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Memory loss and dementia are among the healthcare problems that people fear the most. They are also among those that create the most significant challenges for families and caregivers, and often without the supports or resources to respond as fully as we would like. But knowledge is power and the more we understand the problem, the better prepared we will be to deal with it. So here are some basics.

What is dementia?

Most simply, it describes difficulty with reason, judgment, and memory. There are normal, age related changes that are not dementia (for example, occasionally forgetting a name or an appointment, requiring assistance with new technology, misplacing things) but it’s important to recognize when the problem may be more significant. There are 10 warning signs that can help you to know whether a memory problem or other intellectual decline should cause concern:

  1. Memory loss that disrupts daily life.
  2. Challenges in planning, or in solving problems.
  3. Difficulty completing familiar tasks.
  4. Confusion with time or place.
  5. Trouble understanding visual images.
  6. New problems with words in speaking or writing.
  7. Misplacing things and being unable to retrace steps.
  8. Poor judgment.
  9. Social withdrawal.
  10. Changes in mood or personality.

What causes dementia?

Alzheimer disease accounts for 60 to 80% of dementia. We know that this involves deposits of a substance called beta amyloids (known as plaques) in brain cells, and that there are also disordered protein fibers called neurofibrillary tangles. We do not know what causes these changes and we do not yet have effective treatment. There are medicines which can lead to minor and temporary improvements but they have significant potential side effects as well.

Other causes of dementia include poor circulation to the brain, Lewy Body Dementia, caused by another abnormal protein structure and often associated with symptoms of Parkinson’s Disease and with vivid hallucinations, Parkinson disease itself, and Pick’s Disease, usually occurring at an earlier age and often with speech and language impairment. Alcohol and repeated brain injuries can also lead to dementia. And it is always important to consider whether any medications a person is taking could be causing side effects which contribute to these symptoms.

Who is at risk for dementia?

The risk increases with aging. Dementia is rare before age 50 and common after age 80. Alzheimer disease tends to run in families, and a person with a parent or sibling with Alzheimers may have a 10 to 30% risk of developing it themselves. The family risk is higher if it developed at an earlier age. High blood pressure, smoking, and diabetes may play a role, particularly in the damage they cause to blood vessels.

What can I do?

It appears that staying physically active, socially connected and mentally engaged reduces the risk of dementia. Also, being alert to the symptoms and seeking evaluation early may be important.

www.alz.org has some very important resources, including a checklist for preparing for a visit with your doctor or primary care provider. It includes writing down details about changes in memory, prompts to identify important changes in memory and intellectual function, medication lists and questions to ask your doctor. It can be found here: http://www.alz.org/documents/national/ed_doc_checklist.pdf

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“Open Enrollment” for 2015, which is the time when you can sign up for health insurance and, if you qualify, get subsidy for the premiums, ends on February 15. With that deadline fast approaching you may want to consider the reasons you should consider getting coverage.

  1. You won’t have an opportunity to enroll after February 15. Many people believe that they can enroll once they may have a need for insurance, and while that may sometimes be the case, there is almost always a delay during which you remain uncovered and responsible for all costs incurred.
  2. You can protect yourself from financial devastation. Like car insurance, health insurance covers costs most of us could not possibly afford, and gambling on continued good health can result in huge financial losses. An unexpected illness or accident can lead to hundreds of thousands if dollars in expenses. This is one of the most common reasons that people have to file for bankruptcy.
  3. You can gain access to primary care and preventive care. Under the Affordable Care Act annual physical exams and important preventive care, such as age appropriate cancer screenings, are free, even if you have not yet met your deductible. And as primary care transforms to a more comprehensive approach, which often includes mental health services, oral health and care management, you can gain access to these important resources. This also assures access to appropriate follow up care if you do have an unexpected healthcare need.
  4. You may qualify for a subsidy! People who are not offered affordable health insurance through their employer qualify for subsidy if they earn between 100% and 250% of federal poverty level (FPL). For example, for a family of 4 this is an income range of $23,850 to $59,625. So if you are a family of 3 with one child and two adults, each 30 years old and neither of whom smokes, with a household income of $35,000, you could get a silver plan (very good coverage) for $154 per month (normal cost would be $776 per month). The FPL numbers can be found here: http://obamacarefacts.com/federal-poverty-level/ and this is a very helpful premium calculator from the Kaiser Family Foundation: http://kff.org/interactive/subsidy-calculator/
  5. There are options. If you are young and healthy and don’t qualify for subsidy, you may choose a catastrophic plan, to protect against devastating unexpected costs. There are also bronze plans, with higher deductibles in exchange for lower premiums.
  6. There is help! At PCHC we have Outreach and Enrollment specialists, whose sole job is to help you work through your options and choose the coverage that is right for you. You don’t have to be a PCHC patient – you can call 404-8080 to get more information. Additional help can be found at www.enroll207.com and at www.healthcare.gov .

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Well, it’s that time of year, isn’t it? An opportunity for a fresh start with a fresh year and many of us make resolutions aimed at our health and wellbeing. Our good intentions don’t always translate into sustained action, but perhaps prioritizing our health goals would help. What follows is based on a Facebook post from the Cleveland Clinic – I have listed the suggestions for healthy living in what I consider to be their order of importance and added comments on evidence behind the recommendations.

  1. If you smoke bend all of your will to quitting. There is no more impactful change you can make. On average smokers lose 10 years of life expectancy, largely due to heart and lung disease, a variety of cancers, stroke and inactivity. It often helps to think about or even list the reasons why you would like to quit smoking and to list the things that are preventing you from succeeding. It also helps to think about how ready you are to quit. If you have tried without success previously, keep at it! Most people who quit for good have tried multiple times before they kick the habit. And the day you quit your health can start to improve and the damage from smoking begins to reverse itself.
  2. Get moving. I have been impressed throughout my career that the seniors who are the happiest are those who have stayed physically active. I am not talking about running marathons or power lifting. Regular exercise (as in daily) for relatively short periods of time (as little as 30 minutes and it can be split up) has benefit for your heart, lungs, muscles and bones, and for your sense of wellbeing. Remember that it is good to push yourself – the harder the exercise the more benefit. But this should be done within reason and relative to the point from which you’re starting. Walking, exercise equipment, strength exercises, Yoga, Tai Chi, biking, whatever you enjoy is great. And remember that flexibility matters too!
  3. Eat well. A proper diet is critical to health and the majority of Americans tend to eat in very unhealthy ways. Avoid saturated fats, refined carbohydrates and sugars, trans fats, fast food and highly processed foods. In addition to contributing to high cholesterol, heart disease and vascular disease these foods cause inflammation in your body, which has all kinds of negative effects. On the other hand fruits, vegetables, grains, nuts, legumes and fish oils all reduce inflammation. Herbs and natural spices do as well, and they taste better!
  4. Get some sleep. Poor sleep contributes to inflammation and to a variety of chronic diseases. Good sleep is critical to natural restorative processes and to maintaining good physical and mental health. The chronic use of prescription medication is NOT the answer for sleep problems. These medicines do not increase restorative sleep and they cause all kinds of issues including falls, daytime drowsiness, depression, dependence and addiction. Diet plays a key role; more complex carbohydrates, lean protein, and unsaturated fats can help, as can exercise, yoga and good “sleep hygiene” (Google it!).
  5. Know your blood pressure and check it a few times a year, more often if you are being treated for high blood pressure. Home BP kits work pretty well and you may be able to use a friend or relative’s equipment. Or stop by your doctor’s office and ask for a BP check. Normal BP is below 140/90. High blood pressure contributes to heart disease, stroke, vascular disease and kidney disease and can usually be treated easily and effectively.
  6. Know your risk of heart disease. I think this is far more important than just knowing your cholesterol levels. Indeed, it helps you to make informed decisions about whether medicines for high cholesterol are likely to help you (“possibly” if you have a personal history of heart disease, “possibly” if you are at high risk for heart disease, “unlikely” if your risk is low). Here is a heart disease risk calculator: http://cvdrisk.nhlbi.nih.gov/
  7. Get to and maintain a healthy weight. Note that this is 7th on my list. I don’t want to minimize the importance of a healthy weight and if you are significantly overweight this goal should move up the list. But exercise, good sleep and a healthy diet all contribute to weight loss and for people who are mildly or modestly overweight but not obese these other six priorities are more important.

Best of luck in meeting your goals for the new year and happy 2015 to all!

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Over the last 25 years our approach to chronic pain has shifted dramatically. Beginning around 1990 and without science to support the approach, it was determined that chronic pain should be treated with opioid pain killers (commonly referred to as narcotics – medications like oxycodone, Oxycontin, morphine and Vicodin), that there was no unsafe dose and that the risk of addiction was very low.

These unsupported ideas arose largely from the companies making these drugs (and making a profit from them) and were promoted by some well-meaning experts who also happened to have a financial relationship with these companies and some corrupt experts. The result has been a 600% increase in opioid prescribing in the US since 1990, a 265% increase in prescription overdose deaths in men, a 400% increase in prescription overdose deaths in women, equally dramatic increases in treatment for “near miss” overdoses and for addiction to prescription opioids and no actual improvement in the function of people suffering from chronic pain. In fact we now know that the risk of addiction for people taking daily opioids for chronic pain is about 35% (not the less that 1% which was touted by the “experts” hired by the drug makers). And most importantly, on September 30 this year the Agency for Healthcare Research and Quality released a new document on Evidence Based Practice entitled “The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain”. Given the myriad problems associated with long term opioid use and Maine’s ongoing dubious distinction as a leader in high dose opioid prescribing this publication is timely in its release and its conclusions are powerful. It is a comprehensive review of the literature related to long-term opioid use for chronic pain performed by a panel of experts which include specialists in pain, epidemiology, occupational health, pharmacology, anesthesia, chronic disease, and pediatric pain.

Although the findings of this group are not new, the expertise of the authors and reviewers and the comprehensive nature of the review should lead to dramatic changes in our approaches to treating chronic pain. Two brief sections of this 200 plus page report are most telling. First, in a section entitled “Key Findings and Strength of Evidence” they state:

For effectiveness and comparative effectiveness, we identified no studies of long term opioid therapy in patients with chronic pain versus no opioid therapy or non-opioid therapies that evaluated outcomes at 1 year or longer. No studies examined how effectiveness varies based on various factors, including type of pain and patient characteristics…and no cohort studies on the effects of long-term opioid therapy versus no opioid therapy on outcomes related to pain, function or quality of life were found.

In other words there is no evidence of benefit from long-term opioids in the treatment of chronic pain. On the other hand the report lists the evidence related to abuse, addiction, and accidental overdose, and also listed evidence of increased risk of bone fractures and myocardial infarction (heart attack).

Finally, in their conclusions the authors state that, “Evidence on long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harms that appears to be dose dependent”. That is, the higher the dose the greater the risk of harm.

Health care providers and their teams must work to reduce opioid dosing for chronic pain. It is a challenging undertaking which requires energy, commitment, a unique skill set for which few of us have been trained, and it will require unwavering support from our colleague, co-workers and communities. As we move forward we will also need to improve our evaluation for, documentation of and treatment for diagnoses of addiction in a portion of this population of patients. It is not the easy thing to do, but it is the right thing to do for our patients, their families and our communities.

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The understandable concern about Ebola has raised public awareness of communicable diseases, especially viral illnesses, and some of the challenges in treating them. And while Ebola is a terrible disease and is causing devastation in Western Africa, it actually poses very little threat to citizens of the US. Politics, unrelenting media coverage and the devastating nature of the disease have fed some of the unwarranted fears across the country and, more recently, here in Maine.

Ironically we tend to have a laissez faire approach to the communicable viral illness which actually pose a significant threat here at home, some of which are completely preventable but have been given new life because of poor healthcare decision making among significant parts of our population. Let’s review just a few.

Influenza

Each year, on average, over 200,000 people will be hospitalized and over 30,000 people will die from influenza and its complications. The elderly are especially vulnerable but the very young and those with chronic diseases are more likely to succumb to influenza. It is a highly communicable disease which can largely be controlled through vaccinations and there are very few people who cannot receive the vaccination. There are dead virus vaccines (the shots), attenuated live virus vaccines (the nasal spray), and thimerisol free vaccines (although the safety of thimerisol as an antibacterial preservative is well established). Immunization is recommended for almost everyone over the age of 6 months and people age 2 to 49 who have healthy lungs can receive the nasal spray form of vaccine. In fact, the American Academy of Pediatrics is recommending the nasal spray for children age 2 to 8 who do not have asthma or other lung disease. Pregnant women should receive the injectable vaccine. Healthcare personnel have a special obligation to be immunized. Across the US less than 50% of healthcare personnel choose to be immunized and studies have shown that these personnel play a very important and costly role in transmitting the disease to vulnerable patients whom they serve. Alarmingly, generally healthy people can be infected with and spread influenza while having very limited or no symptoms. Universal immunization of healthcare personnel would go a long way toward reducing this risk.

Pertussis

More commonly known as Whooping Cough, pertussis is highly contagious and causes uncontrolled, violent coughing. It is especially troublesome in infants and children and in babies under the age of 1 it can be fatal. It can also cause very bothersome and persistent symptoms in adults. In the 1940’s, before pertussis vaccine was developed, this was a common disease. But the vaccine reduced the incidence of pertussis by more than 80%. However, beginning in the 1980s people began declining vaccination for their children and the disease is on the rise again, with over 27,000 cases reported in 2010 and a cases already reported in Maine this fall. We have also learned that the childhood pertussis vaccine requires and booster when we reach adulthood and this is now included as part of tetanus vaccine boosters.

Measles

When I was a child most children developed measles and were required to be quarantined until they were no longer infectious (I remember missing Thanksgiving when I was 5 because I was isolated in my room with the disease). Prior to the development of the measles vaccine in 1963 there were over 500,000 cases a year in the US and over 500 deaths from the disease. Measles was almost eradicated in this country until, again, people began refusing the vaccine for their children, this time due to concerns about the vaccine being linked with autism. In fact there was never any evidence of a link and the researcher who promoted the concept has since admitted that it was fraudulent. But the damage has been done. So far this year there have been 18 measles outbreaks in the US and over 500 cases.

 

We do have a viral disease success story. Polio was one of the most devastating diseases of the 20th century. An outbreak in the US in 1916 killed over 6000 people and left 27,000 people paralyzed. But a world wide effort has been undertaken to eradicate polio and through widespread polio immunization that effort is nearly complete. As recently as 1988 there were over 300,000 cases of polio worldwide. In 2013 there were only 407 cases, a 99% reduction in the incidence of the disease.

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Through much of my career the standard approach to contraception for adolescents had been to offer birth control pills and barrier methods (condoms). Intrauterine devices (IUD) were avoided because of concerns about their potential impact on future fertility. In the last decade or so progesterone injections, which offer protection for 3 months at a time, and contraceptive patches have added important options for young women. In the 1990s an implantable form of contraception was introduced. It was highly effective but it consisted of 7 thin capsules and implanting and removing took some time and skill.

All of these options are highly effective when properly used, but notwithstanding that fact almost half of the 6.7 million pregnancies in the US are unplanned and unintended. That proportion is even higher among teens and young women (in their 20s), in minority groups and in women with less education. Of those unplanned pregnancies, fully half occur in women using contraception (but using it ineffectively).

The emotional, social and financial impact of an unplanned pregnancy can be devastating and enduring, so measures to improve contraceptive effectiveness and to allow for emotional maturation, social and financial stabilization and intentional family planning are very important. Long Acting Reversible Contraception (LARC) is an important new approach to this challenge. LARC methods include IUDs (copper IUD good for 10 years of contraception and hormonal IUDs good for 5 years of contraception) and a new hormonal implant (a single thin capsule the size of a matchstick implanted under the skin of the upper arm and good for 3 years of contraception).   Well done studies have shown that LARC methods offer safe and more highly effective contraception for young women. Unplanned pregnancies are reduced by 40% compared to other contraceptive methods and by over 70% compared to the population of young women at large. In addition, when these methods are readily available and women understand all of their contraceptive options up to 75% will choose LARC.

There are two important barriers to the use of LARC:

  • Many teens (and some providers) think that a pap smear and pelvic exam are required as part of contraceptive management and this can be a deterrent to a young woman seeking care. In fact, pap smears are not recommended until age 21 and the other testing necessary as part of this process does not require a pelvic exam. Specifically, testing for sexually transmitted illnesses, which is recommended for sexually active young women, can be done on urine samples or on self-collected swabs.
  • Most primary care providers are not trained in the techniques for insertion of IUDs and implants and often, depending on insurance coverage, there can be delays in obtaining these devices. Providers and practices will need to commit to obtaining training and providing this service and payers will need to ensure ready access to the devices if we are to take advantage of these important benefits.

As with all forms of hormonal contraception, there is no protection from sexually transmitted illnesses so consistent use of condoms should still be recommended for young men and women.

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Last month I wrote about the kind of cancers for which adults of a certain age should consider regular screening examinations.  As part of that discussion I mentioned several forms of cancer for which there is no evidence of benefit from screening, and even some for which there is evidence of harm from screening!  This is often challenging concept for patients and providers.  For many years the common wisdom has been that all screening is good and more screening is better.  But that approach has, in fact, been harmful in some instances.  So let’s take a little closer look at two cancers that fit into this category.

Skin Cancer – It has traditionally been dogmatic that as part of an annual exam a thorough skin exam should be done to screen for skin cancer.  However, there is not evidence that regular full skin exams are useful in preventing or impacting serious skin cancers.  However, that is a different question than having people be aware of what a skin cancer may look like so that they can seek attention if they have concerning signs.  The most useful criteria are for melanoma, known as the “ABCDEs”.

  • A = Asymmetry – if the two halves of a mole do not match each other
  • B = Border – if the borders of a mole are irregular, scalloped or notched
  • C = Color – if there is more than one color to a mole
  • D = Diameter – a mole more than ¼ inch (6mm), which is the size of a pencil eraser
  • E = Evolving – a mole that is changing in shape, size or color over time.

It’s very important to note that these ABCDE characteristics do not mean that a mole is cancer.  In fact, a common benign mole called seborrheic keratosis can often meet all 5 of these criteria.  But the presence of one or more of these traits warrants a discussion with your health care provider.

Prostate Cancer – The PSA test is the poster child for harmful screening interventions.  Beginning in the early 1990s and for 20 year we screened aggressively for prostate cancer in this country, recommending an annual PSA blood test starting at age 50 (often younger if there was a family history) with biopsies if the test was elevated.  The result was a massive increase in the number of biopsies performed and an equally massive increase in the amount of prostate cancer being diagnosed.  This resulted in surgery (removal of the prostate), radiation therapy and other treatments, with all of the myriad side effects, the most important of which are incontinence and impotence in treated men.  In addition, the powerful emotional impact of telling someone that they have cancer takes a significant toll. The result of all of this diagnosis and treatment was zero impact on outcome – no improvement in survival from prostate cancer.  The reason for this is that prostate cancer cells, though often present in the prostate as men age, most often do not behave like cancer as we think of it.  The immune system may keep them under control for life or, once the disease causes symptoms, it is very treatable most of the time.  In a minority of cases prostate cancer is aggressive and fatal, and unfortunately, diagnosing these cases earlier has not led to improved outcomes.  There may someday be an effective screening test for prostate cancer, but the PSA is not that test and the strong recommendation right now is that men not undergo screening, even if there is a family history of prostate cancer.  And by the way, having a rectal exam also has no impact on finding and changing the course of prostate cancer (or colon cancer ofr that matter) – so it’s OK to “just say no”!

There are some very aggressive cancers with typically poor prognoses, like ovarian and pancreatic cancer, for which no effective screening test has been identified.  Women often feel that having an annual pelvic exam is part of ovarian cancer screening, but that is not effective.  And as I said last month, there is new evidence in the last several years that has caused the United States Preventive Services Task Force to begin the process for evaluating recommendations for screening thyroid cancer.

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Over the past weekend I had the pleasure of participating in EMMC’s Champion the Cure Challenge and like most families, mine has been profoundly impacted by cancer.  I lost my father to leukemia and a sister to breast cancer and I have two more sisters who have had breast cancer (one cured and one currently undergoing treatment).  It reminds me of how much this disease, or actually group of diseases, weighs on people’s minds.  It is not unusual for me to have a patient tell me that they would like to be tested for cancer and when I ask which kind, they respond, “all kinds”.  I wish we had a test that could detect and significantly impact all cancers, but because essentially all of the body’s cells have the potential to undergo cancerous changes, there is no single test.  Many cancers are thankfully extremely rare, and often the risk of cancer can be reduced by a healthy lifestyle (avoiding smoking, moderation in the use of alcohol, limiting sun exposure, a healthy diet, etc.).

But there is a partial answer to this common question.  Some of the more common forms of cancer can be more treatable if detected early by screening tests.  And one form is completely preventable (see cervical cancer below)!  So let’s run through what cancer screening tests you should consider, when you should start and how often you should be screened.  These recommendations come from the United States Preventive Services Task Force and are the guidelines most based in science and least influenced by those who may have a profit motive conflict of interest in making such recommendations.

Breast Cancer – mammograms are the cancer screening test that have the most public awareness.  It is also the most widely embraced cancer screening test, both by patients and providers of health care.  The current recommendation is for women to have a screening mammogram every other year between the ages of 50 and 74.   The UDSPSTF recommends that the decision to start mammograms before age 50 (the American Cancer Society recommends starting at age 40, for instance) should be individualized and based on a woman’s personal values regarding benefits (there are not good studies showing improved outcomes in women under age 50 or over age 75) and risks (cost, radiation, unnecessary worry, interventions, etc.).  The USPSTF also recommends against regular breast self examination because it has not been shown to change outcomes and may again lead to unnecessary tests and biopsies.  The USPSTF recognizes that science and knowledge advance over time and these guidelines are currently being reevaluated.

Cervical Cancer – this is the area of greatest success in cancer screening.  Prior to the invention of the pap smear cervical cancer was the #1 cancer killer of women and now it is quite uncommon.  We have also learned that certain strains of the Human Papilloma Virus (HPV) are the cause of most cervical cancers.  The USPSTF recommends screening women between the ages of 21 and 65 every 3 years with a pap smear.  Women aged 30 to 65 who wish to extend the screening interval to 5 years may do so by having both a pap smear and HPV testing (which is done on the same sample).  If both are normal a 5 year interval is safe and effective.  This is a dramatic departure from the time when I trained and we engrained in women that they needed to have a pap smear every year!  Another departure is the recommendation that pap smears should not be done under the age of 21 (mild abnormalities are common during this time, clear on their own and led to many unnecessary treatments in the past).  Women over age 65 who have not had past cervical abnormalities also no longer need to have pap smears because the disease is rare after that age.

Colon Cancer – Screening is recommended for adults aged 50 to 75 by one of three methods:  stool cards (which test for microscopic levels of blood in the stool) every year, colonoscopy every 10 years, or a combination of a sigmoidoscopy ( a much shorter version of a colonoscope) every 5 years and stool card testing every three years.  The guidelines recommend against screening routinely after the age of 75 because there is no evidence of benefit, and they recommend against any colon cancer screening after the age of 85 because of the potential harm paired with no benefit.  There is not yet enough evidence to make recommendations about CT colonography as a screening test.  Many patients have questions about what to do if there is a strong family history of colon cancer, especially at an early age.  This is best discussed with your primary care provider.  There are also some diseases, like ulcerative colitis and familial polyposis, which increase the risk of colon cancer and may require more aggressive screening.

Lung Cancer – this is a new recommendation as of 2013.  A low dose CT of the chest is recommended for adults aged 55 to 80 who meet the following two conditions:

  1. At least a 30 pack year history of smoking (this is calculated by the number of packs smoked per day multiplied by the number of years of smoking)
  2. Currently smoking or having quit less than 15 years prior

It is important to know that this recommendation has not been widely accepted.  Medicare has decided against paying for it and my own specialty grouop, the American Academy of Family Physicians, states that there is insufficient evidence t make this recommendation to patients.

Skin Cancer – there is not evidence that regular full skin exams are useful in preventing or impacting serious skin cancers, but it makes sense for people to be aware of worrisome signs and to seek consultation if they appear.  These signs are probably the topic for another discussion, but are readily available on line in a variety of places, including http://www.skincancer.org/skin-cancer-information/melanoma/melanoma-warning-signs-and-images .

Other Cancers – based on current evidence the USPSTF recommends against screening for testicular cancer, prostate cancer, ovarian cancer and pancreatic cancer and concludes that there is insufficient evidence to make a recommendation about screening for bladder cancer and oral cancers.  They are working on new recommendations for screening for thyroid cancer.  These recommendations against screening are often poorly understood by patients and providers and merit the time for in depth discussion when people have concerns about them.

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Since their inception in the early 1960’s, addressing disparities in healthcare has been at the core of the mission of FQHCs.  Through the ensuing decades, much of the approach has been aimed at access, as we have provided healthcare to all members of our communities, including the most needy and those with no health insurance coverage.  FQHCs have also addressed disparities in other, more dramatic ways.  The first FQHCs were employment centers, engaged in voter registration in the deep south, and provided care to entire populations who had previously been denied access due to their race or standing in society.

In Maine, we also have a tradition of addressing disparities.  Drs. Dan Hanley and Jack Wennberg undertook pioneering work to identify and address geographic disparities in health outcomes in Maine in the 1970s (arguably the first explicit attempt at population health).  The Hanley Center has built on that foundation, and organizations like Maine Quality Counts and Maine Health Access Foundation are national leaders in fundamentally addressing disparities in care and improving the infrastructure of health care delivery in order to create a more consistent baseline of quality.  And certainly here at PCHC a number of important initiatives have been undertaken which are largely aimed at supporting a high standard of quality and service (Patient Centered Medical Home accreditation, NCQA Quality recognition, Meaningful Use in some regards, etc.).

There is, however, some initial evidence that another contributor to disparities in health resides not in our systems or work processes, but in each of us.  Implicit Bias describes our individual, innate, sub-conscious tendencies to react to (and therefore to evaluate and treat) people differently based on their race, sexuality, appearance, gender, or financial standing.  Blair, et al published an important article outlining the challenges of this phenomenon in Permanente Journal in 2011. Whereas explicit bias involves a conscious decision to regard a group of people more negatively simply based on a characteristic (for example racism, homophobia, anti-Semitism), implicit bias is unintentional and unconscious.  It is the result of a life of exposure to certain attitudes or stereotypes, or cultural “norms” and it is activated quickly and unknowingly by cues such as skin color, accent, or appearance, and can impact our perception, behavior and even memory.  It follows that Implicit Bias may impact health care delivery and outcomes, and some initial studies indicate that it is likely the case.  Whereas explicit bias has been on a steep decline in the last 50 years, Blair and his colleagues state that Implicit Bias persists.  Since it is not part of conscious thought, Implicit Bias cannot be measured through standard questionnaires.  Harvard has developed an on line tool which measures response times to paired associations of positive and negative traits paired with contrasting characteristics (white and black, young and old, wealthy and poor, etc.) which helps to identify Implicit Bias.  You can try it here:  https://implicit.harvard.edu/implicit/ .

All of this raises important questions.  Can we quantify the effect of Implicit Bias on healthcare outcomes?  Can we accurately measure Implicit Bias and develop processes to counter its negative effect?  What can each of us do as an individual who cares about providing consistently good care?  I’ll try to address some of these questions in next month’s newsletter.  In the meantime, I welcome your feedback.

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Most Mainers eagerly await the summer months when we can enjoy great warm weather activities in one of the most beautiful sates in the country. Whether it’s sports, fishing, boating, cycling, running, walking, camping or just relaxing outdoors, it is an energizing and fulfilling time of the year.

Of course, nothing is perfect and summertime also offers some unique and sometimes annoying skin conditions. Fortunately, most are not serious and are self-limited and most respond to treatments, but prevention can limit the impact that these rashes have on your summer fun.

heat rashHeat Rash (Prickly Heat): In hot and humid weather, excessive sweating can clog your pores, which leads to inflammation and swelling under the skin. This results in a pimply rash, often in skin creases, under the arms, in the groin, or anywhere where it is more difficult for perspiration to evaporate. You can help to avoid this by wearing looser fitting clothing, keeping your skin clean, and if you are prone to heat rash, try to stay in cooler areas during very hot and humid weather. Heat rash can be treated with cool compresses, over the counter hydrocortisone cream (if there is itching), and anti-inflammatory medications (ibuprofen, naproxen) or acetaminophen if there is burning or pain associated with the rash.

 

poison ivyPoison Ivy: Poison Ivy is one of the skin rashes known as contact dermatitis. In the case of poison ivy, the plant contains chemicals to which some people are highly allergic (I’m one of those people!). Interestingly, there are also people who will get no reaction to poison ivy. After coming in contact with the plant, these chemicals may remain on your hands or under your fingernails for more than a day, and they can also remain on your clothing.  The allergic reaction results in the development of very itchy, tiny blisters (called vesicles) on the skin, often grouped together and sometimes in lines. The vesicles can coalesce to form a blister, and all can leak inflammatory fluid. Contrary to popular belief, this fluid does not spread the rash, but the plant chemicals that remain on skin and clothing can lead to the spread of the rash for a few days after exposure. When the rash is limited it can be effectively treated with steroid creams, though it often requires prescription strength. If the rash is more widespread or if it involves the face or groin, taking prednisone orally is often necessary to manage the symptoms while the rash runs its course. Prevention, of course, involves knowing what the plant looks like and avoiding it if you are sensitive, which is why I do not go fiddle heading!

 

swimmer's itchSwimmer’s Itch: Knowledge about swimmer’s itch has become more widespread but I recall getting a phone call about 20 years ago from a confused ER physician in Boston, asking about a strange rash that a patient had developed after swimming in our area and then returning home. It felt good to help to educate this doctor at Massachusetts General Hospital! This unfortunate malady is caused by a tiny parasite (called schistosomes) that normally live in snails or water fowl. If you happen to be in the water when these parasites float by they may get on your skin and then burrow under, where they die. They cause no illness but the allergic reaction that follows can lead to very itchy, often red pimples or spots scattered on the parts of your body that were submerged at the time of exposure. These can occur within minutes of exposure or up to 12 hours later. Over the counter hydrocortisone cream, cool compresses, and anit-inflammatory drugs can help with itching. Diphenhydramine (Benadryl) can also help but may cause drowsiness. Vigorous toweling after leaving the water can help to prevent swimmer’s itch.

 

pslePolymorphous Light Eruption (PMLE): This rash (to which I am also susceptible) typically occursearly in the warm weather season during our first few exposures to more intense sunlight. Usually within hours the skin exposed to the sunlight develops small bumps (called papules) or spots (called plaques) that are itchy, though not as severely itchy as poision ivy. These tend to last for days to weeks and usually respond nicely to over the counter hydrocortisone cream. More severe cases may require stronger steroid creams to control the itching. Although this rash can sometimes look like poison ivy, there is typically no leaking of inflammatory fluid from the rash and it does not spread. PMLE can be avoided by limiting sun exposure early in the season (hats and long sleeves), and by using effective sunscreens. Once a person has had PMLE it typically may recur on the same areas of the skin and in the same manner in subsequent summer seasons if the skin is not protected.

 

There are, of course, a variety of other skin insults to which we subject ourselves in order to enjoy nice weather (black fly, mosquito and other insect bites, “wood poisoning”, etc.) and certain drugs, like some diuretics and antibiotics, can predispose you to a rash when you’re exposed to the sun. If you have a rash that concerns you or if a common rash appears to become infected you should see your primary care provider for advice.

 

 

I have not covered Lyme Disease and the rashes that can be associated with it because it is a much more serious topic that requires more in depth discussion.