Sunday, January 31, 2010


The American Clean Energy and Security (ACES) Act of 2009 was approved by the United States House of Representatives on June 26, 2009 by a vote of 219-212.  Although counterpart legislation in the US Senate has gone through the Environment and Public Works Committee, the final bill is still under consideration.  The major component of the House bill regulates green-house gases to include carbon dioxide, methane, nitrous oxide, sulfur and several other gases. The bill calls for dosmetic greenhouse gas emissions to be capped at 2005 annual levels, and reduced to 17% of those levels by 2050. Another aspect of the bill would impose tariffs on countries that trade with the United States if these countries do not implement similar regulations on greenhouse emissions.  These cap and trade regulations have given this ACES legislation the popular name "Cap and Trade" in the public media.  The bill provides for utility and manufacturing companies to buy "polution permits" or to pay fines if they do not meet these regulations. Either way, this will increase the cost of doing business, which in turn will increase consumer costs for a variety of products. There has been a widespread debate and much controversy about these greenhouse gas emissions and their affect on "global warming". There are many scienctifc experts on both sides of this issue, as well as many so-call "experts" - such as actors (many who have not even graduated from college).  I suspect this debate will continue on green house gases and global warming for quite some time. 

An issue that is usually not raised is the affect on green house gas emissions on public health. Most greenhouse gases regulated under this legislation do not directly pose a health risk. For example, carbon dioxide is an ingredient in carbonated beverages and methane is produced in abundance from cattle.  However, reducing harmful pollutants (such as particulate matter that share emission sources with greenhouse gases) will have a positive impact on pulmonary and cardiovascular disease. For example fossil fuel combustion for production of electricity accounts for a large proportion of carbon dioxide emissions.

Although the carbon dioxide may not be an issue in one's health, this combustion process produces products that may pose a health risk.

For more complete information on the American Clean Energy and Security Act (HR 2454), go to


The arteries to the heart (coronary arteries) supply blood to the heart muscle that allows the heart to function properly. When fatty material (plaque) builds up in the arteries, the arteries are damaged and platelets (components in the blood that activate clotting) stick together in these areas of damage and cut off blood flow. This can lead to lack of oxygen to the heart muscle (ischemia) which can progress to a heart attack (myocardial infarction).  There have been many clinical studies that identify risk factors for developing coronary artery disease. The most well know study, "The Framingham Study" was a study of families living in Framingham, Massachusetts.  By addressing these risk factors, one can reduce the chance of coronary artery disease. Sometimes, a patient is given a warning of coronary artery disease in the form of chest pain (angina).  Unfortunately, coronary artery disease may not produce any symptoms to warn the patient of impending diaster. A heart attack (uncomfortable pressure, squeezing or fullness in the chest; pain or discomfort in the arms, back, neck, jaw or abdomen; shortness of breath; sweating, nausea or light-headedness) or even worse, sudden cardiac death, may be the first sign of coronary artery disease.
What are the risk factors?
(1) Genetics (Family History of Coronary Artery Disease)
(2) Smoking
(3) Hypertension
(4) Diabetes
(5) Age: over 40 years for men and 45 years for women
(6) Obesity and low physical activity
(7) Elevated Cholesterol (high total cholesterol; low HDL; High LDH)
(8) Elevated Triglycerides
(9) Male Sex

What can you do?
(1) Stop Smoking
(2) Treat High Blood Pressure
(3) Control Blood Sugar
(4) Eat a Balance diet with an emphasis on high fiber; fruits; vegetables; whole grains.
     Limit intake of animal fats, "trans" fats, sugars and starches.
(5) Exercise at least 30 minutes daily
(6) Lower your Cholesterol through diet, exercise and medications as prescribed.

Go to
to calculate your risk of
coronary artery disease.

Saturday, January 30, 2010


Longer surgeries raise infection risk, length of stay

For every 30-minute period between surgery incision and closing, the 30-day rate of infectious complications goes up by about 2.5%, research showed. The study conducted at the University of Kentucky College of Medicine found hospital lengths of stay also increased with operation times, about 6% for every 30 minutes


Aggressive lobbying keeps malpractice system out of health reform

The American Association of Justice spent $1 million on lobbying and advertising campaigns last year to prevent the inclusion in health reform legislation of proposals that would drastically change medical malpractice law. More than 95% of the group's $1.1 million campaign contributions in 2009 went to Democratic candidates. The Democrat-controlled Senate voted 66 to 32 against an amendment that would cap attorney fees. Los Angeles Times (01/19)

Sunday, January 24, 2010


I just viewed a disturbing video on the internet related to "Baby makes friends with Boxer".  Although it is cute and innocent, this is the sort of thing that can quickly turn into a nightmare for the baby, the parents and the dog. The typical sernario: cute baby playing with loving family dog; dog snaps and bites face of baby; hysterical parents bring baby to emergency room; after waiting for 7 hours to be seen, E.R. doctor evaluates and then tries to get a plastic surgeon to come in (most plastic surgeons have stop taking E.R. call because of liability issues); plastic surgeon who is willing to come in is finally located and arrives and prepares to take the child to the O.R. for extensive repair of facial injuries (sometimes, these injuries can involve not only soft tissue injuries with significant tissue loss, but also vital structures to include the facial nerve, eyes, nose, mouth, etc to include underlying bone);  baby is given a general anesthesia and wounds are extensively cleaned to try to prevent infection; after several hours, injuries are repaired; parents are counseled and usually very appreciative - but the conversation usually involves the following statement: "But doctor, our child will not have any scarring, will she??  Not only will this child have permanent scarring, but will probably need several scar revisions in the future.  The parents now suffer life long guilt, the beautiful young baby grows up with facial scarring and possible even facial deformity, and the loving family dog is either given away or put to sleep!  Over the last 30 years of covering the emergency room, I have seen this sernario play out numerous times, and taken care of hundreds of serious dog bite injuries to the face and body in both adults and children.  The presentation in many of these:  "But Doctor, this was the friendly family dog that would not bite anyone."  Especially when children are involved, a "friendly" dog can take a chunk out of the face in a heartbeat. Never, Never, I repeat, Never let your children get their face up close and personal with a dog. Another thing that I have observed over the years is the adult who has been drinking alcohol and then starts playing with the dog. For some reason, dogs don't like the "alcohol breath" in their face and will react with an attack on even the most loving owner. Before those dog lovers out there accuse me of being "anti-dog" and report me to the "dog police", I love dogs and I have had many dogs in the past. Although dogs are our "best friends", simple precautions can prevent a major calamity! 

Monday, January 18, 2010


Revision Augmentation Mammoplasty has become fairly common because of aging silicone gel filled breast implants. Studies have shown that the first, second and third generation implants used in the 60's, 70's, 80's and early 90's have an increased tendency to leak as they age.  This is a linear relationship, with an approximate 75% chance of leakage or rupture after 20 years. Fortunately, most of this leakage is still confined within the scar barrier (capsule) surrounding the implant, and the gel does not leak out into the tissues.  This is called "intra-capsular" leakage. Physical exam and mammography may be completely normal in these situations. M.R.I. examination may detect intra-capsular leakage. If leakage extends beyond the capsule, this creates inflammation in the tissues, possible silicone granulomas (a lump that may be felt - this is a natural response of the body to "capture" the leaking gel), more scar tissue leading to increased hardness, possible pain and distortion. This is called "extra-capsular" leakage and this usually can be seen on mammography or ultra-sound and may be obvious on physical exam.  Even though there is some controversies about when to change out older silicone gel filled breast implants, my indications are as follows:
(1) Any palpable lump in the breast needs to be investigated
(2) Abnormal mammography, ultra-sound, or M.R.I. imaging that suggests leakage
(3) Hardness, pain, distortion in the breasts
(4) Patient concerns about silicone gel filled breast implants
(5) Underlying health problems that concern the patient
(6) Desire for change in size, or desire to change to saline implants

How about the patient that presents with 20+ year old silicone gel filled breast implants but has no symptoms and has a normal physical exam; is happy with the size, shape, contour & softness of the breasts; and has normal mammography and ultra-sound exams?  This is a more difficult decision.  Even though there is a high percentage of intra-capsular leakage, many times I may decide just to follow the patient closely.  I do recommend avoiding any pressure on the breasts and would advise M.R.I. exams rather than mammography.

If the decision is made to proceed with revision augmentation mammoplasty, several options are available:
(1) Remove the implants and not replace implants
(2) Remove the implants, remove the internal scar tissue, and replace with saline filled implants
(3) Remove the implants, remove the internal scar tissue, and replace with the new fourth generation silicone gel filled implants (these implants were approved by the F.D.A. and released for general usage in November of 2006)
(4) Perform any of the above options with a breast lift

Revision augmentation mammoplasty is a major operation. This is done under general anesthesia and may take up to 3 hours. It is done at an accrediated outpatient surgical facility. It is more complicated than the original augmentation mammoplasty operation. Infra-mammary incisions (incisions in the crease under the breast) are used for access.  The old implants and any leaking implant material is removed. The scar tissue is removed, and the pockets are enlarged and new implants are placed. Drains may be needed. The new fourth generation silicone implants have a better outer shell to contain the silicone gel.  We do not have long term studies on these new implants and the F.D.A. is recommending periodic M.R.I. examinations to try to accumulate data on the leakage rate. 

After surgery, the patient is wrapped in tight bandages that have to be worn around the clock for the first week. Most patients return to normal activities (work, school, driving, etc.) after the first week.  The patient needs to limit any major physical activities (swimming, aerobics, exercising, upper body conditioning, excessive arm and shoulder movements, lifting over 5 pounds etc.) for the first 6 weeks.  I see the patient a week after surgery to remove sutures and discuss additional postoperative care.  Most patients are very happy with the results of revision augmentation mammoplasty.

Sunday, January 10, 2010


Some people have the inherited potential to develop small branching superficial veins in the skin.  These are often called "spider veins".  They are common on the lower extremities, and may appear early in life, especially during the reproductive years.  These spider veins many times become more prominent and abundant during pregnancy.  Unlike varicose veins (the larger, deeper dilated veins), these smaller vessels in the skin are not influenced by the presence or absence of damaged or incompetent valves. Many treatments have been used to treat spider veins (chemical peels; electric wire diathermy; cautery; lasers; injection sclerotherapy).  The "gold standard", and still the most cost effective treatment, is injection sclerotherapy. The technique of injection sclerotherapy is to inject a small amount of sclerosing solution (a solution approved by the F.D.A. for vein injections) into the veins using a small gauge needle.  This requires loope magnification and fibro-optic illumination and is a very tedious process. The initial reaction is swelling and bruising for several weeks.  Over the next several months, the walls of the veins collapse, adhere together, scar down and the vessel is obliterated. This process has no advese affect on the overall circulatory system.  Some vessels do not respond to this treatment.  It is often necessary to re-inject about 15% of the spider veins because of incomplete obliteration of the vein channel. The most common problem seen with this treatment (especially if the spider veins are very prominent) is hemosiderin deposits. Occasionally blood will become trapped in a spider vein as it is shrinking.  A "trapped blood" collection is known as a hemosiderin deposit.  This results in a brown or black pigmentation in the skin.  This problem usually disappears, but it may take months or years to resolve. This is one reason I like to perform a "test dose" on a prominent plexus of spider veins before proceeding with mutiple vein injections during a typical 30 min. office session.  We are still trying to find a laser that will eliminate spider veins in a cost effective and efficient manner. The 940 nm wavelength gives an effective penetration with optimal absorption by hemoglobin. There is less chance of skin pigmentary problems.  Re-treatment and cost is still a draw-back to this laser system.


As we begin 2010, Congress will continue to work on health system reform.  The Senate approved the "Patient Protection and Affordable Care Act" by a party line vote of 60-39 on December 24, 2009. A nice Christmas present for the President, but probably one of the worse pieces of legislation that has ever come from the Senate.  The "Affordable Health Care for America Act" passed by the House 220-215 on November 7, 2009 must now be negotiated with the Senate bill to come up with a consensus. Both bills would extend coverage to most Americans by imposing more government mandates on business and enacting new government coverage subsidies.  Neither bill addresses mal-practice reform, nor does either bill address the 21.2% Medicare formula based cut in Medicare re-imbursement scheduled to take place in March.   Areas that will be hotly debated include the following:
(1) The Public Plan:  The House bill implements a national health insurance plan offered by the federal government; The Senate bill  would implement "private plans" sponsored by the federal Office of Pesonal Management.
(2) Federal Taxation:The House would impose a 5.4% tax on individuals with incomes exceeding $500,000; The Senate would impose a 40% tax on certain health plans for individuals and families.
(3) Employer Mandate: The House would require larger employers not offering enough coverage to pay a tax of up to 8% of payroll; The Senate would require larger employers not offering enough coverage to pay a $750.00 penalty per worker.
(4)  Individual Mandate:  The Senate would require individuals to obtain health coverage or to face an annual penalty of 2.5% of income (higher than a certain amount); The House would make individuals pay an annual phased-in penalty of at least $750.00 if they did not have health insurance.
(5) Medicaid Expansion:  Both the Senate and House would expand Medicaid coverage for everyone earning up to 133% (Senate) & 150% (House) of the federal poverty level. (6) Abortion Funding: Both the House and Senate would bar the use of federal subsidies to pay for abortions, but would allow subsidy recipients to choose a plan covering abortion if it were paid for with segregated private funds (Senate) or to purchase separate coverage with their own money (House).

The final compromised version will be forthcoming - stay in touch and get in touch with your elected officials to express your views and concerns.