Concussions

Approximately 1.74 million people sustain a traumatic brain injury (TBI) in the United States every year. The incidence may be higher since so many injuries are unreported. Most TBI in adults are due to motor vehicle accidents and falls. Falls are more common in the elderly and motor vehicle accidents are the greatest cause in the young. Recreational accidents and sports injuries are also important causes in the younger population. In football, 10% of college players and 20% of high school athletes sustain brain injuries each year.

The hallmark symptoms of concussion are confusion and amnesia, sometimes with, but often without, preceding loss of consciousness. The amnesia almost always involves loss of memory for the traumatic event but frequently includes loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the head trauma. TBI may cause a seizure disorder. Slow bleeding around the brain may lead to a space occupying blood clot.

Mild TBI and concussion may be unrecognized by both the injured and non-medically-trained observers, particularly if there is no loss of consciousness. There are standardized assessment tools to assess cognitive function. Imaging, such as CT or MRI, may be used to determine injury.

At the least, a responsible person must carefully observe a patient with TBI for 24 hours. More careful observation is possible in the hospital. The prognosis for complete recovery is good for an appropriately managed concussion. Nonetheless, there are a variety of short and long-term sequelae that have important implications. Close medical follow-up is essential.

For more information from The Mayo Clinic

A sample post-concusion worksheet 

More Flu

Dec 8-14 is National Influenza Vaccination Week. As long as the flu is circulating you can still benefit from an immunization. Flu season typically starts in the fall and peaks in January/February. Influenza activity is beginning to increase in Connecticut and has been classified geographically as “sporadic.”  For the last week of November, fewer than 1% of outpatient visits were labeled as influenza-type illness. This number will certainly soon go up.

Lots of information can be found at flu.gov. There are excellent discussions about the flu vaccine, what exactly is the flu and how to care for someone with the flu. Changes to a woman’s immune systems during pregnancy make her especially sensitive the flu.  This is why it is so important for a pregnant woman to get a flu shot to protect her and her baby.

In addition to the flu shot, there are a couple of common sense actions that will reduce your risk of catching the flu. If at all possible, avoid contact with sick people. Stay out of the way of errant sneezers! Meticulous hand washing is always important. Be sure to have very clean hands before touching your eyes, nose or mouth. Soap and water is best but the alcohol based hand rubs are acceptable.

Flu Emergency

Emergency warning signs for adults with influenza

Any adult who shows the following emergency warning signs needs urgent medical attention. Take them to the emergency room or call 911.

*  Difficulty breathing or shortness of breath
*  Pain or pressure in the chest or abdomen
*  Confusion
*  Severe or persistent vomiting
*  Sudden dizziness
*  Influenza-like symptoms improve but then return with fever and worse cough

It's a fact: every year people of all ages in the United States die from influenza and its complications.

Low T?

The New York Times article about the under the table marketing of testosterone replacement alerted me to the Drive For Five campaign. This website, solely run by a pharmaceutical company, encourages men to have regular checkups. And – during that checkup – why not ask to have your testosterone level checked to see if it is too low? Any by a huge coincidence, the pharmaceutical company that sponsors the website has a product to address that very concern.

The Endocrine Society recommends against screening the general population for low testosterone.  The normal range has a huge span and levels fluctuate widely from hour to hour. A man’s level is affected by hunger, fatigue, time of day and how his favorite sports team is doing. It’s not even clear that low testosterone is a health problem.

Testosterone supplements are controlled substances given their potential for abuse. Yes, it is easier to build muscle mass with testosterone but at what cost? There is consensus that the risk of heart attacks may increase; the package insert warns of congestive heart failure. Body hair might increase as scalp hair decreases. Male pattern baldness is labeled as such for a reason.

The best way to increase one’s level of testosterone is to lose weight. Excess blubber, especially around the middle, will convert testosterone to estrogen-like products. Make the most of what you have naturally by eating carefully and committing to a regular exercise program. Short cuts are a short fix.

Team Care

The delivery of medical care is a team sport. Patients expect to see physicians, nurses, technicians, dietitians and aides working together in the hospital. Even the cleaning people have a valuable role in helping patients regain their health. Less familiar is the team approach in ambulatory medicine.

The care of diabetes has pioneered the use of teams. The diabetes nurse clinicians and educators are well trained in their fields and in most practice settings they have the flexibility to spend time with patients to individualize their care. A typical diabetes care team may consist of one physician, several nurse clinicians or physician assistants, a dietitian, several medical assistants and secretarial support caring for a defined group of patients. There are well-established goals in diabetes medicine. The cornerstone is good blood sugar management in order to minimize kidney, nerve and vision damage. It is also important to keep immunizations current and to control blood pressure and cholesterol. In a well-functioning team, the secretary can check to see if a patient has had his flu shot, the medical assistant can keep track of blood pressure, and the nurse clinicians can tweak insulin doses while coordinating food intake with the dietitian. By acting as the chief clinician, the physician can deliver better care to many more patients than he could if he were working alone.

The shortage of primary care physicians is forcing medicine to expand the notion of clinical teams beyond diabetes. The potential is for better care for more people.

The Older Patient

Early detection of disease is a good thing, but we should not forget about our older patients. Older patients are particularly likely to benefit from interventions to reduce heart attacks and stroke. These include controlling blood pressure and lowering cholesterol as well as weight reduction. Weight loss produces favorable changes in elevated cholesterol, elevated blood sugar and elevated blood pressure. Control of obesity also encourages a more active lifestyle.  

The symptoms of coronary artery disease may be more subtle over the age of 80; patients should be sure to report even what they consider to be trivial complaints. A pain in the calf while walking could indicate a critical blockage in a coronary artery.  

It is never too late to stop smoking! Within five years of smoking cessation the risk of smoke declines to that of people who never smoked. Approximately 15 percent of adults over age 65 years experience health problems related to the complications of alcohol consumption in combination with medication or chronic conditions. Risk factors for alcohol abuse among older adults include bereavement, depression, anxiety, pain, disability, and a prior history of alcohol use. 

All older adults, including the very old, those with multiple medical problems, or those who are in chronic care facilities, can benefit from physical activity. Participation in any amount of physical activity will result in some health benefit.  

It’s never too late to improve your health. Small investments can have big pay-offs.

The High Cost of Medications

Every day I am shocked by the price of medications. Many patients think it’s a little silly when their $10 co-pay receipt states that they ‘saved’ $163 dollars; what they don’t realize is that patients without insurance actually need to pay the full freight of $173. The very high price might be appropriate for a new medication since the pharmaceutical company should be able to recoup that research and development costs. However, due to changes in the health care law many of the old medications that used to be cheaper than Tylenol now carry breath-taking price tags.

I spoke to a pharmacist about this. His belief is that since everyone will soon need to carry insurance that covers medication, the manufacturers are increasing prices. Unfortunately, patients who carry the new high deductible health insurance plans will be paying the inflated costs out of pocket. A round of antibiotics that a couple of years ago cost less than $25 can now sent one back by more than $250.  An excellent arthritis gel that is available over the counter for less than 10 euros in France is $150 per tube here.

One of my patients is not sure that she will have her cataract operation. Medicare will pay for the procedure but on her fixed income she doesn’t have several hundred dollars for the necessary eyedrops. I suggested that she ask her children for an early Christmas gift. This might solve her problem this time. But what about the next time?