Revision surgery...PO DAY 257

Sometimes reverse total shoulder arthroplasty surgery needs surgical follow up. It's not that the original surgery was poorly done, it's  just the procedure is complicated and the outcome is not guaranteed. 

Four hundred forty one patients who were operated between 1999 and 2008 were followed. Of them, sixty seven had follow up surgical procedures. Reasons for additional surgery were identified and the first 37 patients were followed for two years.

Some patients needed only one additional surgery but 30 of them required a second procedure, 11 needed a third procedure and four had a fourth. 

The most common reason for additional treatment was instability of the new joint, 18%. Hematoma or Wound problems accounted for 15% of follow up surgery. And 12% experienced glenoid problems that required surgery. In spite of this unexpected complication, objective scoring of procedure results revealed that patients benefitted from the treatment in general and had improved comfort and use of the operated arm.

Other complications were scapular notching, infection and acromioal fractures. These were not treated surgically.

Two things to note: this study followed surgeries performed in the early years of this operation coming to the U.S. Experience has likely reduced the rate of complications.  And, in spite of requiring follow up surgical procedures (never what you want to hear recommended), follow up revealed improved and satisfied patients. 

Replacing body parts with prosthetic devices is big surgery and changing the configuration of the original joint and bone shaft is a major revision of nature. It's no surprise that there can be problems. It appears, statistically, that the end justifies the means and, in spite of requiring additional surgery, patients benefitted from the operation and had improved shoulder function and comfort. 

Hooray!

A rare pork dinner...PO Day 256

Dear son in law, who lives in Southern California, is here briefly to visit. So I wanted to cook a special dinner tonight. I chose a pork tenderloin recipe with a fennel and white wine sauce. But the recipe called for a slightly pink pork and I usually cremate pork so it turns out tough and dry. A little Google search taught me I have been doing it wrong.

In 2011 Consumer Reports published the latest from the FDA (Food and Drug Administration) on the subject of cooking the new pork. Pork is leaner thsn it used to be due to better feeding and breeding practices. The new pork is 16% leaner than what we knew years ago. Previously we were advised to cook pork to an internal temperature of 175, now it is recommended to cook it to 145, the same as beef, and allow it to rest for three minutes before serving.

The USDA’s recommendation for pork is now the same as for other whole cuts of meat including beef, veal and lamb. "With a single temperature for all whole cuts of meat and uniform three minute stand time, we believe it will be much easier for consumers to remember and result in safer food preparation,” said Under Secretary Elisabeth Hagen in a press release. "Now there will only be three numbers to remember: 145 for whole meats, 160 for ground meats and 165 for all poultry."

Everything changes! I don't know how to keep caught up on events and opinions. This was one little step towards being a modern cook.  Apparently restaurants have been cooking pork at lower finish temps for several years. Perhaps that's why their food is always so tender and good. If this is typical I am sold. The dish was easy and delicious.

Smoking v. Brain...PO Day 255

In the same issue of The Week there is a brief article about the effect of smoking on cognitive function. Researchers analyzed brain scans of over 500 smokers, non smokers and former smokers. Average age was 73 years old. The conclusion was that smoking may cause thinning of the cortex, the outer layer of the brain responsible for memory, language and perception. The more a person smoked the thinner the cortex became. Even quitting did not stop the continued decline in cognitive activity and memory, the effects which can continue for decades.

Thinning of the cortex can cause balance problems, Alzheimer's disease and schizophrenia.

People who stopped smoking did recover some cortical thickness although it did not appear to reverse the damage entirely.

Lead author of the article about the study was Dr. Sherif Karama of McGill University and the article was reported in the New York Daily News. If you are looking for ammunition to convince someone to stop smoking, this would be a good weapon in your armamentarium.

Meditation...PO Day 254

The latest issue of The Week magazine reports on a study at UCLA where researchers studied the effect of meditating on the aging brain. What is common is that as we age, even from age 20, our brains shrink in volume and weight eventually resulting in the loss of some functional ability. The study compared the brains of people who meditate with the brains of those who don't.

It was a small study, only fifty people who had meditated at least four years and fifty people who were not meditators. The research showed that the ones who meditated had less reduction in grey matter, the neuron containing tissue that processes information.  And it wasn't just certain areas, it involved almost the whole brain.

It could be coincidental. The ones who meditated may have other causative factors like diet or exercise. Or it could be the power of meditation.

Television anchor Dan Harris discovered meditation and used it to turn an anxious life around. He wrote  10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-Help That Actually Works. When his book came out I saw him interviewed several times. He certainly was convincing.

There are classes to help you get in the meditating groove. But it isn't necessary to have formal instruction. As they say, it's all in the breathing. A quiet room, no interruptions, and the ability to focus inwardly should get you started. A free activity that might help you maintain some cognitive function and doesn't make you sweat...what could be better?

Last word...PO DAY 253

At least I hope this is my last word on the superbug CRE.

Now reported is an outbreak of CRE in North Carolina of eighteen cases. The good news is that in this instance only three of the people were exposed in the hospital. The bad news is that the infection is active in the general population. It was not reported if there were fatalities.

But the North Carolina hospital involved has taken two approaches to the problem. First they have instituted a screening program looking for the infection as the patient is admitted and, if found, making appropriate arrangements to isolate the bug and patient. And they have changed to a gas sterilization process. It is, perhaps, a better method but the gas used, ethylene-oxide can be very toxic to hospital workers and patients. That may necessitate outsourcing the sterilization process, expensive and inconvenient. And no less toxic to the "outsourced" facility worker.

The CDC called this infection a "nightmare" bacteria. It certainly sounds like it is.

A demanding patient...PO Day 252

In the February 2015, 2015 issue of JAMA Oncology an editorial addresses the demanding patient. A study by  Gogineni and colleagues reports that the idea of the demanding patient, one who presents with unreasonable requests for scans and tests, is indeed a myth. Such demands are uncommon and, when issued, are generally warranted. 

The problem for the physician in the modern world is that patients are so well educated today. Between newspaper medical columns, uninhibited conversation about medical issues, and especially the Internet, the average patient is no longer dependent on their doctor for information. They usually come for their first appointment aware of their diagnosis, treatment options and prognosis. So when the patient asks for the latest scan, MRI or PET or ultrasound, it is usually part of the normal diagnostic work up. But, to the physician who is accustomed to being the one to initiate orders, the request often seems assertive. 

The author suggests ways the doctor can have better control of the situation and deal with the patient who is likely coming from a position of fear and insecurity. 

Perhaps we patients can help too by being open to our doctors' advice and counsel. I often hear from my doctors to not believe everything I read on the web. That has not kept me from doing my own research but I try not to pretend I am as knowledgable as my doctor. :)  They are right in a way, much of what is available on the web is not current, may even be information that is several years old.

Certainly, many of the articles on the web about reverse total shoulder replacement arthroplasty surgery date back ten years to when the surgery was first introduced in the U.S. The procedure was considered radical and unproven in that era. If you based your decision to have the surgery or not on those articles you'd probably opt out.

Now, our doctors just need to take the time to practice their communication skills and reassure us that they do know best. And maybe we can refrain from asking for the latest drug advertised on TV.

FDA warning....PO Day 251

In light of the recent outbreak of the CRE superbug at the California hospital the FDA has issued a warning regarding the use of the suspect endoscope which is used in the procedure that seems to be the source of the infection.

The hospital reports that as many as 179 patients may have been exposed during the exams that utilized the duodenoscopes. The exam is used on patients with digestive system problems, including gallstone and specific cancers. There have been two deaths reported by this hospital.

The FDA warning addresses proper methods of sterilizing the scopes. It also recommends discussing the risks of the procedure with the patient in light of recent events. Their recommendations are as follows:

• Inform patients of the benefits and risks associated with ERCP procedures.
• Discuss with your patients what they should expect following the ERCP procedure and what symptoms should prompt additional follow-up.
• Consider taking a duodenoscope out of service until it has been verified to be free of pathogens if a patient develops an infection with a multidrug-resistant organism following ERCP, and you suspect that there may be a link between the duodenoscope and the infection.
• Submit a report to the manufacturer and to the FDA via MedWatch if you suspect that problems with reprocessing a duodenoscope have led to patient infection.

There may also have been an outbreak of the superbug infection in a Philadelphia hospital last year where a total of eight patients were infected and two died. 

UCLA has addressed the sterilization techniques used and have  switched to a gas sterilization system to be used in the future. The FDA stresses that this infection is not a threat outside of the hospital setting. However, the spread of "superbugs" is a global concern and a British government report warns that these superbugs could "cause 10 million deaths a year and cost $100 trillion per year by 
2050, and called for a global innovation fund to power research and prevention, while President 
Barack Obama's recent budget proposal called for $1.2 billion to fight antibiotic superbugs."

Not new news....PO DAY 250

The television new is all over the story of the CRE infection outbreak at the hospital in California. Dr. Sanjay Gupta is there filming their, obviously inadequate, method of sterilizing the gastric scope that seems to be the agent of transfer of the infection. Two patients have died and several are fighting for their lives. The news is acting like this is shocking and how could this happen?

This is not new! On January 26, PO Day 225, my blog post was about this deadly antibiotic resistant superbug at hospitals in Seattle, Pittsburg and Chicago. The article I quoted from made it clear the infection was transferred from a sick patient to other patients who were subsequently examined with the same gastric scope. The affected hospitals had learned it was not enough to diligently clean and sterilize the instrument. They had put in place a screening program to be sure the scope had not been used on an infected patient.

As you would figure, I did not have access to some privileged, private source of medical information. I was just googling around when I read about CRE. I sincerely hope the News media is just late in getting to this story and that the California hospital currently dealing with this problem took the proper preventive action back when hospitals in Seattle, Pittsburg and Chicago first reported it.

There's just no getting around it...you have to be your own healthcare advocate. I know I am not aggressive enough in questioning what will happen to  me medically, surgically. The informed consent  papers we sign always scare you. "Even death" is usually listed  as a possibility of the
simplest procedure. Usually you are given the anesthesiologist's release as you are being prepped for surgery. Hardly the time to carefully research the possible negative possibilities of the anesthesia. It
seems as if the surgeon usually gives you a little more time to consider the risks. But basically we all figure those bad things aren't going to happen to us.

I guess you have to trust the hospital and your doctors to do the right thing. Hopefully they do.

Apples or rotten tomatoes?...PO DAY 249

I love Apple. All our computer stuff is Apple equipment. It really is, as they say, intuitive. Technical support is wonderful. Laptop communicates with desktop which talks to iPads. I don't have a smart phone but if I did it would link up too.  Everything always works but...

Lately things don't seem to be going so well. I think it started with Apple maps which were (was) a disaster. iOS 8.0 has gone through several iterations and is now up to iOS 8.1.3, about the sixth version. Each fixes one problem but presents another.

Now there are problems with the much anticipated Apple watch with health monitoring features. It was designed to track stress levels by monitoring skin conductivity. There was an electrocardiogram feature to track the wearer's heart rate. But hairy arms or dry skin created problems and if it was buckled loosely it did not work well. The plan now is to go with a less impressive pulse monitoring system.

Also eliminated for the time being are the blood pressure and blood oxygen level monitoring functions due to inconsistent results. But a blood sugar monitor is still being developed as part oft the product.

It is my understanding that the "Smart Watch" is being developed to facilitate collecting and sharing health data with pilot hospitals. If it were to work as designed it would make the virtual doctor visit a real possibility. Hospitals see it as as way to reduce overhead and are creating the HealthKit program to track patient stats electronically. Linking with Apple offers them tremendous technical resources but it is going to have to work properly and reliably.

What we really need right now is Steve Jobs back in charge.

A little ketchup...PO Day 248

Just to catch everyone up and not to forget the topic of this blog...how am I?

I am happy to report that my hair has stopped falling out. At eight months post op. It started shedding at about six weeks post surgery and kept it up until just the last week or two, maybe lessening over the last month. Also, I think it is back to normal growing again. For a while it just did not seem to get any longer and, since my hair is so short, it is pretty easy to tell if it is not growing. I don't think my doctor ever appreciated how disturbing hair loss is to a female. It just wasn't an issue he addressed.

My chief post operative discomfort complaint has always been muscle pain in the bicep and tricep areas of the arm. The doctor explained that is where the deltoid muscle was reattached to the bone to enable it to lift the arm. He said it would take a long time to stop hurting, if ever. The pain the front forearm, what I am calling the bicep area, mostly disappeared at about seven months post op. I still have some discomfort in the back of the forearm, the tricep area, but it is definitely diminishing. DID I SAY FOREARM?.I MEAN UPPER ARM.

My right arm, the operated shoulder side, is not as strong as I would wish. I still have trouble pushing and pulling with it. Opening or closing the bottom freezer drawer on the freezer is too hard. The push and turn maneuver with childproof medicine bottles defeats me. But I am now able to open and close doors, even our back door that sticks a little. Rotating the car steering wheel is very much easier and only tweaks me on the very tightest turns now.

My range of motion is fabulous. I can stretch and reach with the operated side arm very nearly as good as with the uninvolved left arm. Putting away dishes, hanging up clothes, picking up dropped items, replacing the shower massage head...no problem.

Lifting weight of five pounds or more slows me down. I just don't have the strength yet. It is certainly improving but not where I expect or hope to be. So lifting and pouring a gallon of milk is still a left handed job.

Ah, dressing. The ultimate bugaboo. I get so frustrated. I ought to, need to, be able to dress without help! There is nothing easy about putting on the top half of my clothing. Still. Thank goodness for front closure bras, a real necessity. I do pretty well putting on or removing shirts now but jackets and coats are a struggle. Unless the item is rather loose fitting or stretches a good bit it is a battle. I've even thought about asking to go to occupational physical therapy once or twice to see if a therapist can assess what I am not doing or what I am doing wrong. For one thing, I can't do that little shoulder shrug that lets you drop a jacket off your shoulders to remove it. And once I do get it off shoulder, I can't reach behind my back well enough to let one hand grab the sleeve off the other hand and pull the sleeve down and off. I am just beginning to be able to get my hands to touch behind my back so things may be improving. We'll see. Pulling on tight, stretchy tights, leggings, is doable but a bit of a battle. And pants that zip on the side or in the back are to be avoided. Skirts can be zipped and rotated, thankfully.

About the pneumothorax, the collapsed lung, I had post operatively secondary to the nerve block...I believe I am healed. I recently saw the pulmonologist and had a CT scan. He said everything looked fine. But I am often a bit breathless in a way I never was before. I know it is not my imagination. I can climb stairs and do many times a day. I can walk and chatter away for two to three miles. But those things did not used to make me breathless and they do now. I was never a "mouth breather" but I catch myself doing it commonly now. I have read on the web that folks say it takes a year after a collapsed lung to feel perfectly normal so I am hopeful. Tincture of time.

I last saw my orthopod in December, six months post op. I see him next in June which will be one year after surgery. I think by then I will have very little to complain about. This whole experience has been tough. Not easy to go through or get over. But the result has been all I had hoped for. It is easy to forget how handicapped I was pre surgery and how much pain I was in. Everyone warned me that recovery was a long  and difficult process. It's certainly true. Writing this blog has been a great outlet for all the angst and frustration one goes through dealing with any ongoing medical situation. Thanks for being "out there" listening to me complain!

I said I would do this for one year. Four more months to go! Can we make it?

Rethinking 245...PO Day 247

I got to thinking about my post #245, the one that suggested people who run fast every day don't get the benefit from exercise that slower and less frequent runners do. Maybe there's more to it than just the wear and tear of frequent, full out exercise.

Perhaps there is something different about the person who runs every day, rain or shine. Maybe the person who carries a stop watch and times themselves, always hoping to go faster than they did yesterday, has more going on in their head.

Competing is stressful, even when you have only yourself to race against. The type A person can turn a Sunday afternoon stroll into the Bataan Death March. You can take away their stop watch and they will drive the route and memorize each quarter mile increment. Establishing a daily exercise routine is a good idea but if you can't miss running to attend your best friend's funeral, maybe, that's not so good.

So, the self imposed demands of a high energy, high stress existence may take their cumulative toll on  the health of a person. Stress seems to be the wild card in predicting the future health of someone. And harder to control than diet or exercise. This study is a good example of the narrow interpretation of statistical data. Sometimes there is more to the story than just the obvious conclusion.

The Measles...PO Day 247

With all the talk about the measles, I've been wondering why we "persons of a certain age" aren't being told to get vaccinated. Do I need to worry about getting the measles?

I was pretty sure that there was no MMR (measles, mumps, rubella vaccine) when I was a child. So I obviously wasn't vaccinated then. I do know I had not been vaccinated as an adult. The polio vaccine came along when I was eight or ten and I do remember how frightening polio was before that. Measles didn't carry the same terror but it certainly can be a serious threat to health and life. So why don't I need to worry about it?

The guidelines for getting vaccinated say not to bother if you were born prior to 1957. But why?

Because that's when the vaccine became widely available. That's when children stopped getting the measles. Before that everyone was exposed to the virus and became immune. Even if you never had an overt case of the measles, you had the measles. Once you've had the measles you are immune and won't get them again. Having the measles is kind of like being vaccinated against the measles.

I've written the word measles so many times here it is beginning to look weird. Have I spelled it wrong?

Anyway, glad to understand the how and why of MMR.

Just the facts...PO Day 246

As Joe Friday said, "Just the facts, ma'am." But the facts are often ambivalent. While we all identify that quote with the iconic police show of the 1950s, Joe Friday never said it! It was actually said by Stan Freberg in a comedy parody of the Friday character. Just like Ilsa in Casablanca never said "play it again, Sam." Neither did Bogart say it. But both quotes are now accepted as fact.

So it is with a blog. If you repeat something often enough, it becomes fact. Some of what I post is my opinion or my observation. But often times I quote an article I read, mostly on line.  I subscribe to a number of professional health care websites and Dear Husband gets the daily AMA on line news article which he sends to me if it is interesting.

It seems to me that a lot of research is now statistically driven. That is, for example, 10,000 people agree to fill out questionnaires or be interviewed (usually the former for obvious reasons) for several years. Their every day habits, exercise, diet, drug use, alcohol consumption, work experience, aspects of their personality, things, like that are recorded and become part of a giant computer program that can sort and categorize and spew out statistics that support every kind of conclusion.

The researcher is dependent on the truthfulness of the participant and the consumer of the information is dependent on the researcher to report accurately and to "not have a dog in the fight," as they say in the south.

So if I report a study that conflicts with your life experience or what you have read and believe or what your trusted health care professional has told you, rely on your good judgement and maybe your own Google research. Your good common sense goes a long way toward knowing what is right or wrong. Unfortunately a blog is mostly a one sided discussion with the writer pontificating about some subject. Thank goodness that once in a while someone who disagrees or questions some statement speaks up in "Comments" and gives the flip side of the issue. See "Insomnia Drugs PO Day 242."

I just wish commentary was more visible to the casual reader. Thank you, PB, for making my blog more interesting and conversational!

Don't run so fast...PO Day 245

Combine a Valentine's dinner than was not an early bird special with an uncharged ipad and you get a very tardy blog post on February 14th. I do apologize but dinner was wonderful and my iPad is up and running again.

The Las Angeles Times ran a story about a Danish study of 5000 people over a period of twelve years. They found that runners who jogged fast, seven minute miles or faster, four or more times a week had a mortality rate equal to people who did no exercise at all.

But walker-runners who logged twelve minute miles for only two hours a week had significantly lower death rates.

Apparently there is a growing opinion that too much exercise can stress the cardiovascular system, indeed the whole body. So much exercise may not be necessary, in fact, might be unhealthy.

Boy, am I glad to read this in the recent issue of The Week. Everyone walks faster than me...old ladies with three tippy little dogs walk faster than I do. It's embarrassing. I walk an hour every day only because I walk so slowly. If a twelve minute mile is better than a seven minute mile...does that mean a twenty minute mile is better yet? I sure hope so!

Ads on TV...PO Day 244

Last night, while watching the evening news, I saw a commercial for a company that makes prosthetic knee and hips. It was a first for me. Of course I have seen plenty of ads for drugs, prescription and over the counter. And advertisements for hospital systems are quite common nowadays. Locally highway billboards seem to be the medium of choice for hospitals and medicare advantage plans they offer. When the billboard ads first appeared a few years ago several of them featured physicians who were in the hospital system. But now the ads are more generic and one no longer sees a fifteen foot tall version of their surgeon and his group while hurtling down the highway. I did a double take the first time I saw Dr. Kai and his partners smiling down at traffic. But perhaps highway accident victims are more likely to need a referral to orthopedic surgeons than, say, cardiologists.

It's pretty common to see highway ads for emergency rooms. Some of them feature a live action clock showing how long the patient will have to wait to be seen. The waiting room time is always something like five or ten minutes. I've never seen a wait of an hour or longer on the clock but it's hard to believe it doesn't happen in real life. When I went to the emergency room due to the collapsed lung post surgery I was immediately taken back to an exam room. No waiting. But it was at least a couple hours before a doctor saw me and a couple hours more before any action was taken. Was my "wait time" one minute or two hours? By the way, I've noticed medical literature has begun to refer to  the emergency room as the emergency department, ED instead of ER. Makes sense, actually. And highway ads for emergency "departments" do make sense. Hopefully, one doesn't need such a referral while traveling but it's certainly within the realm of possibilities.

I think it was back in the late seventies or early eighties that either local professional ethics or commercial law changed and advertising by physicians became legal or accepted. I think the practice was already common in big cities. Up until then a doctor was not even permitted to publish more than his name, address, phone number and speciality in the telephone book (that archaic device some of us Luddites still use to contact people and businesses). At first a few renegade doctors began to run newspaper ads and/or television spots. The "gimmick" of the era was a limousine that picked up the
potential surgical patient, transporting them to and from the doctor's office. It was considered terribly unprofessional by the traditionalists. But it worked and within a few years it was common and acceptable practice if a doctor wanted to stay competitive.

I don't remember when drug ads began appearing on television but they are certainly rife today. You cetainly can't watch the evening news without getting a dose of pharmaceutical information about blood thinners, erectile dysfunction meds, or injectable fillers for wrinkly cheeks. Obviously there is a certain age group with fairly common medical complaints that watches the network news programs. Not too many ads for acne medications, prenatal vitamins, or birth control drugs. I guess young people are getting their news - and perhaps their medical advice - on line.

Anyway, I haven't seen an ad for shoulder  replacement prosthetic parts yet. I guess it isn't common enough to make it commercially (literally and figuratively) viable. I'm quite sure there is plenty of advertising directly to the surgeons and hospitals. Actually, I think that is better. I don't feel qualified to sift through the facts and fiction of a well designed commercial campaign. I would be too easily influenced by the youthful seniors playing tennis, dancing the night away, and swinging their grandchildren up in the air.

Cholesterol news...PO Day 243

It's all over the news so you've probably seen this already. But eveyrthing we've been taught and believed about cholesterol and diet is out. For years one of our doctors has loved to say,"If you are eating more than two eggs a week, you are on a high cholesterol diet." And he was including the eggs that hide in so many dishes like cake or bread or so many casseroles. I wouldn't say it changed our eating habits but it did make us feel guilty.

Now medical research is telling us that the cholesterol we eat has very little to nothing to do with the cholesterol in our blood which is where the trouble origininates. I guess what they are saying is that we still should worry about our LDL or HDL but there is nothing we can do about it! That is, short of taking a statin drug if indicated. And cursing our genetic heritage.

So continue to limit beef and pork in your diet and other sources of saturated fats. Exercise has a good effect on cholesterol levels, as does a little wine, just one glass, please. All things in moderation seems to be a good policy since science keeps changing the rules on us!

Insomnia. Drugs...PO Day 242

Ever since I fell and broke my shoulder , July 2013, sleeping has been a terrible problem. Mostly it has been the discomfort and not being able to sleep on that side. I think insomnia is associated with broken shoulders so it's not just me. Even now that I have much less discomfort I still do not sleep well. Now I think it is more habit than pain that keeps me awake.

When friends or acquaintances hear about my sleep trouble many of them suggest over the counter drugs that work for them. But I have resisted and now I am really glad that I have!

According to BBC.com researchers at the University of Washington followed 3,434 senior aged people for eight years. Of particular interest was their use of anticholinergic drugs like Nytol for sleep and antihistamines Benedryl and Piriton.

During the course of the study 23% of the participants developed dementia, Alzheimer's disease mainly. People who took the highest doses of anticholinergic drugs had a higher rate of getting dementia and a 63 percent higher risk for Alzheimer's. The suspect drug was present in antidepressants, sleeping pills, and bladder control drugs and was most likely to cause trouble if taken for more than three years.

This is a terrible situation to be in. The anticholerinergic component that's the problem is in over the counter drugs to treat these medical problems. I don't know if it is in prescription drugs that might treat the conditions but if it is I'd be asking my doctor about it. Is a good night's sleep worth the increase in the risk of developing Alzheimer's? I don't think so.

Trekking poles...PO Day 241

I've been thinking about why I feel like my arm-muscle pain is less.  Of course it has to be mainly the passage of time. Tincture of time, Dear Husband says. But also, I have returned to walking with two hiking sticks or poles. I walk for one hour and, while I am not putting out a lot of energy, swinging even a light weight stick for an hour does a body good. I can certainly feel the effects. While the sharp post surgical pain is better, my arm is somewhat sore in the  good work out feeling one gets from exercising. I'm a believer.

Here's a summary from outdoor gear lab.com of what using trekking poles can do for you:

1. Trekking poles, like ski poles, allow your arms to help propel you forward and upward. Whether walking on flat ground or up steep hills, poles can help to increase your average speed.

2. Poles reduce the impact on your legs, knees, ankles, and feet. This is especially true when going downhill. A 1999 study in The Journal of Sports Medicine found that trekking poles can reduce compressive force on the knees by up to 25 percent.

3. Trekking poles can be used to deflect backcountry nuisances. They can push away thorny blackberries and swipe away spider webs that cross trails-- which can help to make you more comfortable.

4. Walking with poles can help you establish and maintain a consistent rhythm, which can increase your speed. This is especially true on flatter, non-technical terrain. 

5. The extra two points of contact significantly increase your traction on slippery surfaces like mud, snow, and loose rock.

6. Poles help you maintain balance in difficult terrain such as during river crossings, on tree root-strewn trails, and on slippery bog bridges. Staying balanced in turn helps you move more quickly and more easily.

7. Poles can act as a probe to give you more information than you can get with you eyes. Use them to learn more about puddles, melting snow bridges, and quicksand.

8. They can help to defend against attacks from dogs, bears and other wildlife. Swing them overhead to make yourself look bigger or throw them like a spear.

9. Trekking poles help to alleviate some of the weight you carry. For example, if you have a heavy pack on, and you take a short break, leaning on the poles will make you more comfortable.

10. Trekking poles can be used for things other than trekking. They save the weight of bringing dedicated tent poles; pitching a shelter with trekking poles can save up to two pounds. (Trekking poles are also much stronger and more rigid than tent poles, so they're less likely to break in high winds. This help creates safer shelters.) Poles can also double as a medical splint and can serve as ultralight packrafting paddles.

Right again...PO Day 240

I'm trying to be more self aware, pay attention to what is happening as it happens, not wake up one morning and be surprised by changes. That's how it usually is. That's how it was when I was surprised to realize the pain in the bicep part of my operated arm wasn't there anymore.

So, I shouldn't be saying this outloud but I think the pain in the tricep part of my operated arm is lessening. There are a million little things I do now that I have been avoiding for more than a year. I can raise the lever for the bowl of my kitchenaid mixer with my right hand. I can stir the chocolate chips into the stiff cookie dough good enough that there are actually chips in the last five or ten cookies. I can turn the shower lever on and off with my right hand and wash my hair with my right hand. I can iron several items and do it better than before. I can open most jars, but still not the childproof medicine bottles. I can reach the miscreant sock that hides at the back wall of the dryer.

I can finally do these things mostly without pain. There is some discomfort still if I actually reach behind my back but even that is improving,

I am adroit again...capable, able. Or french for right handed.  And no longer gauche...awkward, uncoordinated. Or french for a leftie. Not even ambidextrous, which is pretty much how I have been functioning for the recent months. In french, ambidextre.

What a shame left handed ness has carried such a stigma through the past. Thank goodness left handed children are no longer punished for using the left hand to write or throw or eat. And isn't it amazing that so many of our modern day presidents have been lefties....Truman, Ford, Bush (HW), probably Reagan, Clinton, and Obama. I've read that left handed people who have to function in a right handed world grow up to be more flexible and creative. I'm hoping that my spell as a leftie made me grow a little intellectually. Physically, I am still shrinking.

Sunday night TV...PO Day 239

It's Sunday night at 9:00 PM and I am not thinking about reverse total shoulder arthroplasty surgery. I am one of the 120 million people worldwide who is glued to PBS television during the "season" to watch Downton Abbey, the period series set in the early decades of the twentieth century. Renowned for its attention to detail, the series follows the titled family and their staff through love, marriage, death, births, the Titanic, WWI, economic crashes, successes, rebellion and upheaval. I read that the director is so dedicated to authenticity that there is a ban on soft drinks and associated containers after a soda can showed up on a mantle in a publicity photo.

So that's why I can't get over the Mrs. Patmore predicament.

In Season 1 episode 7 Lord Grantham sent Mrs. Patmore off to London to have cataract surgery. It was successful and she returned to Downton Abbey to cook another day. Things came out so well that she doesn't even wear reading glasses, let alone glasses for distance. While that might be possible today, it just wasn't the way it worked in that era. Where is the ophthalmic consultant on set? Where are the letters to the writers demanding accuracy?

In the first half of the 20th century cataract surgery was done, that's true. The cloudy lens (the cataract) was removed and light and color flooded into the eye again. But without the lens the image was totally unfocused, completely blurred. Hence, those coke bottle bottom glasses-think Claude Monet or George Burns. The next advance post WWII was contact lenses which were cosmetically and functionally a huge improvement. It wasn't until the late 1970's- early 1980s intraocular implants came along, putting the lens inside the eye rather than outside. But in the post WWI era, cataract
glasses were the only choice.

So, where are Mrs. Patnore's glasses? Good heavens, she's not even wearing a pince nez.

Okay, I admit it, I am a bit obsessed.

Who has more injuries?...PO Day 238

Who would you think had more injuries, Nursing assistant staff or construction workers?  I would have guessed construction workers but I would have been wrong.

NPR, National Public Radio, reported that nursing staff suffered more musculoskeletal injuries due, mostly, to the strain of lifting patients. Nursing staff experienced injury more than police, correctional officers, truckers and repair workers. When compared by injuries per 10,000 full time employees, nurses and orderlies suffer musculoskeletal injury at about TRIPLE the rate of construction workers! In 2010 the healthcare industry reported 600,000 workplace injuries. That was more than any other occupation. It cost the system $3.1 billion in 2011.

The problem originates with trying to move the patient. Techniques for doing it go back decades. There is just no good way to do it and protect the nurse's back. Extra manpower, or should I say nurse power, helps but is not always available. A cooperative patient is a plus but that is not always possible. When I was brought to a room from the ER after being treated for a collapsed lung I was limp as a wet noodle. I had to be moved from the gurney to the bed. I wanted to help but could not even lift an arm. Fortunately the attending nurse called for help and three other nurses appeared. Each  grasped the side of the sheet on which I lay, pulled it taunt, and half lifted-half slid me from gurney to bed. It took seconds and was unbelievably efficient. But I wonder how well it would work with a patient who weighted, say, 300 pounds.

The VA is working to install special equipment to lift patients, as has Baptist Health Systm in Florida. They report lifting injuries have been reduced by 80%. But such change is expensive and slow to be
put in place. In the meantime, hospitals are focusing on encouraging nursing staff to be physically fit.

I'm not sure being physically fit protects one from the physical stresses that result in back injuries. In the short run calling for help and getting it is a good idea. Long term, the mechanical patirnt lift mechanism is the answer.

Lung cancer screening...PO Day 237

As usual, I am off topic. But this seemed important.

CMS, Centers for Medicare and Medicaid Services (I had been wondering what CMS stood for), has announced they will begin covering lung cancer screening. This is in spite of the negative recommendation by the panel that reviews such matters.

Screening will be with a low dose cat scan which is excellent since cat scans can be heavy on the radiation. Screening will be available for patients between 55 and 77 years of age. Patients will be eligible for a scan once a year, much in the same way mammograms are covered. Persons who are current smokers, those who have quit in the past fifteen years or those who smoked a pack a day for thirty years will be covered. A prescription from your doctor will be required.

Lung cancer is the third most common form of cancer and the leading cause of cancer deaths in the US. It has surpassed breast cancer as the leading cause of cancer death in women in the western world. Proponents say screening could prevent up to 20 percent of  deaths from lung cancer, comparable to mammogram and colonoscopy screening.

Supposedly this is an expensive test, running in the $300 range. But it seems that for everything else medicare approves a much lesser amount so it will be interesting to see what the fee actually turns out to be.

Which is better?...PO Day 236

I went to one of my (seems like many) doctors today.

His office is very low tech. There is no television in the waiting room. There is no pandora radio station playing calming music. There is no keurig coffee maker with assorted coffee and teas in the waiting room. There is no computer in the exam room. If you've had some hospital exam like a cat scan or an x-Ray he cannot show you the pictures, I don't think even he can see them. He is faxed a report from the hospital radiologist who "read" the films and wrote them up in summary. He is not connected to the "grid" so he does not see your electronic health record. There was no  questionnaire asking if I have been to certain African countries, have had a fever of 101 or more, or been exposed to anyone diagnosed with the Ebola virus.

On the other hand, because I was nervous about some test results, yesterday I asked if I could be seen sooner than my appointment next week. He saw me this morning at 9:45. He took the chart from the pocket on the door and spent several minutes reviewing it before he joined me. He looked in my eyes, ears and nose. He listened to my heart and lungs, carefully. He reviewed my test results from six months ago and compared them to the recent tests. He explained things slowly and clearly and reassured me that there was nothing to worry about. He explained why and how we would follow up in six months. Shoot, he even remembered Dear Husband, who was with me, and recalled what he had done for a living. I felt like I had been to a physician, a healer, Marcus Welby, MD!

I just wish you could have it all...the high tech perks and the hands on, old school medicine man. Are the two things mutually exclusive? 

Data breach

I just copied this alert and am posting it here in case any reader is insured through Anthem as administrator of Blue Cross Blue Shield in the affected states of California, New York and "a number of other states," which were not named.



Health insurer Anthem admitted on Wednesday that personal information of customers and employees was stolen by "sophisticated" hackers.

Although Anthem, which offers Blue Cross Blue Shield plans in California, New York and a number of other states, did not say how many customers and employees were affected, the Wall Street Journal reported that the number was around 80 million.

The stolen information includes names, birthdays, medical IDs, social security numbers, street addresses, email addresses and employment information, such as income information. However, neither credit card nor medical information, such as claims, test results or diagnostic codes, was lost.

Anthem contacted the FBI about the breach and hired FireEye's Mandiant unit, the same firm that investigated the Sony breach, to evaluate the insurer's systems and identify security improvements.

Why rTSA?...PO Day 235

Following the same theme, why does someone need a Reverse total shoulder replacement surgery instead of just the more conventional total shoulder replacement surgery?

The shoulder joint is stabilized and held in place by the rotator cuff. The upper arm, the humerus, is not afixed to the socket. They fit together but are held in place by an intact rotator cuff. In the conventional total shoulder replacement surgery the upper humerus is replaced with a prosthetic metal humerus and the socket is replaced with a polyethylene socket but they are positioned in the same arrangement as the natural elements of the joint. They are dependent on an intact rotator cuff to hold the two parts together.

When the rotator cuff is torn such that it will no longer hold the joint together properly, the top of
the head of the humerus tends to drift upward. As the humerus shifts, it allows the deltoid muscle to go slack. A slack muscle is ineffective in moving or raising the limb. With a torn rotator cuff and a slack deltoid muscle the patient is unable to lift their arm. Replacing the humerus and the socket would not change this.

Reversing  the position of the head of the humerus and the shoulder socket allows the muscles of the upper arm and shoulder to squeeze or compress the parts together. They are no longer dependent on the rotator cuff alone. Gravity and time encourage the parts to stay in place. The deltoid muscle is attached to the humerus surgically and becomes the main element in raising the arm. It works!

The road to recovery is a long one. Very conservative physical therapy keeps the joint mobile without risking a dislocation while the muscles recover and knit into the joint. You have to be a patient patient!

Surgery candidate...PO Day 234

The question arose...who is a candidate for reverse Total Shoulder Arthroplasty surgery?

First, the patient should be someone who is pretty much at the end of their rope. I just mean the surgery should not be considered until more conservative treatment has been exhausted. Physical therapy, analgesics and tincture of time should be tried without relief. Persistent and severe disability should be making an extreme impact on the person's lifestyle. The good patient is one in general good health, physically active and knowledgable as to the recovery time involved and have appropriate expectations.

Reverse TSA surgery is indicated when the patient's rotator cuff is fully torn or non functional. An experienced orthopedic surgeon will order x-Rays, cat scans and or MRIs to make the right recommendation for surgery. Surgical experience is a big factor in achieving a good result. Also the patient needs to commit to post operative therapy and physical limitations for quite a while. A sling is worn post op for a good six weeks, day and night. No driving during that time. Very minimal physical activity for six weeks. Long term commitment to gentle use of the operated shoulder is important.

While the age for undergoing this surgery is going down (it used to be performed only on people 70 or older), this is still a surgery for older people. Why? Working people who perform physically demanding jobs like construction are not good candidates. Heavy work puts too much demand on the replaced joint. Also, contact sports and athletic activity where one might fall are contraindicated. Demanding or risky activity is thought to shorten the life of the new joint and hastens the time when a second surgery might be required. Patients must be willing and able to cooperate in their care.

Only the patient can assess their individual disability. Only the surgeon can know his experience and training. When the patient and the surgeon have a meeting of the minds it may be time rTSA. 

Consider the source...PO Day 233

A few weeks ago, maybe a month ago (time flies when you're having fun), I wrote about hand washing in relation to spreading germs in a Hospital setting. Well, there is more to the subject...hand drying!

Researchers in England studied hand drying techniques and equipment. They used three drying systems; a jet air drier,  warm air dryer, and paper towels. They put on latex gloves,,then contaminated their gloved hands with bacteria. Then they dried their hands using each of the three techniques.

Surprising to me, when they measured the levels of airborne bacteria in the area surrounding the jet air drier, they found the germ count was 4.5 times higher than the area around the warm area around the  air dryer. But the germ count was 27 times higher than if paper towels were used and the air around them was tested.

With the jet driers, the bacteria hung in the air for five minutes after the hands were washed and dried.

So these electric air driven hand driers are not only noisy, they can be a sanitary problem. Of course used paper towels overflowing the garbage can is not desirable. Now for the bottom line... The study was paid for by a paper towel Manufacturer. I don't think the outcome is a coincidence. But is it true? Maybe the best thing to do is wash your hands, give them a shake, then wipe them on your pants!

"Old football injury"...PO Day 232

Watching the Superbowl football game started me thinking about how these young athletes get knocked around, fall, tumble and bounce up uninjured. Or are they?

In 2005 the American Orthopedic Society for Sports Medicine published the following findings:

Three hundred thirty six elite college football players were invited to participate in a study of football related injuries. They underwent physical testing and medical evaluation. All had xrays and or MRIs. All shoulder conditions and previous surgeries were recorded. Consideration of playing position was important.

Of the 336 players, 50% had a history of shoulder injury, a total of 226 (1.3 injuries per player). Fifty six players had undergone shoulder surgery (34%), 73 total surgeries. The most common injury was shoulder separation, least common was rotator cuff injury (12%), clavicle fracture (4%) and posterior instability (4%).

Shoulder injuries were more common in quarterbacks and defensive backs. But surgery was more common in linebackers or linemen. A history of anterior instability was more common in defensive players, for whom surgery was required 76% of the time. Linemen had more rotator cuff injuries and posterior instability than other players.

Their conclusion: Shoulder injury is a common injury in college football players, with one third undergoing surgical procedures.

So, knowing this, I am no longer so envious of their ability to take a fall. I will definitely wince a little when I see the quarterback sacked or the lineman run head (and shoulders) into the opponent.

A little late today...PO Day 231

Ah, someone missed me.  What with company, the blahs, and general ennui, I didn't get my post posted like usual. I don't have anything medical to say but with the weather so terrible and me thinking about Dear Son and his family in Wisconsin which is having a veritable blizzard, today's late post is about dealing with the cold.

The magazine The Week offers this Tip of the Week to prepare your house for winter:

Clear the gutters. Be sure water drains at least six feet away from the foundation.

Remove outdoor hoses. If a hose freezes it can break the pipe it is attached to.

Inspect the chimney. If you use your fireplace a lot the chimney may need to be cleaned twice a year.

Check insulation. Look for gaps or weather stripping that needs to be replaced.

Change the furnace filter. You should replace it every two to three months.

Of course, living in the south we seldom have hard freezes. But all those tips still apply to us. And we do like to put on a sweater or a coat once in a while. So I was interested in TheWeek's "The Best of ... Winter Coats." That is until I read the prices! So here's their suggestions...

Carven Old Pink Oversize Coat: wool, full length, pink, classic. $940.00

Voormi AN/FO Jacket: triple layer merino wool, traditional ski shell performance. $549.00

Steven Alan Evening Coat: a down vest inside, detachable hood. Knee length. $625.00

Fjallraven Greenland No. 1 Down: lined with goose down, exterior water resistant fabric suffused with beeswax and paraffin. $500.00

Bottega Venetta Reversible Shetland Wool Coat: an investment, a classic, knee length. $3100.00

Wow, that will buy a lot of t-shirts and shorts! Dear Daughter-in-law, the one trying to adjust to Wisconsin weather, told me she went to a local big box store the other day. Yes, you know the one. She said at the entrance the big main clothing display was bathing suits! I guess those were for the locals who are headed to florida for the winter. :)

Back to normal blogging tomorrow. Sorry for the gap.