Tales from the hospital newborn rounds with medical students…What do we screen for?

Posted on October 9, 2018 by drlesliegreenberg

newborn

Tales from the hospital newborn rounds with medical students… What do we screen for?

Oh, my life as a physician and medical educator.  I have a new crop of green third-year medical students.  They have just spent two years studying books.  Now, they get to see patients and do what most of them have been dreaming about for years.

I am the “newborn attending physician” this week and am tasked to see new babies at the local hospitals.  The medical students, most of whom are not parents themselves, are bright and eager to learn about babies.  One question that they brought up is…

Which newborn screenings are recommended and why?

  1. Congenital heart defects.  To screen for this we measure the oxygen saturation in the newborn’s blood with a probe (that looks like a light on a bandaid) at 24 hours of age.  If this is abnormal, an ultrasound of the heart (an echocardiogram) is done to see if there are structural cardiac problems.
  2. Genetic and metabolic disorders.  A heel-stick blood draw is done after 24 hours of age to test the newborn’s ability to break down milk proteins and other genetic abnormalities.  This is done by the State lab and Nevada asks for two “newborn screens”:  one done at 24 hours of age and one at 2 weeks of age.
  3. Hearing impairment.  This is done by screening for the auditory brainstem response wherein a hospital technician does a non-invasive test on a hopefully sleeping or calm infant.  (It is done this way as newborns will not raise their hand when a sound is heard.)  Sometimes, the initial screen is abnormal (most commonly due to fluid in the ears) and is repeated a few weeks later.  If still abnormal, then an audiologist is consulted.
  4. Hyperbilirubinemia (jaundice).  A transcutaneous bilirubin level is obtained by putting a non-invasive light on the newborn’s upper chest to read how much bilirubin is in the skin.  If this is elevated, then a venous sample is obtained.  If this is high, then the newborn is placed under blue lights called “bili lights.”  This is to help the bilirubin from crossing the blood-brain barrier and causing brain damage.

I hope this helps….newborn

 

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Reno: Free Family Estate Planning Series

Posted on September 12, 2018 by drlesliegreenberg

Reno: Free Family Estate Planning Series

 

2018 Family Estate Planning Series

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Marijuana and adolescents…

Posted on September 10, 2018 by drlesliegreenberg

Marijuana and adolescents…  I live in Nevada and it is now legal to use marijuana for both recreational and medical use.

How prevalent is marijuana use? 5.4% of 8th graders, 14% of 10th graders and 22% of 12th graders have used marijuana at least once in the past month.  Marijuana is second most-used substance after alcohol for adolescents.

Adults may view marijuana use as benign or not harmful, but there are major concerns about use in adolescents.  Regular or heavy or daily use of marijuana can lead to adverse medial, mental, psychosocial and cognitive outcomes.  Brain maturation is not complete until the mid-20s.  Negative outcomes can include

  • delayed reaction time,
  • impaired motor coordination,
  • higher rates of serious or fatal motor vehicle crashes,
  • poor work and school performance,
  • increased school dropout rates,
  • and anxiety.
  • Those with a predisposition to schizophrenia can have their first episode of hallucination associated with marijuana-use.

What is the risk of chronic marijuana use?  It increases the younger that marijuana is started.  Those adolescents who use marijuana daily, the risk of long-term use is 25-50%.  Whereas there is a 9% regular use in those who experiment with it.

There is a lack of regulation by the US Food and Drug Administration regarding marijuana…  so purity, THC (tetrahydrocannabinol) concentration and CBD (cannabidiol) concentrations are different with each batch.  Also, the method for which it is ingested changes its effect: eaten, drank, topical administration, vaped or smoked.  The concentration of THC (the psychoactive substance in marijuana plant) has increased greatly over the years: 4% in 1995 to 12% in 2014.

Talk with your children about the dangers of marijuana use.  Consider stopping yourself.   Ask your physician for help.

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Should you as an ex-smoker have a CT scan to rule out lung cancer?

Posted on September 3, 2018 by drlesliegreenberg

Should you as an ex-smoker have a CT scan to rule out lung cancer?  This is a great question.

A few years ago the National Lung Screening Trial found a reduction in disease-specific and all-cause mortality with lung cancer screening.  THEN the Canadian Task Force on Preventive Health Care AND the U.S Preventive Services Task Force voted in favor of a low-dose lung CT scan in those aged 55-80 who have a 30-pack/year smoking history (like one pack a day for 30 years) and currently smoke or have quit within the past 15 years.  So, we physicians, have been ordering low-dose lung CT scans on appropriate patients.

What were the results?  In a small group of Veterans Health Administration patients, it was found that 97.5% of patients who were told they had an abnormal lung CT DID NOT have lung cancer.

Where does this leave us?  The patient and physician should have a discussion about the risks of a false-positive result (a concerning lung CT with subsequent negative work up) and other harms such as radiation exposure, over-

Big C

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diagnosis and incidental non-lung-cancer findings.

Talk to your doctor.  Make a plan.

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Pregnant women, should you ask for skin staples or stitches with a C-section?

Posted on August 27, 2018 by drlesliegreenberg

Pregnant women, should you ask for skin staples or stitches with a C-section?  A meta-analysis (combined multiple studies) with 2300 patients looked at complication rate or infection, separation, hematomas (blood collections under the skin surface) and cosmetic result.

All 10 studies included showed that the staples group had an increased risk of wound complications compared with the sutures group.  Otherwise, the cosmetic result between the two groups was comparable at 8 weeks postpartum, but at 12 months postpartum the suture group had a better looking scar per observer scores (and similar-resulting scar per the patient themselves).

Want more information?  Journal of Maternal and  Fetal Neonatal Medicine 2016:29 (22) 3.   pages 3705-3711.

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Getting squeezed by health insurance premiums?

Posted on August 22, 2018 by drlesliegreenberg

Getting squeezed by health insurance premiums? Is your insurance covering less? Charging more premiums? More in copays?

You have options!

Consider direct primary care! Here’s a fascinating Bloomberg article. Cobble together coverage that works for you.

https://www.bloomberg.com/news/features/2018-08-22/priced-out-of-health-insurance-americans-rig-their-own-safety-nets

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Men, do you know your cholesterol level?

Posted on August 20, 2018 by drlesliegreenberg

Men, do you know your cholesterol level?  There was a recent lipid (cholesterol) guideline released by the American College of Cardiology/American Heart Association which showed that men with a low-density lipoprotein (LDL) component of cholesterol of at least 190 benefit from starting a statin drug.  The study showed a clinically and statistically significant reduction (!!) in cardiovascular events (meaning heart attack and stroke) in those who took a statin daily.  Additionally, it is also thought that all-cause mortality is decreased in these men after starting on a statin drug.

Want more specifics?  This study enrolled men 45 to 64 years of age with an LDL level of at least 155.  They randomized them to either receive pravastatin 40 mg or a sugar pill (placebo).  There was a 20 year follow-up.  There was a consistent  25% relative reduction in cardiac events with the use of statins for those with an initial LDL of 190 or more.  This study excluded men with a known vascular disease, meaning this study was studying how well did statins work for primary prevention of cardiovascular disease.

Want even more information?  Look up Analyses from the WOSCOPS (West of Scotland Coronary Prevention Study).

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Antibiotic prescribing is rampant at urgent care and retail clinics. Does this surprise anyone?!

Posted on August 13, 2018 by drlesliegreenberg

Antibiotic prescribing is rampant at urgent care and retail clinics.  Does this surprise anyone?

JAMA Internal Medicine recently published a study including 2.7 million urgent care visits, 48,000 retail clinic visits, 4.8 million emergency department visits and 148.5 million medical office visits. Read this…. there are a sufficient number of patient visits to extrapolate antibiotic prescription habits in different locales.

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In the study, antibiotic prescriptions are linked to 39% of urgent care and 36.4 of retail clinics.  This contrasts with 13.8% of emergency department visits and 7.1% of medical offices.

For suspected viral respiratory illnesses which antibiotic use is inappropriate, antibiotic prescriptions were given at 45.7% of urgent care visits whereas emergency departments gave antibiotics 24.5% of the time.  Medical offices gave antibiotics 17% of the time and 14.4% of retail clinic visits.

The risk is that antibiotic over-prescription may cause antibiotic resistance.  This is important when a patient truly has a bacterial infection.  You would like antibiotics to work when INDEED you need it.

Your best care is given by a physician who knows you, who you trust.  Secure a primary care physician and cultivate a relationship.  Your healthcare would be more individualized, with better follow up.

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Breastfeeding linked with reduction in diabetes…

Posted on August 6, 2018 by drlesliegreenberg

Breastfeeding linked with reduction in diabetes…

This is not new news, as my children are now teenagers…and this was known then. What is new is the percentage DROP in incidence of diabetes in mothers who breastfed per JAMA Internal Medicine.

The Coronary Artery Risk Development Studying Young Adults (CARDIA) study followed 1,238 women aged 18-30 for 30 years.  Their blood sugar was tested over the course of the study.  Women who had breastfed for at least 12 months had a 47% (!!!) lower relative risk of developing diabetes during the ensuing 30 years compared to those mothers who did not breastfeed.

Did the study take into account other factors?  Yes!  They adjusted for race, number of pregnancies, physical activity, weight change, and gestational diabetes status.

What if you breastfeed for 6-12 months there was a 48% reduction in the risk of diabetes and those who breastfed for 6 months, there was a 25% reduced risk of diabetes.

What if you have gestational diabetes (high blood sugars during the pregnancy that doesn’t occur when not pregnant)?  If the mother did not breastfeed, she has a 2.08% higher risk of diabetes per YEAR compared with women who breastfed for at least 12 months.

Why is this?  It is thought that lactating women have lower circulating glucose both when fasting and after eating.  These women also have lower insulin secretion and 50 grams of glucose per 24 hours is diverted into the breast to help make milk.

How many women breastfeed?  It is estimated that 55% of women breastfeed at 6 months and 33% breastfeed at one year.

What do you need to breastfeed?  You need breasts (any size will work), patience, support, and the desire to breastfeed.  There are some women who do not make milk… but you will never know until you try.  I urge women to dedicatedly breastfeed for the newborn’s first 2 weeks of life with professional lactation support, if needed.  This support is offered through the hospital they delivered at or with outside breastfeeding organizations like La Leche.  Do these steps before deciding that she does not make milk.  The mother can always supplement with formula to help give the newborn the nutrition needed.

Want more information? doi:10.1001/jamainternmed.2017.7978

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One more form of birth control “bites the dust.”

Posted on July 30, 2018 by drlesliegreenberg

One more form of birth control “bites the dust.”  Which one?  What was its history? Why?

The Bayer company is taking Essure off the market.  Essure was marketed as a nonsurgical alternative to “tying tubes.”  Instead of a surgical tubal ligation, done in the operating room under anesthesia, Essure is a small, flexible metal coil that fits into each fallopian tube.  The insertion requires the Essure to be placed through the cervix, into the endometrial (uterine) cavity, and then a coil is placed into each of the right and left fallopian tubes.  The ensuing inflammation causes permanent scarring within 3 months of insertion…so that the blockade will not let egg and sperm meet.

The device has had a troubled past.  The FDA placed a black box warning on the Essure warning physicians and patients about the risk of device migration, allergic reaction, pain, and implant perforation.  This credible warning caused a sales drop of 70% of Essure.  Not surprising, right?!

So, Bayer has decided to discontinue the sale of Essure.  The FDA has vowed to “remain vigilant” to protect women who have already had the device implanted.  Device removal also has risks.  If you have Essure implanted and have no problems, no further investigation is needed.  If you have Essure implanted and have pain or other problems, see your physician.

I hope this helps.  See anatomy below… pretty cool, huh?!

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