Archive for August, 2013

Ceasing aggressive physical therapy after total knee replacement

August 21, 2013

Total knee replacement (TKR) is an elective surgical procedure performed on patients affected by knee joint diseases, such as end stage osteoarthritis.  The demand for TKR in the United States has increased, which increased the demand for optimal results, such as increase range of motion, decrease incidence of infection, etc., after TKR.


“Above (Far left picture) is what a normal knee looks like. The next picture (middle picture) is what an arthritic knee would like.  The last picture (far right picture) is what a knee replacement would look like.”


Evidence suggests that aggressive physical therapy after TKR, is ideal to obtain full range of motion post-operatively. Yet, as orthopedic surgeons continue to perform TKR, they are finding that this evidence is false. Patients are unable to achieve full range of motion after aggressive physical therapy because they are causing an inflammatory response in their knee that thickens the soft tissues surrounding the TKR, and decreases the patient’s range of motion.  


Surgeons at Hospital for Special Surgery (HSS) found that patients that do not undergo physical therapy have better outcomes then those that do.  HSS instructs patients and physical therapist not to perform aggressive physical therapy after TKR.  Yet, they are reluctant to listen to the surgeons’ opinions and believe friends, or old methods, as oppose to being open to new information.  



“Passive exercise is always good! Never let anyone force your knee back!”


In order to combat this issue, we as public health officials should stop aggressive physical therapy. We can do this by educating physical therapists and patients through social support groups, which would provide experiences from patients who have gone through passive/aggressive physical therapy.  Also, we can ask HSS to share their experience and understanding with aggressive physical therapy through seminars/classes, which would help increase awareness.



Time to Act on the Affordable Care Act

August 20, 2013

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America’s leaders approved a sweeping healthcare system reform, the Affordable Care Act (ACA), signed March 2010. The National Conference of State Legislatures details ACA’s intentions: “expand access to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health workforce, and curb rising health care costs.” The American Medical Association’s figure above emphasizes benefits and access to care for millions who cannot afford healthcare expenses or health insurance.

 The ACA’s current challenge is sustainable, efficient implementation. The American Public Health Association highlighted ACA’s provisions (Medicaid expansion, insurance exchanges, and minimum coverage provision (“individual mandate”)) scheduled to phase-in by 2014, though USA Today anticipates delays. Implementation requires careful and extensive local, state, national coordination. Healthcare providers need to manage resource more cost-effectively, and promote preventive care. The ACA permits co-pay free preventive care, including screening for blood pressure, obesity, cervical cancer, and chlamydia infection, and others, as detailed by the American College of Gynecologists memo on the ACA.

A vital factor to ACA’s sustainability is individual and employer participation. This will be challenging since individual-purchased insurance will increase 30-40% with possible $5,000 deductible, according to the Miami Herald. Many will choose the no-purchase penalty and remain uninsured instead. Numerous companies are shifting personnel from full-time to part-time to avoid 5-20% cost increases. Maximal participation will offer lower long-term individual, employer, and federal cost. Thus, efforts should promote participation to deliver the greatest good, for the greatest number, and most importantly–better health and well-being for millions.

Health Literacy as a component of primary care in Ante-natal and Pediatric clinics in Northern Nigeria

August 20, 2013

Source: Jimmy Nyambok/USAID

In September 2011, there was a cholera epidemic across several States in Northern Nigeria, notably Yobe and Borno States. The Federal and State health Ministries were certainly overwhelmed and ill-equipped to handle the challenge. Repeated outbreaks of preventable diseases are not uncommon.

The Centers for Disease control and prevention (CDC) describe cholera as a disease caused by the bacteria vibrio cholerae, rare in industrialized nations, yet on the increase in many other places including Africa. It is a life threatening disease but easily preventable.

As a nation, Nigeria pledged to fulfill the indices of the MDGs. The fourth index of the MDG elaborated in the child survival strategies lists health education as its component.

Locally, the Ministry of health also developed the National health promotion policy.

Following the cholera outbreak of September 2011, an informal health education session in the pediatric clinic at the Umaru Shehu Ultramodern Hospital (Maiduguri, Nigeria) with focus on hygiene was undertaken by a corps’ Doctor. The women listened with rapt attention, often accompanied by incredible nods, as they were told the benefits and impacts of hand washing in curtailing the disease. It was an unfamiliar message.

The Nation’s leaders, health team and key affiliates must recognize the crucial role of health education in general public health. The maintenance of a healthy status begins with prevention and not clinical treatment. The advantages of disease prevention and consequent reduction in morbidity and mortality cannot be over-emphasized.

Electronic Cigarettes: Guilty by Association

August 20, 2013


Since their introduction to the US market in 2007, Electronic cigarettes (EC) have caused a major controversy in the Public Health domain. This is partially because they bear the unfortunate name of a product that has been fought for decades and touted as one of the leading causes of preventable deaths in recent years. The problem is further compounded by the bad reputation that nicotine has, as 40% of GPs interviewed in one study ranked nicotine as the first or second riskiest component of cigarettes, wrongfully attributing cancer risk to nicotine by itself, a view that is as misguided as stating that flavorings in alcohol cause Liver Cirrhosis in alcoholics.

Currently, the FDA is planning to classify EC as tobacco products, a move which will harm the EC industry as stakeholders will be required to dedicate enormous resources to conduct testing specifically designed for traditional combustible cigarettes, which is would be inappropriate for EC since they do not have any combustible properties. While well-established tobacco companies like Philip Morris and British American Tobacco will not have an issue with such regulations, startup companies will be at a significant disadvantage due to the cost of these tests. Excessive regulation can have devastating effects on innovation and competition, which are key components for a successful technology. While EC, just like any other consumable product, do need to be regulated to ensure their quality and safety, this regulation should be tailored carefully to ensure a balance of quality and safety assurance on one hand, and on the other avoid limiting access to such promising products that, while having yet to be proven to be entirely safe, are definitely a safer alternative to regular cigarettes.

Burundi- Reduce Neonatal-Mortality by Preventing Maternal Malaria

August 20, 2013

Malaria continues to severely burden many Sub-Saharan countries, including the nation of Burundi. In Burundi, 78% of the country lives in high or low transmission areas.  In this population, pregnant women are at greater risk of experiencing spontaneous abortions, low birth weight, neonatal deaths and even anemia due to malaria.  However, researchers have found that prevention treatment (Intermittent prevention therapy or IPT) during pregnancy can significantly reduce neonatal mortality and morbidity.

The WHO has a three-pronged recommendation for the prevention of malaria, including IPT, distribution of insecticide treated nets (ITNs) and proper management of disease.  Burundi adopted an ITN policy in 2004 and has many in-country and international programs that distribute ITNs.  Burundi even reports 100% treatment coverage for tested malaria cases.  However, unlike some other African countries, Burundi has not adopted an IPT policy for malaria, leaving pregnant women and children extremely vulnerable.

In 2011, the government of Burundi (GOB) developed the Global Health Initiative, in partnership with international organizations, that is aimed at reducing maternal, neonatal and child health disease. The GHI holds a specific tenet regarding the “prevention and treatment of malaria”.  In 2009 Burundi also received funds from the US- Agency for International Development (USAID) to complement already existing malaria activities.  These activities sometimes include IPT but there is no formal requirement or enforcement of the treatment. WHO suggests that confusion amongst health workers may contribute to the lack of recommendation for this preventative treatment.  A national policy that is developed and properly implemented would train health officials and workers in assuring that this treatment is integrated to the provision of services for women.

It would increase the overall health of the country and further bolster the work of other organizations such as Doctors without Borders and the Canadian Red Cross who are invested in Burundi’s malaria management. Adoption of this policy in Burundi will also reduce the negative impact of malaria, and may even reduce overall health spending by helping to maintaining better health for mothers and neonates.

In order to contribute your voice, leave a comment for the USAID (who works directly with Burundi), encouraging them to work with the Burundi government to adopt an IPT policy.

Photo Credit: Médecins Sans Frontières (Doctors without Borders)

IPT Table:

S.744 – Transforming The Process to Practice Medicine in the U.S. for International Medical Graduates

August 20, 2013


The New York Times recently reported on the process that physicians who are international medical graduates must complete to practice medicine in the United States.

For most, the multi-year process involves:

  • Being certified by the ECFMG.  This confirms fluency in English and graduation from a recognized medical school.
  • Getting recommendation letters from an American institution –  often through unpaid volunteer work.
  • Completing a minimum three year U.S. residency program, even if the physician has completed a program outside the U.S.
  • With the J-1 Exchange Visitor Visa, after the residency program, you must then return to your home country for two years.

There are current federal policies such as the Border Security, Economic Opportunity, and Immigration Modernization Act (S.744) that would transform the above process. S.744 passed the Senate in June, and will be sent of the House of Representatives.

S.744 permanently reauthorizes the Conrad-30 J-1 Visa Waiver Program, waiving the requirement to return to a home country for two years after residency. Additional related waivers and provisions are outlined by the American Medical Association, supporters of S.744 (AMA). The AMA cites that the act will help address U.S. physician shortages.

Organizations such as IntraHealth highlight the negative impact physician migration can have on the country of origin, citing that, “The countries that people come from are left without healthcare workers to take care of their pressing needs”.

Academicians like the former Dean of the Medical College of Wisconsin support further streamlining the process, by eliminating the U.S. residency requirement for select physicians. Other academicians such as Fitzhugh Mullan of George Washington University believe that “reliance on foreign physicians” has prevented policy from focusing on longer-term solutions to U.S. physician shortages.

While long term solutions are necessary to solve the U.S. physician shortage and ethical issues must be addressed, international medical graduates are a well-qualifed source to help meet our population’s healthcare needs.  S.744 is a positive first step in facilitating the process of allowing international medical graduates to practice in the United States.

Maryland Drops the Ball on Teen Access to Tanning Beds

August 19, 2013



As this Coppertone ad shows, the US has had a long love affair with the tan.  But at the turn of the 21st century,  cases of melanoma, the most deadly skin cancer, were increasing at an alarming rate, and the concurrent increase in the use of tanning beds suggested a connection.  In July 2009, the International Agency for Research on Cancer reported strong  scientific evidence that tanning beds are “carcinogenic to humans,” and that use of tanning beds before age 30 increases melanoma risk by 75%.  The risk posed to young users of tanning beds was apparent.

Just months after the IARC report was released, the Board of Health in Howard County, Maryland set a US precedent by banning access to tanning beds for individuals under 18.   Soon California enacted a statewide ban on minors’ use of tanning beds,  the American Academy of Pediatrics released a policy statement recommending that pediatricians  “strongly discourage” adolescents from using indoor tanning, and Vermont, New Jersey, Nevada, Texas, Oregon, and Illinois passed bans on minor’s access to tanning beds. Meanwhile, evidence was accumulating that tanning bed use increases throughout high school, peaking at age 18.

Image(Photo: Rob Engelhardt for USA TODAY)

Almost 4 years after Howard County’s groundbreaking act, the State of Maryland has not followed its lead.  In spite of urging by  the Maryland State Medical Society, the State Department of Health and Mental Hygiene does not support a ban on tanning devices for minors.   In March, a bill to ban minors’ access to tanning beds died in the Maryland Senate Finance committee.

Parents, physicians, and melanoma survivors who believe that Maryland should not forget the example set by Howard County must contact their state legislators to urge passage of a bill to prevent minors’ use of tanning beds in the 2014 session.

Should HPV vaccination be required for school age children?

August 19, 2013

Human papillomavirus (HPV) affects nearly all sexually active individuals. There is no cure for HPV and the virus is associated with many different cancers including cervical and oropharyngeal cancers.

HPV vaccination is not being administered to meet the national coverage goal of 80% for females 13-15 years old. The number of adolescent girls who received at least one of the three doses of the vaccine increased from 25% in 2007 to 53% in 2011, but remained at 53.8% in 2012. If the vaccine was administered at the same time as other scheduled vaccinations, it is estimated that approximately 93% of children would receive at least one dose of the HPV vaccine.  Legislation has been introduced in 41 US states to require the vaccine, funding of the vaccine or to educate the public.

Due to the high HPV transmission rate and increased vaccination coverage enforced by the Patient Protection and Affordable Care Act (ACA), we need to intervene more on the side of prevention to reduce the growing rates of HPV. It is important for providers to discuss the potential risks and benefits of the HPV vaccine with parents of school age children. Every state should have legislation that requires HPV vaccination for all children during scheduled age appropriate vaccinations. Exceptions may be granted to parents with substantial arguments against vaccination. Currently, the National Advisory Committee on Immunization Practices, American Academy of Pediatrics, American Academy of Family Physicians and American Academy of Obstetricians and Gynecologists all recommend vaccinating girls and boys beginning at age 11 and 12. Increasing vaccine coverage will greatly benefit public health by preventing genital warts and many types of cancer.

The Shale Gas industry in New Brunswick, Canada and effects on First Nations communities

August 19, 2013

US Environmental Protection Agency

Hydraulic fracturing is quickly emerging in the oil industry. It is a method of accessing natural gas from underground shale rocks using water (combined with sand and chemicals) to fracture the rock through pipes drilled vertically into the ground, then horizontally (making it ‘unconventional’ gas).


Potential health effects related to fracking include:

o Disorders of skin, eye, respiratory, gastrointestinal, nervous system, immune, kidney, cardiovascular, cancer, and endocrine disruption

o Air, water quality, and wastewater effects

o Explosions, spills, accidents

o Impacts on ecosystems

o Rapid transient population growth leading to disruption of traditional cultures and problematic substance use, mental health issues, social disruption, and economic inequity

In New Brunswick, Canada,  the Chiefs of the Maliseet Grand Council, St. Mary’s, and Elsipogtog First Nations are repealing the provincial government’s policy on fracking, based on contradiction to prior legislation that states that industry and government must consult with First Nations prior to these initiatives. In media and press releases, they have stated concerns regarding contamination of drinking water, and local economies (investment of profits into the communities for use of local raw materials). Representatives from the Assembly of First Nations (a non-governmental organization aimed to protect existing Aboriginal treaty rights), have joined the local chiefs in their advocacy efforts. Meanwhile, SWN Resources Canada is conducting local exploration.

Through current legislation in Canada, First Nations have no direct power in influencing policy other than through lobbying efforts. While changes can be made, the oil industry promises immense economic return to provincial governments and provides a new source of natural gas for consumers, but at what expense?

Less Dollars and Sense for Refugee Healthcare in Canada: A Wrong Over Right

August 19, 2013

Refugees seeking asylum in Canada have special health needs, well-recognized by the medical community and its evidence-based practice guidelines. Until June 30, 2012, refugees had healthcare coverage as a matter of right, upon entry. The Interim Federal Health Program (IFHP) assumed temporary coverage, until provincial/territorial health coverage activated for those qualified.

The Canadian government has since unilaterally enacted policies that (a) classify refugees by country of origin and status within the claims process, and (b) claw back or eliminate IFHP health coverage, according to class.

Barring imminent threat to public health or safety, now lost to all refugees:

– pharmacy (e.g. vaccines, life-sustaining medications like insulin)

– dental

– vision

extended services (e.g. pregnancy care, mental health, prosthetics)

Those from a designated “safe” country are no longer eligible for any services, besides preventing/treating a disease posing a public risk. Rejected claimants who stay are undocumented, those from a “moratorium” (unsafe) country cannot be deported, and so join the half-million uninsured in Canada.

Exempt are government-assisted and some private-sponsor refugees.

Complex rules confuse providers and would-be patients. Afraid to seek medical help, compounding individual and public health concerns, many cannot work. Families and communities suffer.

With fundamental inequity now written into Canadian law, healthcare for refugees abandoned by IFHP is increasingly assumed by individual provinces, cities, charities, hospitals and clinics. Federal costs saved (offloaded really) approximate $20 million annually, just $0.60 per Canadian.

Divisive, accusatory partisan rhetoric overshadows the obvious: refugees do not flock in to bum months of free dental care from unsuspecting taxpayers, pre-reform IFHP coverage was never “gold-plated” (same as welfare recipients’), and even refugees in Canada pay Canadian taxes.

Healthcare is a human right. The Canadian government cannot keep ignoring: for the real bottom line, look to Canadians and the frontline.  New rookie minister Chris Alexander needs to hear this, from you.