Obama’s main competitor for the Democratic nomination). Ultimately it is my judgment that the awarding of kudos to what are in fact excellent centers of medical care are just so many marketing ploys to promote the interests of marketing companies (i.e. Yahoo) and political interests. I sense that it is unlikely that we will either address the real issues of disparity in the availability of superior health care or address the issues of educating a poorly informed public as to their more rational choices in times of serious illness.
By Edward Lack on 2010.07.25
Liposuction is Safe and Effective
Sometimes it’s good to reflect on where we have been and where are we now. Sometimes it even leads to where are we going, but for this blog that will have to wait another day. I have practiced liposculpture since 1992 so I have seen the fads and the promises and the disappointments and mostly I have seen an incredible evolution in body contouring. For what must be first and foremost, the procedure is safe when performed by well trained surgeons in certified surgical centers. Blood loss has been all but eliminated and pain has been minimized. Most cases can be done using local anesthesia and recovery time has been minimized. Virtually all patients can walk 4-8 miles per day the morning after surgery if they could walk 4-8 miles per day before surgery. A decade ago total body liposculpture meant one procedure to sculpt the abdomen, waist, back, and hips and another procedure to sculpt the circumference of the thighs. Today liposculpture can be performed on the face, neck, breasts, abdomen, waist, back, thighs, legs, and ankles. Fat can be transferred from one part of the body and used to make the face more youthful or enhance the fullness of the buttocks. A decade ago our notions of what constituted an ideal body appearance was grandiose and existed only in the mind of the beholder because there were no criteria for what a normal body looked like or how people with different body types could achieve their ideal form. Today we know that it is the musculoskeletal appearance which dictates body shape and the purpose of body sculpting is to show that as best as possible. A decade ago we understood that removing fat would cause skin to retract but we didn’t know how to enhance it. One of the banes of the procedure was loose or hanging skin after a procedure and while we haven’t completely solved the problem laser lipolysis has greatly improved results in addition to shortening healing time. So now we have liposculpting for women and liposculpting for men. We have laser lipolysis known as smartlipo and coollipo, and slimlipo among others to enhance skin appearance. We have circumferential liposculpting for thighs and torsos, and liposuction for breast reduction for men and women. Stove-pipe legs and ankles can be shaped and sagging arms tightened. Perhaps my one concern is that so much liposculpting is performed in non-accredited surgical centers and so many by doctors who are board certified but not cosmetic surgeons who are appropriately trained dermatologic surgeons, plastic surgeons, facial plastic surgeons, oculoplastic surgeons, general surgeons, oral-maxillofacial surgeons, and gynecologic surgeons. While price certainly matters the disillusionment in patients I see who have had surgery done at some of these locations is disturbing. Most puzzling are how many patients go to medi-spas as a result of internet advertising despite the fact that they don’t know who their doctor is much less have a relationship with him. I guess for a fogey like myself it is a product of the IT age and I will have to keep my concerns to share with patients who already agree with me. In the meantime, the technology is here for safe, reproducible, and efficient body sculpting and for that I am grateful.
By Edward Lack on 2010.07.15
You probably need Vitamin D
As my friend and mentor on Mad Money, Jim Cramer, likes to say: When the facts change, change your position. It is so easy to make fun of experts after they stake out a position that is tenuous at best, even when they are your colleagues. So it was when I took out my pen-cudgel and attacked the bandwagon proponents of Vitamin D. You know who they are. They are the doctors who have you come in repeatedly for the same blood tests, give you medicines which are natural and homeopathic and of course which are good for you. They are the doctors who use baby talk as when they refer to “your tummy” or listen to your heart and take blood pressure through your clothes and who interrupt you as your describe your symptoms (oops, did I do that?). They are doctors who rationalize that placebos are actually good for you because they do no harm. So here I am indignantly self-righteous, proclaiming truths and pithing the parochial platitudes of self indulgent monoliths of medicine. Thus it was that I took out my sword and slayed the dragons who proselytized the universal good of Vitamin D. Indeed they would have you believe it cures everything from cancer to depression to arthritis, to gout. It can be bought over the counter or with a prescription and in doses from 400 units to 50,000 units and damned if anyone knows where it came from or how it works but we all need to take it and for sure follow it with repeat blood tests. Yet now I am taking vitamin D and I can tell you I am swallowing a lot more than a little capsule with each morning dose. So maybe if I give you a little information I can expiate some of my guilt and still maintain my peacock airs: Previtamin D comes from cholesterol. Yes, the same cholesterol you are paying your doctor to reduce. It is converted to vitamin D in the skin. It has been linked to heart disease and to diabetes and there are a host of other diseases which have been implicated. I am struck by the first two. I am also struck by the fact that Vitamin D concentration diminishes with age and most especially by a reduction in exposure to sunlight. So here is the kicker. The darker skinned a person is the more likely he will have vitamin D deficiency. And by extension if you are an adult (chronologically) and a city dweller you have up to a 70% chance of being deficient in Vitamin D after the age of 40; worse if you are African American. One last point: sun screens may reduce the ability to form Vitamin D. For all my readers in Miami you are stuck between a rock and a hard place. But listen up Chicago: we are lucky if the sun shines 4 months a year! It is OK to lighten up on the sunscreen during the winter and other cloudy months. So there you have it. I took a friend’s advice and measured my own Vitamin D and I am really deficient. I took my friend’s advice and began with large doses of Vitamin D3 (the stuff we normally make) and then followed it with repeat blood tests and as my levels headed toward normal I switched to the exogenous or externally produced forms. I would worry about my forthcoming guilt but I think I am developing Alzheimer’s and I will forget my embarrassment by tomorrow. For those of you living in the city and over 40 years old, it may not be a bad idea to have your doctor draw vitamin D levels. But never tell him that it was I that suggested it.
By Edward Lack on 2010.06.29
To Evaluate Your Appearance, Really...
A person cannot live without seeing with his eyes. A blind person is also a person but if you are not seen you are nothing. Per Olov Enquist My appreciation to my wife for translating this beautiful piece of prose from her native Swedish. As you can “see” seeing with your physical eyes is not the subject of this man’s observation. Seeing with your heart and mind is. I am torn between the emotions of Father’s Day, the emotions of my Swedish wife and friends on the day after the wedding of the Swedish princess, and the consternation of some of my patients' who do not appreciate their reflection in the mirror. For Father’s Day: I am struck at the perceptions I keep with me as I reflect on life with my father. I remember now how he would pull the car off the road on vacation and take the time to say “Look how beautiful that tree is”. I had no idea what he was talking about. Now it is I who pull off the road. When he spoke of every man being equal he had never heard of The Tea Party or envisioned Arizona, embattled with crime, unemployment, and a housing crisis passing a law to discriminate against one ethnic group. And he loved to travel and visit people with other customs and other heritage. I didn’t know I would marry my lovely Swedish wife and she would introduce me to cultures and customs I only vaguely appreciated. As to the wedding of the Princess: I have no feelings. But I finally grasped how we took the Kennedy’s into our hearts, how Barbara Bush taught us family values, and how I enjoy seeing President Obama’s children grow up. I cannot relate to the Princess but I value the tears of joy my wife sheds for a nostalgic connection. Now for the mirror. I have clichéd the lies of the mirror portrayed in Cinderella for years, yet the cliché’s do not go away. Most of us would not drape a child in make-up, revealing clothes, high heels, or hair spray; nor would we cover their beautiful faces with coiffured hair, or piercings through every orifice imaginable. Yet time after time I see people do this who see something odious, something distasteful, something shameful in the mirror. Rather than enhancing their image they vilify their appearance. All of this in an attempt to be seen. To be valued. To be important to others and secondarily to themselves. For me, we can each do ourselves a favor. Pull your hair back off your face; lose the make-up and jewelry for a day; lose the earphones, the cell phones, and the music; go for a long walk; smell the smells of nature; and be grateful that we are alive and some of God’s beautiful creatures.
By Edward Lack on 2010.06.20
Stretch Marks, Wrinkled Skin, Scars,...
For the last decade fads and bogus claims have promised to remove or reduce stretch marks, wrinkled skin, scars, and cellulite without actual proof. These money-making schemes have brought riches to some entrepreneurs and little pleasure to patients who have opted to have a variety of creams, potions, and treatments applied to their faces, bodies, and especially thighs. At last the wait may now be over as effective treatments have been elucidated to improve and in some cases resolve these age-old cosmetic concerns. Pioneering research from the University of Michigan Department Of Dermatology has revealed some of the answers to questions of how to regenerate skin. While more research needs to be done, their work conclusively demonstrates that old or damaged skin has frayed collagen fibers which do not stimulate fibroblasts (the cells that produce collagen) to do their jobs efficiently. In fact, just the opposite. The frayed fibers somehow induce the fibroblasts to curl up and produce collagenase which further dissolves the good collagen that exists. The therapeutic pearl of their work demonstrates that fibroblasts can be made to stretch out and again produce normal collagen, even if they are old in age or worn out by injury. The only caveat is that the fibroblasts must still be present in the affected tissue. First described in Europe and now elucidated at the U of Michigan, injected hyaluronic acid (aka Restylane and Juvaderm) has been repeatedly shown to stretch fibroblasts and thereby induce them to produce new collagen. Therefore, the rejuvenating effects of injected hyaluronic acid fillers are not only due to their volume but also to new collagen production. Saline was also tested for its stretching abilities at the U of Michigan and it was found to be less effective than hyaluronic acid. Nevertheless, work by Dr Mitchell Goldman and repeated by me at MetropolitanMD, has repeatedly demonstrated scar remodeling when used to stretch scars in which there has been a loss of tissue volume. And for the coup de gras, further work showed that injury to the epidermis, the outer 1 millimeter of skin, sends a message to the dermis, the bulk of the skin, to stimulate fibroblasts to make new collagen. Now we understand a mechanism for the healing effects of ablative fractional laser therapy. Here is the skinny: Stretch marks, wrinkled skin, scars, and cellulite are now treatable using a combination of salt water injections, hyaluronic acid injections and fractional laser resurfacing. The bad news: as this information hits the mass media medispa charlatans and entrepreneurial physicians will advertise their ability to use these new applications of available technology and because of the nature of their business the public will again be abused.
By Edward Lack on 2010.06.12
There is no Team in...
Peter (not his real name) developed a red spot on the tip of his nose 2 years ago. He is now 16 years old. Last week the spots became more red and formed 2 blisters. His mother took him to a board certified plastic surgeon. The surgeon told the mother he didn’t know what the lesion was but that he could cut it out. He advised them Peter would be left with a permanent scar on his nose. A 30 year old man told me every time he sees his dermatologist the doctor removes a mole from his body. A mother told me her dermatologist removed 6 moles at 6 different times from her 16 year old son. The moles were said to be “suspicious”. The moles were all benign! A man came to me and said he had a lesion removed from his face. The doctor told him the biopsy showed “it was nothing”!! A patient with arthritis was seeing a rheumatologist. He saw her monthly and did repeat blood tests each month which showed no change in her condition. The chief of orthopedic surgery at one of our Chicago university hospitals billed a patient for a complete physical exam while she was in the hospital. He never saw her! A patient went to a plastic surgeon asking for help with her neck. He did not comment on the anatomic abnormality which caused her neck appearance or on the obvious bone erosion of her chin due to a 35 year old chin implant. He offered to raise her eyebrows and do a facelift. (I raised my eyebrows too.) An allergist did repeat series of allergic skin tests in a patient with eczema. The patient cleared in 2 weeks with a prescription for antihistamine. The stories go on and the conclusions are the same. Many patients experience inaccurate diagnoses and needless care at the hands of medical specialists. The reasons are numerous and include the fact that payments are higher for performing a procedure instead of using diagnostic skills; reduced reimbursements lead to doctors spending less time with patients; failure of any effective oversight for medical care. Yet the most overlooked cause may be the patient. Last week I did an informal survey of 10 consecutive patients. I asked each if they had seen a primary care doctor in the past 3 years. None had done so! In fact most did not even have a primary care doctor. Patients are self-referring to specialists, which raises the cost of medical care and deprives a patient of the managing expertise a primary care doctor brings. Most of us doctors spend little time in hospitals and because of that we rarely see each other. We certainly don’t talk to each other about our care for a mutual patient or whether our treatments conflict with one another. We don’t discuss what is best for the patient. This is the role of a primary care doctor. The patient who thinks the specialist is smarter than the primary care doctor is cheating himself. He exposes himself to abuse of possibly less ethical or less concerned specialists. He not only gets poor care, he deprives himself of the opportunity to get proper care. The team concept simply doesn’t work without a manager. Following my own advice I made an appointment to see my primary care doctor today. I suggest you do as well.
By Edward Lack on 2010.05.25
The Many Sizes and Shapes...
Baldness comes in various shapes and sizes, but when it appears on a woman’s head it is always bad. The problem is of such magnitude that doctors vacillate between dismissing female hair loss complaints and ordering a battery of tests they have little idea what to do with. An organized approach to the problem is necessary. In many cases hair loss can be slowed or stopped and in some cases it can be reversed. Compounding the problem is that baldness now affects women from age 20 to death. Clearly, younger women are losing hair and losing it in greater quantities than in the past, and this has led to more cosmeceuticals and outright irrational remedies for a vexing problem. In addition dermatologists are making diagnoses of hair loss that do not hold up to rational examination. Perhaps over simplistic, the most common examples of female pattern baldness can be understood in 3 categories, of which there are several subcategories. The most common cause of hair loss is called female pattern baldness or Ludwig’s female patterned hair loss. Most commonly women aged 50-80 present with these complaints however it is more and more commonly presenting in younger women. The hallmark of the process is the maintenance of the frontal hairline, although it may thin. In male pattern baldness the frontal hairline disappears or shrinks. Not so with women. Hair loss tends to be diffuse although most noticeable on the top of the head. Initial complaints range from “my part is getting wider” to “I can see my scalp” to “I am shedding hair everywhere”. Traditionally this is considered a form of genetic hair loss, a pre-programmed event in which cell death of the hair follicle precedes death of the individual. It is often called androgenetic alopecia even though blood tests for androgens, male hormones, are universally normal and the hair loss pattern is completely different from men. In questioning some of the leading authorities in the country I cannot get them to explain why they use this term. The second most common form of female hair loss is called telogen effluvium. Hair growth goes through cycles: growing, regressing, and resting. The resting part of the cycle is called telogen and typically up to 20% of the scalp hair is resting at any one time. However, when a greater percentage of hair goes into a resting phase at the same time the hair begins to shed more than the normal 100-200 hairs per day and scalp hair appears less dense. Most often this occurs after pregnancy but other causes such as general anesthesia, trauma, infection, and medicines can cause this. The prognosis is excellent and hair growth normally resumes in 9 months as most of the hair will be restored. The third category involves nutritional deficiency or hormonal abnormalities. Iron deficiency is known to cause hair loss and since many women have heavy menstrual periods with borderline or frank anemia and low iron levels it is one of the first tests ordered by dermatologists. Disease states characterized by hormone abnormalities are unusual but a known cause of female pattern baldness. Polycystic ovary disease (PCOS) and adrenogenital hyperplasia are diseases of the ovaries and adrenal glands respectively and are characterized by associations with masculine changes such as deeper voice, bearded face, and acne. Not uncommonly patients with over or underactive thyroid glands lose hair but often doctors know about their thyroid disease before the hair loss becomes a problem. I have purposely left out diseases of the scalp since these patients complain of changes in their scalp as well as problems of hair loss. These patients also tend not to present with diffuse hair loss and maintenance of their frontal hairline. While not an article on remedies, this blog is an attempt to make some sense of the frustration many women experience as they go from doctor to doctor in search of answers for their hair loss. As with all medical problems a history, physical examination, and sometimes a biopsy is necessary to make a diagnosis and from this rational treatments can be prescribed. A rational understanding as well as a realistic approach to hair loss are necessary if treatment is to be effective and if patients are to avoid the plethora of fake treatments available to grow hair.
By Edward Lack on 2010.05.17
Is Your Community Hospital Worth...
Jim lies in a hospital bed clinging to life as I write this blog. Ten months ago he was diagnosed with severe mitral valve disease and advised to have surgery. Jim declined. As his health deteriorated he could no longer put off surgery. He had a choice of going to a community hospital or to a university hospital. He wanted to stay near home so he chose to stay in the community. The morning after surgery as Jim lay in the cardiac intensive care unit he complained of vague chest pain. He complained several times until his nurse said ” Now, Jim, You have just had open heart surgery. You should have chest pain.” Six hours later his right lung collapsed. Several hours later the left. Then kidney function deteriorated. Now he clings to his life. Kyle needed surgery for cancer of the esophagus. The cancer was limited but Kyle was obese and not in good shape. I told him that if he went to a community hospital he had a 25% chance of dying from the surgery vs. only 1% risk of mortality at a university setting. Kyle wanted to stay in the community to be near his wife. Kyle declined to be operated on at a university hospital in Chicago. Six hours after surgery Kyle’s kidneys began to fail. Three days later he was dead. The evil secret that no one wants to say is that community hospitals cannot provide the post operative support for major surgery that a university hospital can provide. An excellent surgeon can do his job to the best of anyone’s ability, but life and death hangs in the balance of the post operative care unit. Another evil secret is that affiliations of community hospitals with university hospitals are economic alliances and do not bring the level of care of the community hospital up to the level of the university center. The trauma of a life threatening disease is difficult at best and emotionally traumatizing. It makes little sense that the welfare of a patient is left to the economic survival of a local hospital or the medical staff of a community center. Decisions like these should not be at the whim of emotions of a confused and traumatized family. The only solution is to have centers of excellence where such difficult surgeries can be most safely performed. In fact, we have the centers and we have the statistics to prove them. What we also have is a politically dominated system that cares more for the economics and welfare of local politicians and health care systems than for the welfare of a patient. Every patient needs to read the book “How Doctors Think” by Dr. Jerome Groopman. Do this before you need to make a decision. Do it before someone has to write a blog about a person close to you.
By Edward Lack on 2010.04.27
The Problems Women Have With...
Hair presents a conundrum of conflicting problems to women. On the one hand they are troubled by loss of hair, any hair at any time. The presumption is that hair is flattering, youthful, and aggrandizing. At the opposite end of the spectrum women obsess about what to do with hair when they have it. Used incorrectly, as it is often worn by women, it works to their disadvantage (a bald man can write this with impunity since he has no hair-ax to grind) . I will ignore the nascent attempts at creativity by young women since this is the time in their lives for experimenting with all sorts of presentations to the world. However, adult women should have completed their experiments and should have learned something about the message that hair styles produce. I will try to list the most obvious hair styles women use to their disadvantage: The Samson Neurosis- Long attributed to men the Samson neurosis implies that the longer one’s hair is worn the more strength (and youth?) it gives to the wearer. When I see hair down the back my first thought is the woman is identifying with a horse and the more it is flaunted the more ridiculous it looks. Older women trying to look young: ring a bell with anyone? Add 20 years to your appearance. Bangs – Bangs cover the forehead. They create a lowered frame for the face and project a tiny face from the wearer. Also an up-tight, taciturn look. Tiny is cute in a child, it has no place projecting maturity and vivacity in an adult. Add 14 years to one’s appearance and a complementary membership the DAR. The Mata Hari Look - Hair worn forward covering the cheeks. This is the best look for narrowing the face beyond that which nature has already produced with time and is a non-verbal sign for “aging”. It is also a good sign for reduced self-esteem since it shrinks the face to its minimum and advertises “I am hiding”. In this it does have a relation to youth who hide their hands within their sleeves, and their faces within their hoods. Looking young and timid may be appropriate for children; it is not in an adult. Given these misconceptions and possible delusions, try pushing your hair behind your ears, exposing your forehead, and wearing hair no longer than shoulder length. Unless, of course, you are opposed to looking your youthful best.
By Edward Lack on 2010.04.09
Facial Rejuvenation For the Thin...
Pan-facial atrophy. The 21st century word for the aging face. As fat and bone, muscle, and skin whither, the face shrinks and wrinkles. Most important, the face looks older. To my regret Google Tyra Banks and Sandra Bullock. What a shame these 2 lovely ladies don’t understand the gestalt they communicate with their newly minted gaunt appearance. It seems strange that in a country where our primary health problem is obesity, a new generation of women and some men seek to enhance their appearance with an asthenic appearance. Pan-facial atrophy, the whithered aging face, is a natural product of aging and is enhanced when adults do not maintain adequate body weight to support their skin envelope. For people with normal body weight the best solution is fat transfer from a more robust area of the body such as abdomen or hips to the depleted cosmetic units of the face: the temples, the cheeks, the mouth, and in front of the ears. However, it is not uncommon to see patients who have normal to low body fat and aging withered faces, for whom gaining weight is not a psychological option. The answer for them is Sculptra, poly-L-lactic acid. Poly-L-lactic acid is a synthetic particulate which can be produced as minute fibers that can be suspended in salt water and then injected under the skin. Once injected, this alpha-hydroxy acid acts as a biostimulant to induce collagen production in both fat and skin. There is some consideration in Europe that when layered over bone the collagen may cover the bone and in some way add to its bulk. Regardless, the new collagen restores depth to the subcutaneous layers and, when properly distributed, restores normal contours to the aging face. Like previous fillers, hyaluronic acid (Restylane, Juvaderm) and collagen, poly-L lactic acid is naturally metabolized in tissue and presents no harmful foreign tissue. Unlike these other fillers the Sculptra fiber does not provide the bulk needed to restore normal contour but rather induces our own body to generate tissue needed to restore shape. Sculptra is not a new product and was successfully used 10 years ago to treat the facial ravages of HIV patients who had been treated with antiviral agents. It was quickly recognized that it had great potential for treating cosmetic patients. Unfortunately, the dilutions that were recommended and used were too concentrated and they induced unsightly nodules in some patient’s skin. There are numerous, probably exaggerated, horror stories on the web of patients treated with Sculptra. Now however, following reports by Dr. Rebecca Fitzgerald of some 2000 patient interventions treated at UCLA and by Dr Neil Sadick of some 1000 patient interventions in New York City, it is recognized that this is a very safe product when diluted and injected correctly. To protect the public the company, Dermik Sanofi-Aventis, has stipulated that it will not sell its products to medispas or non-board certified cosmetic and plastic surgeons. This is the first practical use of a group of compounds which will be developed over the next decade that will reverse the stigma of an aging face by inducing the human body to regenerate tissue that was lost through aging and/or a low caloric lifestyle. We have implemented the Sculptra program at MetropolitanMD and Drs Rachel, Franco and I anticipate it quickly becoming the gold standard in facial rejuvenation. For patients who do not want to undergo a fat transfer procedure or who do not wish to gain weight, this is a most significant break-though in preventing and reversing facial aging.
By Edward Lack on 2010.03.31
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