All posts by Jeffrey Sterling, MD

Straight, No Chaser Editorial: The Future of Medicine – Nurses are Stepping Up to the Plate

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I doubt you’ll hear this perspective anywhere else anytime soon, but there are some very interesting developments in health care underway. By way of introduction, a few decades ago, physicians abdicated the ownership and preeminent leadership role in healthcare, leaving the industry to the business minds of HMOs. During these early days, non-physician corporations actually owning medical practices and developing practice parameters were outlawed as to ensure that sufficient protections would remain in place for autonomous (and presumably honorable) medical practice. 
The combination of for profit hospitals and the advent of contract medical practice management groups (particularly in emergency medicine, hospitalist medicine and radiology) combined to erode away at the corporate practice of medicine laws to where even though the laws are still on the books, suits to enforce it are now routinely defeated. Today, in addition to emergency room physicians, radiologists, surgeons, hospitalists, and anesthesiologists are more likely to be employees than owners of a practice.
In recent times, health care costs have skyrocketed to 17% of our economy, while 50 million Americans went without insurance. Meanwhile, the combination of a shortage of primary care physicians and for-profit entities’ desire to cut costs has led to the development and proliferation of alternative, less costly methods of paying individuals to provide health care. Most notably, this has included the development of advance practice nurses (e.g. nurse practitioners and nurse anesthetists – instead of family doctors and anesthesiologists). Similar interest in cost savings has led to nurses assuming senior managerial positions in hospitals instead of MBA-type executives.
It is against this backdrop that the Patient Protection and Affordable Care Act (aka ‘Obamacare’) passed, seeking to infuse 30 million more paying patients into the primary care arena. With ongoing physician shortages unable to meet this demand, and with there being downward cost pressure on salaries due to the goals of the ACA and desires of corporations, it’s reasonable to predict that we will see a dramatic increase in primary care nurse practitioners (NPs) and physician assistants (PAs), which will lead to further abandonment of primary care as a physician specialty.
Meanwhile, nurses have stepped up to fill the void.  In addition to the ongoing advancement of Nurse Practitioners, nurses have successfully lobbied for and created a new provider entity: ‘The Doctorate in Nursing Practice’. It is important to note that NPs and PAs can successfully treat about 85% of the things physicians routinely see. Quality concerns aside, it is an important public health consideration that additional healthcare professionals and health options are being established to fill the need of care for tens of millions of individuals more likely to use the healthcare system.
Meanwhile, regarding your doctors, a conceivable end result is physicians are being marginalized in virtually every aspect of health care. It is easy to see a future in health care 25 years from now where cost concerns have been addressed by nurses having replaced physicians in more specialties than just primary care and anesthesia, and nurses have more control of the hospital apparatus than physicians. Physicians remain oblivious to what’s happening under their noses and an insufficient interest in contributing to healthcare solutions in the ways nurses have. The Straight, No Chaser perspective is given the large segments of society that continue not to have access to care (even with implementation of the Affordable Care Act, it is estimated that 20 million American still won’t have insurance), new innovative options to address these needs are welcome and have a place in the system. What’s next is for society to ensure that this transition occurs with appropriate quality controls and public education.
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Straight, No Chaser: The Tragedy of Septic Shock

Septic Shock
There are bad days and then there are really bad days. In many ways, the occurrence of septic shock is a culmination of a lot of bad things that can happen to you. Septic shock is the condition your body finds itself in as a result, progression and complication of a serious infection (The most common cause is pneumonia, but urinary tract and abdominal infections are also major causes.). This infection overwhelms your body, producing a massive inflammatory reaction, bringing many complications along. These complications include a significant drop in your blood pressure and can also include organ failure, most notably of the heart and lungs. Septic shock doesn’t occur to just anyone. It most often occurs in those with weakened immunity in one form or other (elderly, immunocompromised, diabetics, recent surgery, infection or prolonged hospital stay, burn victims, newborns and the pregnant), and it is the single most common cause of death in intensive care units in the U.S.
Signs and symptoms are routine and include low blood pressure, confusion or other signs of altered mental status, fever, chills and a fast heart rate, weakness, shortness of breath and noticeably diminished urination. Don’t focus on that list, though. Septic shock is a situation where your physician will know it when s/he sees it. If something like this happened at home, you’d recognize that something horrible was wrong, and you’d find yourself in an emergency room.

In terms of treatment, the ‘when’ is just as the important as ‘how’. The earlier this is diagnosed and treatment is started, the better chances of survival are. And let there be no doubt. Life is in the balance with this condition. Treatment simultaneously seeks to hold the patient up and support him/her while the underlying condition is being addressed. This is when the big guns are pulled in, including major antibiotics, intravenous fluids to rehydrate you, medications to support and enhance blood pressure and possible use of a breathing machine (ventilator) to ensure optimal oxygenation. Even surgery may be necessary to remove dead abdominal tissue, burn tissue or an abscess that may be the source of an infection.

The truth is septic shock carries a death (mortality) rate of 50%. It is always a bad situation and is best viewed as a medical miracle when survived as opposed to a treatment failure when death occurs. I can only wish you and your family the best if you find yourselves in this situation. Time is tissue.
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Straight, No Chaser: The Week in Review

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Another information packed week is in the bag.  Thanks for all the comments and suggestions for posts.  I’ll try to get to them as the schedule allows.  In the meantime, be sure to use the information I’m giving you.  I’m not just doing this for fun!  On to the week…
On Sunday, we began the week with a review of MRSA, a variant of the bacteria Staph Aureus, made into a ‘superbug’ by resistance to many traditionally used penicillin-class antibiotics.  We only talked about the skin infections (believe me, it gets much worse), but those are very important as a portal of entry to the rest of your body.  Pay attention to the tips given to stay clear of it.
On Monday, we began a ‘Life Over 40’ series by reviewing changes in the aging skin.  Remember to hydrate, moisturize and limit naked exposure to the damaging effects of the sun.  We also looked at folliculitis, another skin infection caused by Staph and often attributed to shaving and hot tubs.  You’ll think of me the next time a hotel wants you to reuse a towel.
On Tuesday, we looked at changes to your muscles and tendons as you age.  I didn’t mean to scare anyone, but it did appear that I sent some of you to the gym!  Get a personal trainer, and don’t hurt yourself.  We also taught some readers a new word: vaginismus.  This serious, painful and very treatable condition is a cause of much damage and destruction to relationships.  Think Kegels, and get help.
On Wednesday, we looked at changes to your genital system as you age.  The good news is good overall health leads to continued good sexual health as you age.  Even with your hormones seemingly working against you, there’s no reason for you not to stay sexually active as long as you desire.  We also started a series on erectile dysfunction, driving home the same points.  Keep that blood flowing throughout your body, and a lot of good things will happen.
On Thursday, we looked at changes to your heart and lungs as you age.  This really is a great topic with good news for you.  Remember that your heart and lungs will last a lot longer than you typically allow them to if you avoid the toxins that affect you.  We also reviewed the various disease entities that can cause erectile dysfunction.  The common thread is bad health that affects your blood flow will diminish your ability to stay sexually active.
On Friday, we addressed the ways your brain is affected by aging.  Let this serve as a warning to you.  The physical, mental and social effects of brain damage are devastating and epitomizes the stigma of aging.  This is to be forestalled as best you can for as long as you can.  We also gave a look at the treatment options for erectile dysfunction.  Did you know anything about injections, suppositories and pumps?  Did you recognize Smiling Bob?
On Saturday, we gave you a best practices tool many physicians use to determine the need for treatment of strep throat.  Although you may try this at home, as always, if you have concerns, ask your physician what should be done.  The week came full circle with a discussion about inappropriate antibiotic use.  We truly underestimate the body’s ability to cure most illness and too often rush for a solution in a pill.  We’d be better off saving that option for when we really need it, as that gives the highest probability that antibiotics will remain effective.
Thanks as always for your readership and support.  Your feedback and comments are much appreciated.
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Straight, No Chaser: Inappropriate Antibiotic Use

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Here’s a great concern regarding strep throat and the previous post that leads to a much more important topic (I’ll take the liberty of paraphrasing.): What about the concern of missing strep throat? Significant complications can result, including damage to the kidney (in a condition caused post-streptococcal glomerulonephritis). First I’ll address the concern, then I’ll get to the topic at hand.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned just this week how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.
The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Consider the following lists of conditions that commonly can be treated without antibiotics.

  • Common colds and upper respiratory illnesses, including non-strep pharyngitis
  • Influenza (flu)
  • Most coughs and bronchitis (chest cold with a cough)
  • Many ear infections (also called otitis media)
  • Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.

Straight No Chaser: About that 'Strep Throat'

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Here’s a pretty common scenario. You’re a first time parent with the most adorable kid in the world. You’re in full tiger mom or dad mode, and you’re not going to let anything in the world hurt your baby. Your child has a sore throat, and you’re worried that it could be strep throat. You want to know if s/he needs antibiotics (Actually, you’re demanding antibiotics, but that’s another conversation!).
If a physician is actually using evidence based medicine to treat you instead of just throwing antibiotics at you to make you feel better (We call that ‘treating the parents’), there are criteria (based on what is called a Centor score) that determines when antibiotics are indicated and will make a difference (because most sore throats are caused by viruses and don’t respond to antibiotics; they’ll get better on their own in time). The Centor score is simple enough that you could figure it out yourself. Here are the components.
The patients are judged on six criteria, with one point added for each positive component.

  • History of fever
  • Tonsillar exudates (those white patches in the back of the throat)
  • Tender anterior cervical lymph nodes (those swollen lumps in the upper neck right below the angle of the jaw)
  • No coughing
  • Age <15 add 1 point (because strep is more likely at this age)
  • Age >44 subtract 1 point (because strep is way less likely at this age)

After that, you’ll have a number. Physicians use that number to guide management as follows:

  • 0 or 1 points – No antibiotic or throat culture is necessary; the risk of strep. infection is less than 10%.
  • 2 or 3 points – A throat culture should be done, and the patient should be treated with an antibiotic if the culture is positive.
  • 4 or 5 points – The patient should be treated with an antibiotic (The risk of strep. infection is 56%), and no throat culture needs to be done.

So… if you do this calculation at home and get a 0 or 1, don’t expect antibiotics, and don’t get mad when you don’t get them. There are consequences to inappropriate usage of antibiotics. As I’ve discussed in the past (as with Staph becoming MRSA, for example), antibiotic resistance is a real phenomenon with dangerous ramifications for patients. At a patient, you really don’t want to take medications unnecessarily. Microorganisms develop resistance when you’re taking medications inappropriately. You want to remain such that when you need them, they work.
I’m happy to answer any questions or take any comments. Thank you.
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Straight, No Chaser: The Treatment of Erectile Dysfunction

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Well, here’s what many of you’ve been awaiting.  Assuming the preventative efforts I mentioned didn’t work for you, there are several different treatment approaches. If there’s an underlying medical cause, then treatment of that cause is not only a good way to relieve erectile dysfunction (ED), but it’s a good way to get healthy and avoid other complications from the primary disease. Today, I’ll review different treatment strategies your primary care physician or urologist may discuss or recommend to you for treatment.
The medications
A first consideration is to be wary of (any) medications via mail order. The same level of testing, scrutiny and quality control just doesn’t exist to the same degree as do medications obtained through a pharmacy. Reports abound of people receiving expired or weak formulations of the pills, as well as fake or hazardous substitutes of the pills they thought they were receiving. Engage at your own risk.
Now, regarding those medications you know all too well by name and brand (e.g. Levitra, Cialis and Viagra), there’s no special ‘magic’ to them. They all are variations of the same theme, physiologically relaxing muscles in the penis, resulting in increased blood flow to it.  Unfortunately, that’s not the entire story with these medications.  ED medications all lower blood pressure throughout the body, and that increased blood to the penis is coming at the expense of decreased blood flow elsewhere (This is called a ‘steal syndrome’.).  If you’re otherwise unhealthy, and your redirecting blood that was needed in the heart or brain, you could end up with a heart attack or stroke while taking these meds.  Therefore, this leads to two very important cautions regarding ED meds.  You shouldn’t start them without discussing with a physician first (to determine “…if you’re healthy enough to have sex”, as the commercials say), and secondly, don’t keep the fact that you’re taking them a secret (to your significant other, and especially to any physician you come across if you’re sick).  These medications could be the cause of whatever medical issue has you in an emergency room. They could also be contributors to life-threatening adverse effects if you’re being treated for something else with a medication that interacts with the ED med you’re taking but didn’t bother to mention to the emergency physician.  This is why ED medications generally aren’t given to men also on medications for high blood pressure, an enlarged prostate, blood thinners or certain other heart diseases (e.g. angina).
There are actually even more intricate medications used to treat ED.  Taking testosterone injections is an increasing means of addressing low hormone levels.  Additional injections directly into the penis or inserting a suppository into the penis itself are additional, effective treatment methods.  You’d be given these options by your urologist if necessary.
The counseling
If your ED is due  to anxiety, stress or other psychologically generated reasons, psychotherapy (possibly with your partner) may be of incredible assistance.  If you pursue this option, you and your partner must be prepared to be patient and to work through a variety of issues and possible approaches.
Surgery and additional methods

  • If you’ve ever seen an Austin Powers movie, you’re familiar with (well at least the jokes about) penis pumps.  These are real things, and involve placing a hollow tube over the penis and creating a vacuum to pull blood to the penis via a pump.  A tension ring is placed about the base of the penis to maintain the erection during intercourse.
  • Actual vascular surgery to repair damaged arteries may be indicated in certain cases.
  • Penile implants are an additional option.  Inflatable rods are placed into the sides of the penis.  These rods are simply inflated when needed.

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If you think some of this is a bit much, it may or may not be, depending on if you’re the one suffering.  As I usually conclude, prevention would have been a much better course of action.  Hopefully if that’s not the case, you’ve understood the information provided well enough to have an informed conversation with your physician.  Good luck, and I welcome your comments and/or questions.
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Straight, No Chaser: Life Begins (To End) at 40 (Unless It Doesn’t) – The Cerebrovascular System (Your Brain)

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Last but not least, in the first part of this series, let’s talk about your brain. But first a summary comment. Life after 40 poses both opportunity and obstacles. 35 to 40 is either the age when your lifestyle begins to catch up with you, or the work you’ve put in begins to pay off. For those who’ve lived life smartly and healthily, 40 really is the new 30. For those who’ve lived life less diligently, 40 may as well be 60, and your health probably reflects that. It’s really not that difficult. Diet, exercise, don’t smoke and alcohol in moderation keeps a body strong. Now to your brain…

Changes: As you age, cholesterol based blockages (plaque formation) inside the arteries and hardening of the arteries in the blood vessels that supply the brain is called cerebrovascular disease, and it causes strokes. These changes begin in earnest at about age 35. Prior to the complete blockage of the blood vessels, the brain is deprived of adequate blood flow (and oxygen) resulting in less than optimal brain functioning, such as confusion, disorientation, memory loss and ‘mini-strokes’ (TIAs). Strokes may result in paralysis, speech disorder, and sensory deprivation in varying degrees.
Challenges: Unlike many of the other systems I’ve discussed, the effects of these changes on our brain health status can be drastic, ranging from slight discomfort to death, and they involve major physical as well as social components. The social implications of these effects can be just as severe as the physical, as those suffering become less functional both mentally and physically. Unfortunately, in varying degrees stroke survivors become or perceive themselves to be a burden to others. Social interactions are doubly inhibited: internally, the patient is less able to interact; and externally, family, friends, and others may be less interested in interacting with them. This is sad, but true (think about the lives of the stroke survivors you may know…).
Solutions: The alternatives are twofold: after the fact, education is essential by a loved one’s support group and community, otherwise a stroke becomes a different type of life sentence. Physical and occupational therapy save lives and the quality of lives. Continuing to value and show value to your loved ones can make all the difference in the world. Before the fact, again, it’s preventive measures such as diet and exercise that have been shown to decrease or even prevent strokes. I cannot overemphasize how vital diet, exercise and the avoidance of toxins are to your long-term health.
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Straight, No Chaser: Erectile Dysfunction, Part Two – Causes

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In my last post on erectile dysfunction (ED), I gave a simplistic way to understand and address it.  However, the truth of the matter is the overwhelming majority of cases of ED are not related to stress or other psychological issues.  First, some sense of ‘reasonable’, expected performance should be established, especially as one ages (as discussed here).  Beyond that, you should know that approximately 90% of ED cases involve an underlying medical concern, including, but not limited to, the following:

Diabetes

High blood pressure

Changes/disease to your blood vessels

Low testosterone

Kidney disease

Smoking

Alcohol and Drug abuse

Obesity and High cholesterol

Effects of your medications

Therefore, today’s message is simple and brief, but I’d suggest it’s probably more important than you have previously thought. You should consult your physician if and when you or your partner’s sexual performance becomes an issue. You may actually discover something that will not only save his performance, but his life.
Finally, in the next post we will review the wide variety of treatment options for ED.
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Straight, No Chaser: Life Begins (To End) at 40 (Unless It Doesn’t) – The Cardiopulmonary (Heart and Lung) System

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The fourth part of this series looks at your heart and lungs.  One thing the heart and lung share in common is, left to their own devices, they could function normally for much longer than typically ends up occurring. It’s important to discuss because heart disease is the most common cause of death in people 65 and over, and it is also the most frequent cause of activity limitations. Let’s quickly review changes, challenges and solutions.

Heart Changes: Coronary artery disease increases as your activity declines. Blockages accumulate on the inside of your arteries, and they harden as they lose their elasticity. Both of these factors resulting in lessened blood flow. High blood pressure increases with age, independently and as a result of this.
Lung Changes: The air sacs, airways, and tissues lose elasticity and become more rigid with age. In general however, serious disease notwithstanding, the respiratory system can serve one well throughout a very long life. However, if you’re a smoker or have lung disease (e.g. asthma, COPD), the reversible damage to the lungs starts becoming irreversible about age 35. At that time, you in effect begin tearing out useful lung tissue, which diminishes your respiratory capacity and sets you up for chronic bronchitis and cancer, as the body attempts to repair this damage and does so incorrectly.
Challenges: In the absence of structural disease or continuing to expose yourself to toxins (e.g. cigarettes), the effects of these changes on our health status need not be severe. The social implications of the effects of normal changes due to aging often would not hamper reasonable normal functioning. The real challenge is to avoid inhaling toxins that will harm you (duh, right?).
Solutions: This is much simpler than you’d think and mostly involves prevention. The biological changes can be greatly diminished and held off by a regular, strenuous exercise regimen that causes deep breathing and elevation of your heart rate over a period of time and by avoidance of toxins, especially cigarette smoke and fatty foods. Your heart and lungs are well situated for the long haul in the absence of bad genes and bad habits.
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Straight, No Chaser: Erectile Dysfunction, Part One

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It seems appropriate to follow-up a post on age-related changes in your genitourinary system with a discussion on erectile dysfunction (ED).  The nature of the topic is such that I’m going to approach this in two different ways.  Today, I’ll give you a functional, overly simplistic view of ED and tomorrow, I’ll look at it from more of a clinical orientation, because there really are nuances involved. So keep in mind the lead picture. There are many medical and psychological issues that can lead to problems having erections.  I’ll get into that more tomorrow.
In many ways, your health is related to the quality of your blood flow, both in quantity (successful circulation to tissues) and quality (relative absence of toxins we ingest and deliver throughout). This is true for the brain (mental health, absence of strokes), the heart (stamina, absence of heart disease/attacks), and your penis (sexual function, lack of impotence), as well as every other organ.

Excluding truly medical considerations, the two surest ways I know to be a sexual stud (without implants or being of a certain age) are to have a legitimately healthy ego (psychologic health) and more importantly, to be in good physical shape and otherwise healthy. However, for now, given that an erection simply results from strong blood flow to the penis, your overall health better enables that process (the first time as well as if you want multiple contiguous encounters). Everything being equal, the best way for a guy to be able to have sex for whatever you define as a ‘sufficient’ period of time (besides being of a certain young age) is to maintain good cardiovascular health by spending that physician-recommended 20-30″ or more at a time on a treadmill, bike, running, etc.

Drugs like Viagra, Cialis, etc. are really nothing more than drugs that lower blood pressure (and resulting demands by other bodily organs on your blood), such that your penis’ call for an erection is otherwise unimpeded.  Sounds good?  The risk is varying forms of a ‘steal syndrome’, where that blood isn’t being distributed to your heart and brain, which could result in a heart attack or stroke.  That’s why you must “ask your doctor if you’re healthy enough for sex” before using…
Bottom line: practice for good sex and stamina during sex by working out.  It’s just another benefit to being healthy.
I welcome any questions or comments you may have.
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Straight, No Chaser: Life Begins (To End) at 40 (Unless It Doesn’t) – The Genital System

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The third part of this series is about your genital system after 40. There’s a lot here both for the ladies and the gentlemen, but  everyone should want to know all the information provided. As before, I’m going to go through changes – challenges – solutions. I welcome any questions or comments.
Prologue: Sex is good for your long-term genital and mental health. I can’t think of a better, more sexy application of the truism ‘knowledge is power’. Men, feel free to discuss this with your ladies. Ladies, I promise you I’m not being biased here (wink).
Changes: Allow me to start with the most important point: sexuality is not truly an issue of aging as much as it is more an issue of education, psychological response and health. However some changes specific to the genital system do occur with aging. In men, the prostate may enlarge (does so in 50% of men at age 50), potentially causing frequent and urgent needs to urinate and difficultly holding urine. However, more changes occur in women than in men. In women, the uterus shrinks, and several changes occur in the vagina, resulting in decreased lubrication and elasticity being lost.
Challenges: The challenges here are interesting ones. Simple rules to better genital health – Women: Stay sexually active! Men: Be confident in your sexual stamina! It is important to understand that the changes that occur in the genital system are not as related to age as they are to one’s sense of sexuality. The physical changes in the genital system should be non-problematic, especially if sex has been occurring without long periods of abstinence.
Venus Challenges: On the female side, the physical changes all can be dealt with if the woman has maintained some regular level of sexual activity. Yes, genital responses to stimulation slow gradually in both men and women, but you can have normal sexual relations at any age, as long as you are healthy. If after the age of about 40, a woman abstains from intercourse for prolonged periods (such as 3 to 5 years) the ability to secrete lubricating fluids, and much of the elasticity of the vagina are permanently lost.
Mars Challenges: On the male side, a particularly annoying challenge for some men with prostate enlargement is to avoid self-wetting. The even greater challenge is (not believing, but) ‘knowing’ your sexual prowess and stamina are still intact, particularly if dealing with an intimidating female partner (e.g. better conditioned, more adventurous or perhaps younger). For males, premature ejaculation and impotence are dramatically reduced in men when they become legitimately confident in their sexual skills set. Work on that! Women, feed your men confidence! It will come back to you!
Venus Solutions: Masturbation can effectively help to maintain female capabilities to provide lubrication and elasticity, especially if object insertion is included. Since most research shows that less than 50% of women practice object insertion during masturbation, these women who also abstain from intercourse lose some vaginal elasticity, even with regular masturbation. In the event that the woman has been sexually abstinent for a period of 3 to 5 years or more, the use of K-Y Jelly or some other non-alcoholic, non-petroleum lubricant specifically designed for compatibility with the chemistry of the vagina may sufficiently reduce discomfort in sexual intercourse.
Mars Solutions: Remember that most sexual problems are social/psychological problems, and they occur at all ages. Men: work on learning what’s necessary to give you confidence, and better performance will follow. For some it’s a certain partner, for others it’s a pill. Do not underestimate this point: if you’re otherwise healthy, that enhances your ability to perform sexually! It’s all about blood flow anyway.
Solutions Epilogue: The main solution to age-related issues of the genitalia are all within your reach (no pun intended): it’s all about activity, especially continued regular sexual activity, exercise, good nutrition and other healthy habits.
Post-script: Petroleum products such as baby oil and vaseline must never be put in or on the vagina, as they will upset the pH balance of the vagina, making it susceptible to yeast infections and other problems like BV (bacterial vaginosis).
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Straight, No Chaser: When Sex Hurts Her – Vaginismus

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The human body is fascinating and mysterious in so many different ways. Unfortunately, that’s not always a good thing. Not every medical condition has to be life threatening to have a powerful and detrimental impact on one’s life. Vaginismus is an example of that. It’s a condition in which women suffer involuntary contractions of the floor of the vaginal walls. These contractions can be so violent and incapacitating that it renders sex very painful and uncomfortable at best and physically impossible at worst. No, this is not esoterica. Many women suffer through this, not knowing what it is or ascribing the pain to ‘size’.

Here’s three things you need to know:

She’s not faking it. 

Vaginismus is horrible for the sufferer, as you’d imagine, and it’s a tremendous stress on relationships.  It is the number one cause of unconsummated marriages, and can be complete or situational.  It may be complete, impacting ability for a physician to complete a pelvic examination or for a woman to even place a tampon.  These contractions can be reflex occurrences such that the symptoms occur when presented with any effort to penetrate the vagina.  That said, the reflex is thought to be physiologically learned, and it has been demonstrated that it can be unlearned (Consider your immediate impulse to lift your arm when a fast object comes at you; one episode of vaginismus can prompt a lifetime of similar reactions during efforts at sex.).

Vaginismus can be cured.

It stands to reason that in the many cases in which vaginismus is a learned reflex, the reflex can be overcome.  Muscle training and control are the keys to overcoming vaginismus and is a process that can be accomplished over weeks to months.  The good news is developing this level of training and control can also have wonderful benefits for couples that do get past the problem.  Many women are familiar with Kegel exercises from prenatal classes.  Application of these in the correct manner (with systematic progression until penetration is possible) provides success in approximately 90% of patients.  If you require details, feel free to ask, or discuss this with your physician.

Vaginismus requires patience (and flexibility) to overcome.

Healthy sex lives are enjoyed by many couples without penetration.  This is an important frame of mind to have, less the additional stress can hinder treatment and torpedo the relationship.  It may seem like a lot to ask for some, but believe me, many couple maintain happy relationships in the midst of this, either during treatment or throughout a lifetime of suffering through it.  Taking this mindset into the period during which treatment is ongoing can lead to a very happy outcome once the vaginismus has been overcome.
I welcome your questions or comments.
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Straight, No Chaser: Life Begins (To End) at 40 (Unless It Doesn’t) – The Musculoskeletal System

Physical Therapist Working with Patient
The second part of this series is about your muscles. This section combined with the previous skin section explains why you wrinkle. As before, I’m going to go through system – changes – challenges – solutions. If you’re keeping score, especially focus on the take home messages within solutions. I welcome any questions or comments.
Changes: Did you know that muscle cells are unable to replace themselves once they are formed? Therefore, muscle cell loss is permanent. Plus, muscular response gradually slows with age. That said, the loss of muscular capabilities over time is by far the result of cell loss due to inactivity. As muscle cells are lost, weakness and slowness increase. Plus, some of you don’t exercise at all, or as much/vigorously as you used to, so you’re not building up anything new.
Challenges: The effects of these changes on our health status are mostly due to the fact that the muscles are the main tools for effecting strong circulation throughout the body (i.e. muscular contraction pushes blood around). As the muscles become smaller, including the muscles in the face, and as fat tissue accumulates, including in the face, the entire appearance changes to that of an older person, with all the ramifications described in the post on the description of skin changes with aging. In addition, as muscle fibers decrease, weaken, and slow, it becomes increasingly difficult to keep up with younger people, who may make allowances, but who may also become avoidant. Your recognition of this creates a vicious cycle, and you eventually settle into ‘being old’.
Solutions: In two words – exercise & activity. A well designed, consistently followed exercise program addressing both strength and response is indispensable for the maintenance of muscle cells, and of good health over time. A personal trainer is a pretty good idea after a certain age. You neither need to under nor overdo your weight lifting regimen. In any event, move those muscles as much as you can, whether via walking, yoga, running or sex. Being a couch potato is never a good thing.
Post-scripts:

  • Another thing that very few of us do is stretch. Those old muscles are tight, and the tendons/ligaments are short and ready to pop. You really must stretch before your weekend warrior events or most any big exertional activity. That’s a big part of why yoga promotes longevity.
  • Fortunately, the main muscles of the heart and the diaphragm (your breathing muscle) do not lose muscle fibers with age because they are continually active. Yet, your heart and lungs have their own problems besides the muscles. That topic is forthcoming. All that said, be mindful that through ongoing exercise and training, you can stem the tide on these changes.

Young is as young does.

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Straight, No Chaser: Hot Tub and Barbershop Folliculitis (Yep, Even More Staph Infections!)

hottubfolliculitis_20 Folliculitis
Follulicitis. You know it well as hot tub rash, barber bumps, ingrown hairs and many other names. The first thing you need to know is the ‘itis’ means inflammation, and the follicle is the pouch from which your hair grows. Any inflammation of that area is folliculitis. You’ll typically see white-headed pimples with or without itching, pain and redness. So what? Let’s quickly run through causes, problems, prevention and treatment.
Causes

  • It’s usually caused by microorganisms (usually bacteria, including Staph and others, but also yeast, fungi and viruses may do the same).
  • Blocking skin pores will also get you there (think heavy application of make-up or oils, or heavy sweating in tight spandex-type clothing).
  • External irritation can be a cause (think long-term topical steroid use, tight clothing, untreated scratches or lacerations, improperly chlorinated hot tubs, whirlpools or swimming pools).

Problems
It’s inflammation that most commonly is an infection. The irritation can progress to a skin infection (cellulitis) and/or a boil (abscess). These can range from annoyances to ‘not-fun’ to outright problematic, particularly if you’re diabetic, have HIV or otherwise have a compromised immune system.
Prevention
I’m just going to give you a list of healthy hygiene tips that will serve you well in many circumstances, including prevention of folliculitis.

  • Use antimicrobial soap.
  • Don’t share towels, and avoid using the same towel multiple times (Sorry, hotel chains!).
  • Shower immediately after getting out of the swimming pool, whirlpool or hot tub.
  • Don’t shave (and avoid otherwise irritating) areas where razor bumps exist.
  • Be moderate with application of lotions, makeups and other moisturizers.

Treatment
Most cases of folliculitis, whether an inflammation or an infection, resolve in 1-2 weeks, assuming you don’t further irritate it to the point where an substantial skin infection sets in. Consider the following a treatment progression for the overwhelming majority of cases; cases more severe (or any you may be concerned with) require consultation with your individual physician.

  • Warm compresses (clean, hot towels) to the area do a world of good.
  • Wash with antimicrobial soap, and consider using medicated shampoo, particularly if the discomfort is on the scalp and/or beard.
  • Your physician may consider topical or oral antibiotics if the situation warrants or worsens. That means you need to be alert for spreading of the bumps, fever, drainage or worsening of pain, swelling or redness.

Good luck, and I welcome your questions or comments.
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Straight, No Chaser: Life Begins (to End) at 40 (Unless It Doesn’t) – The Skin

agingsmoker
Being on the other side of 40 is a trip. I’m still pushing the rock up the mountain, but I’ve seen the challenges of maintaining and continuing to advance. This is a lot to digest, so I’m going to go through five different body systems this week in a simple way: system – changes – challenges – solutions. If you’re keeping score, especially focus on the take home messages within solutions. And don’t be depressed! Forewarned is forearmed. Take action! I welcome any questions or comments.

Part 1/5: Your Skin

Changes: As the skin ages, blood flow to the skin is decreased, and nerve endings are lost or become less sensitive. As a result, the skin loses some of its effectiveness as a protector against bacteria, as an insulator, as a heat/cold regulator, and as a sensory receptor. These losses cause wrinkling, loss of elasticity, freedom of movement, and expression are inhibited. The slowing of circulation results in slower healing. The loss of color is also seen, as the hair becomes gray.
Challenges: The skin generally functions well throughout life though, and most changes in the skin due to aging are not life threatening. Most of the damaging changes in the skin are cosmetic. The drying and thinning result in sagging and wrinkling, the hair becomes sparser and gray or white, and the fingernails become rigid, tend to yellow, and are prone to splitting. Skin disorders more common in the aging skin include enhanced itching, thickening in patches, skin cancer, ulcers/pressure sores, and herpes zoster (shingles). These effects bring social implications based on a significant cultural tendency toward ageism. One’s social life becomes more limited as younger people view elders as “not fun”, “slow”, “grumpy”, less desirable as friends and sexual partners, and so on. These views spill into the workplace or what might be a potential workplace, as one who looks “old” is not considered as having ‘much’ to offer.
Solutions: Two words: hydrate and moisturize. Avoid excessive exposure to the sun, maintain moisture in the skin, provide adequate nutrition so that the skin can be maintained and repaired, and get regular exercise to maintain circulation in the skin. Sounds simple, but we really fail to adhere to this consideration. Many of these changes can be delayed for very long periods of time.
Post-Script: I would be remiss if I didn’t point out that those of you of all races and ethnicities must be diligent in getting rapidly growing or changing moles evaluated. It is an untruth that Blacks and Browns don’t get skin cancer.
Post-Post-Script: Ever imagine what effect holding a cigarette up to your face for decades has?  Here’s a depiction.

agesmoke

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Straight, No Chaser: MRSA, the Big, Bad Staph Infection

MRSA
One of the things that’s changed a lot from when I first started practicing medicine is people show up every day to the emergency room for mosquito and spider bites.  The local news has done a number on you, as now everyone is afraid of MRSA.
Methicillin-resistant Staph Aureus (MRSA) is a bacterial infection that’s resistant to the penicillin family of drugs that we used for decades to treat many infections. Staph Aureus itself is a bacteria akin to flipping a light switch.  Normally, it resides within us (approximately 30% of us have it in our nostrils but only 2% of us carry the MRSA variety), not causing any problems, but it is also the source of many dangerous and life-threatening illnesses if it enters your bloodstream.
Over the last 50 years of treating Staph infections, resistance to many different antibiotics has occurred, meaning that when a serious infection occurs, it’s potentially very harmful.  The emphasis there should be on potentially.  Most MRSA infections are community-acquired skin infections that resemble a spider or other insect bite but are still mild and are treatable with different antibiotics than historically used.  Regular Staph and MRSA infections are even more likely to occur in those institutionalized (i.e. in hospitals, nursing homes, etc.) and have tubes and wounds.  Consider and discuss the risk with your physician when you see someone on a breathing device, a urinary catheter, needing gauze for surgical wounds or on feeding tubes.  Amazingly, MRSA causes approximately 60% of hospital-acquired Staph infections now.
My primary goal today is to inform you of what you need to know to prevent obtaining these infections and when to be especially diligent in seeking treatment.  It’s really a simple task of maintaining hygiene.  Just prevent that ‘light-switch’ from flipping to the on position and most times you’ll be ok.
1.  Staph is everywhere.  You can best protect yourself by simply practicing good hygiene.  Wash your hands early and often.
2. MRSA is spread by contact. Don’t be so quick to feel and squeeze on someone’s (or your own) boil.  Wash your hands before and after such contact.  Don’t share towels or razors.
3.  Keep any cuts, scratches, nicks or scrapes covered until healed.
If you do see or develop signs of a skin infection (redness, warmth, tenderness, pain and possibly discharge from the wound site), it’s worth contacting your physician to see if s/he’d like to start antibiotics or drain a possible abscess.
So… don’t be afraid, be smart.  Prevention is key.
Hand_Washing_MRSA
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Straight, No Chaser: The Week In Review

week-in-review-header3-589x237
Happy Sunday, everyone. In the midst another all-time best week here, I got to discuss the topics I spend most of my time discussing with patients in the emergency department: high blood pressure, smoking and obesity. What that triad has in common is how they manifest in many different disease presentations. Well, at least now you know. I guess drinking and STDs will have to wait for another time. Here’s your week in review. Feel free to click the underlined topics to access the original posts.
We started the week on Sunday reviewing how the nerve gas sarin, allegedly used against the citizens of Syria, creates death and disease. Someone actually asked me why the victim in the lead picture was wearing shaving cream. That’s not shaving cream, folks. Victims wallow in their own secretions from everywhere, including salivation, excessive tearing, runny nose, diarrhea, urination, vomiting and lung secretions before they die of respiratory failure. We certain wish the best for the people of Syria and the country as a whole.
We spent Monday reviewing high blood pressure (hypertension), also known as the silent killer because yes, it can cause you to drop dead without knowing what happened. Just remember to try not to poison the pump that delivers oxygen and nourishment throughout the body (That would be your heart!). In part two of our hypertension review, we gave you numbers to know for monitoring your blood pressure and cues as to when that high pressure warrants a visit to the ER. I’d suggest you commit a few brain cells to that information. That’s information that could save your life, given the time dependent nature of treating the strokes and heart attacks that result from high blood pressure.
On Tuesday, we began reviewing smoking cessation and the benefits associated with it. We also discussed best practices in achieving smoking cessation. It remains interesting that many more people use the patch to stop (and many do so successfully), but stopping cold turkey remains the most effective way of stopping, for those able to pull it off. Consider the 10 Quick Tips I offered and consider working with your physician on the START method. I know this is a struggle. Over two-thirds of smokers want to stop, and over half attempt to stop every year. I wish you the best if you’re in that group.
On Wednesday, we took a look at obesity in America. Based on the data, it’s clear more people are choosing the pursuit of happiness (in excess) over the pursuit of health. That said, we’re still doing something right, as our life expectancy continues to increase despite approximately two-thirds of us being overweight (although we’re living longer with more disease).
On Thursday, we reviewed the health risks of obesity and introduced you to the caloric equation, which largely determines if you’re gaining or losing weight. It’s actually a pretty simple concept that you might consider learning, because every bit you lose reduces the load on your heart (in particular) and other organs. These relative, incremental amounts do matter.
Friday was a fun day, because we discussed solutions instead of just problems. We talked about how to lose weight the good old-fashioned way, reviewing how to pace yourself, set reasonable expectations and lose healthily. Just remember it’s going to take a lifestyle change, not a fad. The tortoise always did beat the hare. On Friday, we also discussed how to jump-start your metabolism, regardless of age. The Quick Tips I gave you couldn’t be simpler and do make a difference.
On Saturday, we completely switched gears and reviewed the painful topic of hemorrhoids. Don’t forget the self-help tip ‘WASH’, and trust me, your goal is to stay away from the ER or surgeon with these. Deal with them sooner rather than later, before it becomes a pain for everyone involved! Saturday, we returned to smoking – this time of the cigar variety. I had to bring the Surgeon General along to point out the cigar smoking is not a safe alternative to cigarettes. Can you believe a single large cigar contains as much nicotine as an entire pack of cigarettes? Who knew?
Your comments, concerns and disagreements are welcome. My goal is always to provide you information that you incorporate into making your lives happier and healthier, not to be the ‘health morality police’. As the obesity posts noted, there is too often a crossroads between health and happiness. When you’re younger, you really are investing in your health to secure your future happiness, because as you age, there is a much higher correlation being your health and your happiness. My mental health colleagues will be quick to tell you how the lack of health as you age leads to higher rates of depression and suicide in the elderly. Your goal is to head down the road that offers both health and happiness. And speaking of aging…
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Cigar Smoking: Facts and Fiction

Fidel-Castro-smoking-ciga-001 mouth_cancer_cr

It’s the latest, greatest, coolest past-time.  Endorsed and practiced by celebrities the world over, cigar smoking has clearly and successfully marketed itself as a convenience of the successful.  Even the notion that the ‘best’ cigars are forbidden fruit (i.e. come from Cuba) adds to the allure if and when you’re able to wrap your lips around one.  I wasn’t surprised, but it’s worth noting that beyond the success stories received from those of you who have successfully stopped cigarette smoking, the next set of questions involved whether cigar smoking is a safe alternative.
Since you have little old me taking on an $8 billion a year industry and the wrath of the very passionate, I have no recourse but to arm myself with some data – cold, hard facts.

  • 49% of all cigars sold are large cigars.  A single large cigar contains as much tobacco as an entire pack of cigarettes.
  • Cigar use is on the rise, with over 13 million people identifying as current users.
  • 15% of male students in grades 9-12 are current users.
  • African-Americans have the highest rate of cigar smoking (among ethnicities/races), with a 7.7% user rate.

You want to know the effects of cigar smoking?  Let’s cut to the chase.
Here are the five “SURGEON GENERAL WARNING” text-only labels, one of which must be displayed on all cigar packaging and advertisements.  This is done on a rotating basis.

  1. Cigar Smoking Can Cause Cancers Of The Mouth and Throat, Even if You Do Not Inhale.
  2. Cigar Smoking Can Cause Lung Cancer and Heart Disease.
  3. Tobacco Use Increases the Risk of Infertility, Stillbirth and Low Birth Weight.
  4. Cigars Are Not A Safe Alternative To Cigarettes.
  5. Tobacco Smoke Increases The Risk of Lung Cancer And Heart Disease, Even In Nonsmokers. 

Beyond what the Surgeon General requires, here are some additional facts:

  • All tobacco smoke contains more than 60 chemicals that can cause cancer, and cigar smoke is no exception.
  • Regular cigar smoking increases your risk for the following cancers: lung, esophagus, larynx (your voice box), and oral cavity (lips, tongue, mouth and throat).
  • Cigar smoking is linked to gum disease and tooth decay and loss.
  • In addition to lung cancer, heavy cigar smoking increases the risk for emphysema and chronic bronchitis.

The bottom line?

Cigar smoking is not a safe alternative to cigarette smoking.

There is no level of cigar smoking that does not pose health risks.

As always, it’s not my chore to convince you to do or not to do; freedom of choice is a beautiful thing.  That said, be advised that if you read this blog, you will be an informed consumer.  I welcome your comments or questions.
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Straight No Chaser: Got Hemorrhoids?

hemorrhoid Bath reading

Yes, you do.  I can hear you now.  Aww, doc!  Why are you talking about this first thing in the morning?  Well, a lot of you have them 24 hours a day, so now is as good as a time as any.  I know this topic is a pain (no pun intended), but you should consider reading this before your next bowel movement.
Let’s talk about hemorrhoids, and we’re gonna make this simple.
1. What are they?  Hemorrhoids are swollen veins either inside (internal hemorrhoids) or outside (external hemorrhoids) the anal canal.  It’s not uncommon for people to have both types at the same time.  You should wonder if you have them if and when you experience pain, bleeding and itching to the perianal area.
2. Why do you get them?  It’s all about pressure.  The blood that is circulating to the skin near the anus finds itself in outpoutchings when you strain and stretch the skin while having a bowel movement.  Pregnancy is another time when hemorrhoids become common.  I’ve literally seen hemorrhoids form before my eyes during the straining of childbirth.  The table is set for that in advance, as the pressure of the last two trimesters on the pelvic vessels also causes development of hemorrhoids.  The same goes for the obese.  Plus, you sit too much.
3. How can I prevent them?  You should start with ensuring that you’re eating a high fiber diet (fruits, vegetables and whole grains), exercising and drinking a lot of water.  Becoming constipated and having to strain is a sure way to developing hemorrhoids.  Does anyone remember Al Bundy from Married with Children?  Notice how he always took a newspaper to the toilet?  That’s the other part of prevention.  Allowing your bowel movements to occur on their time-table without you straining keeps you without hemorrhoids.
4. How can I treat them?  The problem with hemorrhoids is they hurt, and hurting causes a vicious cycle.  Because they hurt (and bleed), you don’t want to have another bowel movement.  If you’re not having bowel movements, chances are you’ll get constipated.  If you get constipated, you’ll have to strain and endure pain.  And the cycle continues…  So, in order to break the cycle – WASH yourself (like the young lady in the lead picture).

  • Water (sitz bath)
  • Analgesics (pain medication, either topically or by mouth)
  • Stool softeners
  • High fiber diet

5. How will your physician treat them?  Treatment in an emergency room setting is largely dependent on whether or not the external hemorrhoid has developed a blood clot (as shown in the lead picture).  These are the type that are especially painful and are called thrombosed external hemorrhoids.

  • Non-thrombosed internal hemorrhoids usually are initially treated conservatively as described above.
  • Sometimes internal hemorrhoids will need to be tied off with a surgical band, eliminating the blood supply to the hemorrhoid and forcing it to shrink or fall away.  Alternatively, the tissue around the internal hemorrhoid may be surgically scarred (ouch!) to the same effect.
  • Thrombosed external hemorrhoids need to have the clot removed.  This is done by the physician with a particular type of incision.

By this point, you should be thinking “I’ll take the prevention!”.  Trust me, that’s the correct choice.
As an emergency physician, I’m even more concerned about the possibility of something else being wrong.  Given that 10 million Americans are walking around with hemorrhoids anyway, that rectal bleeding could be due to something else, such as rectal, anal or colon cancer.  You may receive additional examinations specifically to rule out those considerations (they may involve tubes, probes and/or scoping).  Feel free to ask if you really want details.
Feel free to read this again as motivation during your next bowel movement.
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Straight, No Chaser: Quick Tips on Boosting Your Metabolism

fat crying
It would be improper for me to have dragged you through the mud for three days and depressed you into thinking you can’t improve your situation. Hopefully, you’re not feeling that way. You should now have a better understanding of how the body works, how to count calories and how to compare yourself to a baseline for health. What left is giving your body a leg up on your efforts. Yep, I’m talking about boosting your metabolism. Any of you that have been with me for a while know that means I’m not promoting something you’ll find in a bottle, although there are many good supplements that can assist in that effort. I’ll refer you to your (or my) favorite personal trainer for those considerations. As always, I want to offer you the tools to be self-empowered. To that end, here’s five Quick Tips to boost your metabolism. Why five? Because five is easier to implement than six. Once you get these five down, let me know, and we can get a bit more intricate.
1. Eat smaller meals, and eat more frequently. It’s true. More meals more often is better, but only if they’re smaller. Calorie counting is still a major part of the equation. The point of more frequent meals is preventing the body from going into starvation mode, which slows your metabolism as the body attempts to conserve energy. If you do this, you’ll discover those meals are smaller and you will get closer to eat more appropriate portions than we typically do. Also, make those in-between meals healthy choices like a handful of fruits or nuts.
2. Prime your pump. Remember, it’s all about your heart’s ability to efficiently move blood around the body anyway. The healthier your heart is, the better your metabolism will be. You need aerobic exercise that increases your heart rate for 20-30 minutes at a time. Learn your target heart rate for your age, and exercise to get into that range. Your metabolism will better approximate that of a fine tuned machine rather than a sputtering old car.
3. Weight train. This is very simple. The more muscular you are, the more calories you will burn, especially relative to someone of the same weight who is obese. Not only will you become a finer calorie-burning machine, in this case you actually will look better! Add weight training to your exercise regimen.
4. Choose the fish (and not the fried variety). Fish oil contains substances called omega-3 fatty acids (EPA, DHA) which increases levels of fat-burning enzymes and decreases levels of fat storing enzymes. Daily ingestion has been shown to help by approximately 400 calories a day.
5. Enlist a personal trainer. Everyone needs help and motivation. Some of us need a lot of help and a lot of motivation. We also need expertise. There’s nothing more frustrating than working hard yet not seeing any results because you’re working incorrectly. A good trainer can put you on the path, supervise your regimen, and hold your hand through the process. The minutia of age, sex and body habitus considerations that also play a role in this can be managed by a good trainer. Your ideal trainer will have knowledge of nutrition, wellness and supplements that are tailored to your specific considerations. This will get your metabolism revved up!
By the way, if you’re into green tea, caffeine or spicy/hot peppers, enjoy them for their other benefits, but don’t expect them to contribute significantly to your efforts to improve your metabolism. At least that’s what the consensus in the medical literature points out.
Finally: yes, it’s true that metabolism naturally slows with age (starting as early as age 25); everyone has heard that fact. However, here’s what you don’t usually hear: that’s not inevitable and is more a result of your becoming less physically active than just aging. That demonstrates the need for you to be even more diligent in your efforts. Good luck, and I welcome your questions and comments.
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