Monthly Archives: April 2011

Smokeless Tobacco: Safer or Still Risky?

The use of smokeless tobacco has grown over the last few years, primarily in the under 21 age group. As smoking has been socially less acceptable and the overwhelming amount of evidence of tobacco’s serious health effects are slowly acknowledged, tobacco companies have spent increasing amounts of advertising dollars on smokeless tobacco.

A significant portion of those users are adolescent males, and their numbers are growing by 30-50% since 2006. Of the estimated 10 million users of smokeless tobacco, 3 million are under the age of 21. Young users start as early as the sixth grade and are regular consumers by high school. The Center for Disease Control reports that the largest increases in smokeless tobacco use has been in the 18-24 age group.

A Lesson from the Pastphoto © 2010 Ted | more info (via: Wylio)

Smokeless tobacco contains nicotine and around 30 cancer-causing substances just like tobacco that is smoked. A common misconception is it is somehow different or safer. Nicotine is rapidly absorbed through the mucosa in the mouth, easily attaining higher and possibly longer-lasting nicotine levels than cigarette smoking. Manufacturers have packaged, flavored and marketed their smokeless products to entice young people. Due to the addictive nature of nicotine, surveys show that users commonly move to higher levels of use due to their increasing tolerance.

Many of these users simply do not understand the serious risks that ingesting tobacco retains. In many respects, it is equal to or worse than smoking tobacco.

The World Health Organization International Agency for Research on Cancer reported in 2008 that those who ingest tobacco have an 80% higher risk of developing oral cancer and 60% higher risk of contracting pancreatic and esophageal cancer. The high risks of developing ulcers of the esophagus or stomach, heart disease, high blood pressure, fetal abnormalities if used during pregnancy, are the same as smoking tobacco.

Smokeless tobacco wreaks havoc on the teeth, tongue and gums. More tooth decay and oral ulcers are common. A precancerous condition known as leukoplakia occurs in about half of all users within the first three years of regular use. If these white patches or plaques are identified early, it may be treated if tobacco use is stopped.

Quitting smokeless tobacco can be just as difficult as smoking due to the addiction to nicotine. The same options are available to users such as nicotine replacement products. Consult your healthcare provider to see if one of the prescription medications and counseling can help you quit.

Nicotine is a strong addiction and is difficult to overcome; nonetheless, it can be done with an organized approach. The profound and devastating health problems are entirely avoidable.

– Dr. Bruce Kaler


What It’s Like To Be a Provider at U.S. HealthWorks

We recently asked our providers to share stories about their experiences in providing care at U.S. HealthWorks. We thought this piece from Dr. Donna Diziki, Center Medical Director of our Edison, NJ, clinic, was a great example of what’s it like to practice medicine and be part of the U.S. HealthWorks team.


The word conjures up images of sweaty men on chain gangs hammering railroad ties.

Life’s work.

Now that image is quite different in your mind’s eye – sunshine on a flowering meadow, commitment, fulfillment.

But how do you merge these two visions?

As physicians, we must decide our paths early on in our training. Sometimes this path has no exit or detours, such as choosing to be a surgeon, and we follow the colleagues before us. With these career choices, there is little control over the work; rather, the work steers the provider.

Others have the luxury of career options and ways to broaden the spectrum of their training. In my opinion, these are lucky ones. These doctors can venture down alternate routes on their career paths and find amazing destinations where fulfillment and growth are possible and encouraged.

Not all of us are meant to be solo providers, so the tricky part is finding a place where one can practice medicine in a meaningful way and be allowed to grow in a position. How do you find such a place?

U.S. HealthWorks has given me that elusive blend of a fulfilling medical practice coupled with an opportunity to fill my need to develop new skills in the areas of management, business practices and marketing. I joined the company hoping to be able to have a little control of the daily running of a medical office without the financial burden of opening my own clinic. What I have found is a company that encourages me to push my boundaries to make our collective futures successful.

The Managing Physician program at U.S. HealthWorks allows the participating physicians to play a vital part in the management team. It is a reflection of the company’s commitment to support physicians, and it enables them to be professionally successful. The program empowers me to learn new skills, innovate new policies and motivate staff. U.S. HealthWorks offers me the tools I need to lead and flourish in both the business and medical arenas. When the local centers are successful, the company is successful.

I have the utmost respect for the employees of U.S. HealthWorks. How many companies would entrust a physician with operating a medical office where the only rules are “Do your best” and “We will give you what you need to succeed”? They have the faith that the physician will perform to his or her potential, and the company will assist in areas that need cultivating. We have open access to upper management at all times – this awe-inspiring fact makes U.S. HealthWorks a truly unique place to work.

There’s that word again. Work. Some days it feels like the chain gangs are toiling on the railroad. But most of the time, working at U.S. HealthWorks is more in line with what I see as my life’s work: working for a company committed to our mutual success, fulfilling my needs as well as the needs of those we serve.

How to Quit Smoking

Smoking is basically a two part problem. The physical addiction to nicotine is very strong. If it wasn’t, it wouldn’t be so hard to quit. Medications (i.e. Chantix, Wellbutrin or Nicotine replacement in gum or patches) can be helpful to address the physiologic addiction.

Nicotine gum or patches substitute small amounts of nicotine to allow a weaning and gradual easing of withdrawal symptoms when quitting. Chantix and Wellbutrin work in a way that is both imperfect, not well understood, but probably most effective in fooling the center in the brain that controls nicotine desire. Neither has any nicotine but favorably affect neurotransmitters, chemical messengers between brain cells. This is similar to the way antidepressants have a positive effect on mood and anxiety. The net result is less interest in the seductive power of nicotine.

The second part of quitting is the habit or simple automatic behavior. Once you can see past the strong addiction to nicotine, you have to learn to cope with the stressors (boredom, anxiety, etc.) for particular situations in a different way. Changing your behavior is more straightforward but requires a plan and structure. Creating new habits in place of the old ones takes some persistence but is very attainable.

cigarettephoto © 2006 Bruce | more info (via: Wylio)

Here’s a simple behavior modification tip for quitting smoking:

1) Make a very specific list of the time of day “when” you smoke and “why” you smoke at that time. You can map out a typical day in writing. It should be in writing, but you need not share it with anyone. It is simply for your own edification. Writing it down allows you to be clear with all the tough moments throughout your day giving it careful review.

2) Then decide what you are going to do instead of smoking “at 9:40 a.m. when you have your break.” The structure and planning ahead provides a type of handrail to get through the difficult moment. Some ideas could be: eating hard candy, baby carrots, celery sticks, chewing gum, going for a walk, making a phone call. Any activity except for smoking will do. You must write it down so you can outline what you do accurately and make a definite plan in anticipation of the moment. Don’t leave it to the impulse of the moment.

Many people who quit smoking are not successful the first time. Anyone who has quit after the first try remains the lucky exception. Most people need a few times before they stop for good. So don’t view your past efforts as failures. The next time you are ready to give it a try, you are more likely than ever to succeed in being tobacco free – forever.

This small investment pays big dividends no matter what method you use to quit. Obviously, consult your physician to see if one of the helpful medications is right for you.

Ultimately, you have to change your behavior. It may seem daunting, but you can do it.

– Dr. Bruce Kaler

Nuclear Reactors 101

This week, Japan raised its nuclear reactor accident to a level 7, the highest stage on the nuclear incident scale created by the U.N.’s International Atomic Energy Agency. That is the same level as the 1986 Chernobyl disaster in Ukraine.

One thing is certain to come out of the reactor trouble in Japan – an international dialogue on nuclear energy generation. Both Japan and the U.S. depend on nuclear energy for approximately 20% of their national energy needs. Both countries have a long history of safe nuclear energy production with a few notable exceptions.

There are 436 nuclear reactors in the world at last count, possibly 433 now. These account for 15% of the world’s electricity production. The U.S., France and Japan alone account for more than half of the electricity generated by the world’s nuclear reactors.

What is a nuclear reactor, anyway? It’s a device used to control a sustained nuclear reaction (as if that helps).

Let’s start with the fuel. Uranium is a naturally occurring element found in bedrock in certain areas, like gold or diamonds. It’s dug up in mines where it occurs as a mixture of several kinds of uranium. Uranium 235 is the stuff used in nuclear reactors, and it’s about 1% of the uranium in the world. It’s a dwindling resource – we’re slowly running out because being radioactive, it burns itself up. The half-life is 700 million years, so don’t hold your breath.

For use in a reactor, uranium is concentrated (enriched) to a mixture of 20% U235. Continuing this enrichment to an 85% concentration of U235 would give you weapons-grade uranium.

Advanced Test Reactor core, Idaho National Laboratoryphoto © 2009 Argonne National Laboratory | more info (via: Wylio)

U235 is radioactive or unstable. What does that mean? It means it’s continually throwing off little high-energy particles (neutrons). It just sits there and cooks. Some of these particles hit other U235 atoms and more neutrons are released. Picture a pool table. Line up the balls so one hits two, and each of these hits two more. That is called a chain reaction. The other name is nuclear fission. As you can guess, it increases rather quickly – exponentially, the physicists would tell you.

U235 makes reactors go. It doesn’t need to be lit with a match or a spark plug. It’s constantly throwing off neutrons and releasing energy all on its own. The trick is to keep it from going too fast.

For use in a nuclear reactor, U235 is put in hollow tubes called fuel rods. These rods are placed in a reactor so they are close enough to cause a chain reaction. These tubes are surrounded by another material that can be adjusted to capture some of those neutrons to slow down the chain reaction. These are control rods. Simply speaking, if more neutrons hit other U235 atoms, the chain reaction speeds up. If the control rod captures more neutrons, the reaction slows down. U235 wants to release more and more energy, and the control rods slow it down. Conceptually it’s a glorified motorcycle throttle. The thing that makes a nuclear reactor work is controlling that chain reaction.

So we have U235 releasing a lot of heat and energy in the center of the reactor. The reactor coolant, usually water, circulates through the reactor where it absorbs energy and heat and turns to high pressure steam. This steam spins an electrical generator called a turbine. The steam cools back to water and is pumped through the reactor again. So, the water or reactor coolant does two things: it absorbs heat to cool the reactor, and it produces electricity. Pretty nifty.

The nuclear reactor will get too hot if the coolant stops circulating. The U235 can get so hot it melts through the bottom of the nuclear reactor. That is called a “meltdown.” That releases radiation, and that’s bad. The coolant absolutely needs to keep circulating.

Pound for pound, U235 will produce three million times the energy of the same amount of coal.

When the fuel rods have used up most of the U235, they are removed. Old fuel rods are still very radioactive and are stored in water to soak up those flying neutrons. We don’t want a chain reaction in an empty swimming pool. They need to stay completely submerged.

Nuclear reactors are designed with back-up systems for their back-up systems…for their back-up systems. Think many layers of redundancy. They are designed and built to never stop circulating coolant through the reactor. Very smart people spend a great deal of time trying to think up things that can go wrong – and preventing them.

Unfortunately, the Japanese nuclear plant was hit by a combination of natural forces the designers did not plan for. The unthinkable literally happened, and coolant stopped circulating.

So they are spraying water on the reactors with fire trucks, and trying to keep them cool. They are also filling the old fuel-rod pools from a distance. If it appears a bit unscripted and hazardous, it is.

But the result will not be Chernobyl 2, 3 and 4. These reactors are in containment buildings. There will be a local mess, but more so along the lines of the BP oil spill, not a radioactive wasteland.

Take care,

Dr. B

Cholesterol – the Good, the Bad and the Ugly

I have recently been concerned by the eternal question: should I eat only the top or only the bottom of a slice of pizza? Perhaps I need to invest in a new Zen calendar, just live for the moment and eat the darn pie. This of course is a sideways approach to a quick and dirty discussion of good and bad cholesterol.

Rainbow Pizzaphoto © 2008 Food Recipes | more info (via: Wylio)

What is cholesterol anyway?

Cholesterol is a fat that is in the chemical class called a sterol (kind of sounds like steroid, doesn’t it?). In fact steroids and vitamins are made from cholesterol. Cholesterol occurs naturally in plants and animals. You actually make it in your body. Cholesterol is also an essential part of your cell membranes. Cells, you might remember, are your little engines of life. You won’t go far without them. So cholesterol is a good thing in many ways. Don’t hear that very often, do you?

But, like so many other thing in life, excess leads to trouble – like the glass of red wine versus the whole bottle phenomenon. A little cholesterol goes a long way.

The trouble occurs in the handling and transport of cholesterol in your body. The liver is the main source of cholesterol production. The intestines absorb dietary cholesterol. Cholesterol is a fat, and fats don’t mix well with blood (blood is water based).

Your body makes lipoproteins which function like a soap to transport cholesterol. Soaps dissolve oil in water. For the record, Tide gets the grease out by surrounding the grease particle with molecules that dissolve in water on one end, and in oil/fat on the other end? The grease is suspended in the water in kind of a porcupine looking thing, with the soap acting like quills – how’s this for a mental picture.

These cholesterol containing particles (porcupines) are called lipoproteins, and come in several flavors, some more tasty than others. Low Density Lipoproteins (LDLs) are the bad guys. They are low density because they have more cholesterol and less protein. These have been associated with heart disease, stroke, and any manner of metabolic mayhem. They float around and are a large part of the plaques that form in arteries – the higher the LDLs, the worse the risk. LDLs are increased by dietary sources such as cheese, egg yolks, and meats like beef, pork and chicken, even shrimp. They are decreased by reducing animal fats in the diet and some medications.

HDLs are the good guys – you want lots of them. Their formal name is High Density Lipoprotein. They have a higher protein to cholesterol percentage, making them dense. They function to gather cholesterol from areas where it is problematic (in the wall of blood vessels) and transport it back centrally for disposal.

The medical community has increasingly seen HDLs as one of the most important factors in a healthy lifestyle. Many things raise the HDL levels. Among them are exercise, weight loss, moderate alcohol intake, a low-fat diet, fish oil supplements and quitting smoking. Medications can also be used to raise HDLs.

To tie up a few loose ends:

Trans fats are not naturally occurring. They are made in factories as a food additive and used in the fast food and pastry industry. Eating trans fats is a pretty bad idea as a little of these fats really raises the bad cholesterol.
• Saturated fats (animal fats) also raise cholesterol.
Poly unsaturated fats do the opposite – they lower cholesterol.

The answer to my original question about pizza (if you have been holding your breath) is of course a choice.

If you believe in the Atkins diet, eat the top of the pizza (protein and fat) and throw away the crust (carbohydrate). If you think cholesterol is more worrisome than weight, eat the crust and sauce (for the lycopene) and throw away the top.

My plan is to live in the moment and eat the very occasional whole pie with a glass of red wine – and exercise tomorrow.

Take care,

Dr. B

Delivering Care in All Situations

U.S. HealthWorks' Dr. Cori Repp

We recently asked our providers to share some stories about their experiences in providing care at U.S. HealthWorks. We thought this piece below from Dr. Cori Repp, Center Medical Director of our Bradenton, FL, clinic, was a great example of the diversity of experience as U.S. HealthWorks provides the care our patients need every day.

“Doctor, you’re not going to believe what you’ve got in Room 2.”

I looked up from my chart to see Mary shaking her head.

“This woman was assaulted last night,” she said.

I walked into the room and introduced myself. The patient was an older lady, with a slumped posture. She was visibly upset and had multiple bruises on her legs.

“Please tell me what happened,” I said.

“I was attacked,” she cracked a faint smile, “by a rooster! I’m worried that it has the rabies. I don’t want to get the rabies.” She confided to me in a soft drawl. “I hear it makes you crazy.”

She was actually the second patient attacked by the same rooster. It wasn’t at a farm or a processing facility but in the wooded, scenic garden of a nursing home, where she worked. It took longer to convince her that she wouldn’t get rabies from the bird than it did to treat her wounds.

As physicians, we look forward to challenges that keep our careers fresh and exciting – and keep us on our toes. In our occupational medicine clinic at U.S. HealthWorks, you never know what to expect behind the exam room door.

Occupational medicine is a rewarding field centered on the care of injured workers. Many physicians talk about their love for the field of medicine but express disappointment with the actual practice of it. Not at U.S. HealthWorks. Being part of a dynamic company with one focus greatly improves a physician’s ability to concentrate on the most enjoyable part – patient care.

Our case closure evaluation system is based on choosing the right tools to quickly return the worker to full function. Doctors are encouraged to provide appropriately intensive care to decrease the overall time for an injured worker to recover.

The diversity of occupational injuries keeps even a routine office day from being mundane. When a dog chases a delivery person into a canal and bites him, a provider has to put some thought into antibiotic coverage spectrums. Even routine musculoskeletal injuries become less repetitious when you consider the stories behind the cases. Wrist contusions are common, but how many occur from being squashed under a manatee when the chunky fellow rolled suddenly? I’ve seen three, all caused by the same animal.

U.S. HealthWorks encourages physicians to get to know the companies whose injured workers we treat. We visit companies that are household names, getting a backstage tour to see where the magic happens. I have toured the factory where Chris-Craft boats are born. I saw the entire process that turns Florida oranges into globally shipped Tropicana orange juice. I’ve even been to the nursing home where my patient lost a fight with that territorial rooster.

We treat those who assist us – firefighters, police, EMTs and teachers – when they are hurt in the line of duty. It’s rewarding to feel like an important part of your community.

Every day another exam room door opens to present a new challenge. Working for U.S. HealthWorks provides a variety of opportunities to practice occupational medicine that is as diverse as the businesses we serve.