Monthly Archives: May 2011

Chronic Sinusitis at a Glance

No273 13 Oct 2009 Sneezephoto © 2009 mcfarlandmo | more info (via: Wylio)Sinusitis makes you and almost 30 million people each year feel miserable. The combination of facial pressure, headache, fatigue, sneezing, runny nose, drainage of thick colorful mucus from the nose and severe nasal congestion contribute to the misery. It is often difficult to treat, in many people is very slow to improve, and recurs frequently.

The chronic recurring condition known as chronic sinusitis or rhinosinusitis is a bit of a puzzle. We do not really understand all the factors that promote the symptoms that make you so vulnerable to recurrence.

Although the causes are not understood, there are several theories and observations floating around. Clearly, this is a stubborn condition often slow to resolve.

  • Infections are a common component but not the only piece to the puzzle. Research suggests there is a certain amount of swelling and inflammation in the sinuses and nasal passages that cause the congestion blocking airways and connections between sinus cavities. Any time there is warm, moist, closed-off space in the human body, it predisposes to problems.
  • Many factors may stimulate the swelling and inflammation. Environmental allergies are common and probably an underrated contributor to the inflammatory response.
  • The presence of some kinds of bacteria without actually causing an infection may also irritate the immune system to produce inflammation.
  • Structural abnormalities to the septum or polyps, which also result from chronic inflammation, may serve to block nasal airways as well.
  • Other medical conditions can be part of the problem. This can range from simple allergies, acid reflux from the stomach reaching nasal passages while asleep, cystic fibrosis, or any chronic conditions that affect immune system response.

The importance of identifying chronic sinusitis and initiating management can help provide greater comfort and prevent serious complications.

Treatment should aggressively address infections when they are present.

  • Since so many clues point to the role of inflammation, nasal steroid sprays have become a cornerstone of management.
  • There are several non-sedating antihistamines available without prescriptions that are effective when allergies play a role.
  • Many people find benefit from daily use of saline irrigation done with an inexpensive neti pot or irrigation bottle. Regular use of simple saline spray also is very helpful to help open and provide added moisture to nasal airways.
  • Surgery should be left as a last resort for only extreme cases that have failed all other measures.

Over-the-counter decongestants should be avoided. Although they provide quick short-lived relief, they just as quickly become less effective and can actually stimulate rebound congestion. This means they become part of the problem rather than the solution.

Chronic sinusitis is undoubtedly a stubborn and all too common problem. Although we do not understand completely why, many treatment options are available. Consult your healthcare provider to tailor a regimen that suits your needs. Do not ignore it and keep suffering. There is help!

– Dr. Bruce Kaler


Debunking 3 Weight Management Myths

Overweight? You have lots of company. It is one of the greatest public health issues of the last 20 years. Let’s discuss a few myths, as well as a few ideas.

Myth: Eat three meals a day.
Not so! Three meals a day is a modern concept. Historically there never was enough food for the average person to eat three meals a day. In many parts of the world, that is still true. If you eat three “reasonable” meals a day, you will be overweight.

Chinese Food Macro 12-6-08 7photo © 2008 Steven Depolo | more info (via: Wylio)

Myth: The kind of food you eat dramatically affects your weight.
That also is more myth than science. Your body needs somewhere in the neighborhood of 2,500 calories per day. If you take in more calories, you gain weight; taking in less means you lose weight. If you eat 4,000 calories of carrots per day, you will gain weight (and turn orange – I’m not kidding). The body happily converts protein, carbohydrates and fat in your diet to whatever the body needs. Carbohydrates are not the great Satan, nor are fats. Fats do happen to be twice as calorie-rich per weight as everything else. So you can only eat half as much fat. On that thought, it really is too bad that the body stores extra calories as fat (4,100 calories per pound). If it stored excess as carbohydrate or protein, it would only take 1,800 calories to burn a pound.

What is a calorie anyway? The calorie is a certain amount of energy that is contained in food. It can be thought of as “stored work.” You use it when you exercise or to keep your heart beating. Calories are good stuff, in moderation.

Myth: Exercise absolves you of food sin.
Unfortunately, there is no absolution. You need to exercise, and it is one of the most important health habits you can have. Exercise will burn 200-500 calories per session. That will help you lose weight or keep you trim. Keep in mind that 200-500 calories isn’t even a candy bar’s worth of calories. So exercise alone won’t do the job.

Now I would like to suggest the concept of dining for enjoyment vs. for fuel. I define fuel as calories I take in only to keep going. These are not tasted, savored or enjoyed. They are simply thrown down my throat hastily. Here is the important thing, in my opinion: if I am not going to savor and enjoy a meal, I might as well throw down something good for me (a protein or yogurt drink). If I have time to sit down and really enjoy a meal, I might as well eat something tasty, even if it’s not that great for me.

So get some exercise and don’t throw down bad food without enjoying it. If you are trim, it will help you stay that way, and if not, you will make steadily progress toward a lesser you.

Stay well,

Dr. B

Unlearning Supposedly Healthy Practices

Health information these days comes at us with the volume and velocity of a fire hose. Is anyone else struggling to stay afloat, or is it just me? Today let’s unlearn a few things and do a little myth-busting – kind of take out our brains and rinse them off with cool water.

Doctor Handphoto © 2009 | more info (via: Wylio)Retirement
Let’s start at the end with retirement – the golden years. Americans have eagerly awaited retirement since it was invented, which was only about 100 years ago. Retirement came about with the invention of the pension system. Previously people literally worked until they dropped. Ah, but to permanently abandon the grindstone and pursue a life of leisure filled with fly-fishing, golf and grandkid wrestling. What could be more healthful?

Retirement is actually one of the worst things you can do for your health. Everybody knows retirement is associated with a higher death rate, but we assume that is simply because old people retire. This has actually been studied, and if you match people for age, smoking and all important risk factors, the group that retires first, dies first. That is a curious phenomenon given retirement is a reprieve from the stress of work life.

Some of the reason for this is retired people’s activity level is often reduced – too much time watching TV or playing cards. Any job gets you out of bed and provides some exercise. The other factor is psychological. People need a reason to live. Believe it or not, endless rounds of golf or any other leisure activity gets tiresome. Work provides structure, social interaction and self-esteem that is not easily replaced after leaving the workplace. Retired people sometimes are haunted by feeling unimportant. They sometimes lose the “will to survive.” The body soon gets the message.

Avoiding Sun
We all know that sunshine is terrible for your skin. It will make you old and wrinkled, and it causes skin cancer. Surprisingly enough, this also not the whole story. Scientists study death rates all around the country looking for trends. The so-called Sunbelt consistently has lower death rates than our more cloudy neighbors. Serious diseases like a number of cancers (colon cancer is one of them) are less prevalent in the Sunbelt. It turns out sunshine on your skin produces Vitamin D, which is good for more than simply preventing rickets in children and osteomalacia in adults. Vitamin D is a potent antioxidant. The elevated levels of Vitamin D after regular sun exposure offers you some protection against cancer and premature death. It might very well be a choice between looking old and getting old. Just to be safe, try 15 minutes of sun a day without sunblock.

Dirt can’t be good. My mother kept the house spic and span. Cleanliness was not just desirable, it was elevated to the moral plane of godliness. All that sanitization, however, can wreak havoc with an immature immune system. Kids in very clean houses have elevated rates of asthma and autoimmune disease. These are diseases that can last a lifetime. One of the initial scientific findings that suggested dirt is good studied houses with dogs. Houses with two dogs have drastically reduced asthma rates. If you ever had a dog or two, you know it’s impossible to keep the house antiseptically clean. For those with no knowledge of the dog experience – dogs like to roll around in dirt, come in the house and joyously shake, raising a huge dust cloud. Makes you want to go right out and buy one, doesn’t it?

Single Life
Marriage is talked about a lot in both glowing and derogatory terms, but it has a surprisingly big impact on your health. This is a total surprise to every medical student who learns it. Mortality from almost every cause is significantly reduced by marriage. The truly amazing thing is no one mechanism is able to account for this. Married people have less heart disease and cancer, possibly because they eat better. But they also have lower rates of death from shark bites, gun shot wounds or almost any other cause you can think of. This has remained stubbornly unexplained after literally decades of research, and still today baffles young (single) medical students.

Reading About Health
Finally, obsessing about your health might not be a healthful activity, even though it seems like it should be. Many of us spend a lot more time researching, reading and discussing health than actually doing something healthy. Unlike your diet, where it matters very much what you consume, your reading choices don’t have nearly as much impact on your health. This might have considerable individual variability. The $10 million question is: does health obsession lead to more healthful activities? After 30 years of medicine, I remain unconvinced. Usually people just decide. Tomorrow is your next chance.

Take care,

Dr. B

California Healthline: Use of Urgent Care Growing in Southern California

Two of our esteemed doctors, Drs. Alesia Wagner and Franz Ritucci, spoke with California Healthline recently about the growth of urgent care. Check out what they had to say:

Use of Urgent Care Growing in Southern California
By Stephanie Stephens, California Healthline Regional Correspondent

Having matured from their early 1970s image of “Docs in a Box,” urgent care centers are growing in popularity with patients who would rather not wait to see a doctor — whether in an office or in the emergency department.

Urgent care’s growth is partly attributable to immediate and projected shortages of primary care physicians. California barely meets the nationally recognized standard for the number of primary care physicians. According to a July 2010 California HealthCare Foundation report, only the Orange, Sacramento, and Bay Area regions meet the recommended supply. Los Angeles falls just below.

Read the rest of the article here

Food Allergies at a Glance

The topic of food allergies is murky and confusing. Many reactions reported as allergy to a food product are really mere intolerance, over-eating or other factors. True food allergies are thought to occur in 8 percent of children under age 5 and only 3 to 4 percent of adults. The frequency of allergies does not vary much around the world, while both genders are equally affected.

True food allergies can cause reactions that differ from mild digestive issues, rash, hives or difficulty breathing. Anaphylaxis is the most severe form of allergic reaction, with onset within 20 minutes of ingestion that progresses rapidly, resulting in hives, shortness of breath, rapid pulse and even death if not immediately treated. Although estimates of life-threatening reactions vary widely, it comprises only a small number of the overall allergic reactions to food. True food allergies usually occur within 2 hours or less after ingesting the food. Onset of swelling or tingling around the throat, lips, face or hives and itching are early signs. It can progress to dizziness, nausea, vomiting or difficulty breathing. Which symptoms and how rapidly it progresses may be different in one person to the next.

Food intolerance is only sensitivity to a food that is driven by a different physiologic mechanism that causes much milder symptoms and does not lead to more severe reactions. A good example of this is lactose intolerance, or sensitivity to milk and dairy products. Due to an enzyme deficiency, it often results in abdominal gas, discomfort, cramping and diarrhea. It is a lot more common and vastly different than a true food allergy.

FOOD by Wolfgang Wildnerphoto © 2011 Wolfgang Wildner | more info (via: Wylio)

The most common food allergies are eggs, milk, peanuts, tree nuts (i.e. walnuts, pecans) wheat, and shellfish (shrimp, lobster, crab, clams). Regular fish and chocolate are much less common allergens than anecdotes suggest.

Food intolerance can be confused with an allergy. Only a small amount of a food can trigger a severe allergic reaction. Food intolerance, food poisoning, stress, a virus, medications, food additives (preservatives, coloring) can all produce similar but milder symptoms, particularly intestinal problems. So it can be confusing at times to ascertain what the origin of the reaction may be.

A family history of food allergies, asthma or eczema increases the risk of true food allergies. Allergic individuals may cross react between certain allergens. Some of those sensitivities can extend between dissimilar items that may not be obvious. Consulting your healthcare provider, an exam and possible testing may be able to provide peace of mind, appropriate treatment and identify what to avoid in the future.

The most important aspect of managing food allergies is avoidance. Unfortunately there is no specific treatment. Antihistamines are still the first line of defense in both children and adults at the onset of a food allergy. If severe, prompt medical attention may be needed. Food allergies in children often change over time. The onset is most common in the first few years of life but can occur at any age. Allergies do get better in some children as they get older. Research shows there is no relationship between allergies and when new foods are introduced after 6 months of age.

Variation in personal experience seems to be the rule. Family and personal history of allergies are stronger predictors of future course. The severity of a past reaction cannot predict the severity of a future reaction.

When in doubt about food sensitivities or allergies, simply avoid it! Consult your healthcare provider to help with any confusion.

– Dr. Bruce Kaler

Occupational Medicine at Work

We recently asked our providers to share stories about their experiences in providing care at U.S. HealthWorks. We thought this piece from Dr. Alix Thorson, Managing Physician of our Lynwood, WA, clinic, provided interesting insight into some of the work-related injuries she has seen at U.S. HealthWorks. Names have been changed to protect patients’ privacy.

When an individual gets injured at work, we at U.S. HealthWorks understand that this can be a vulnerable, unpredictable and painful time in the patient’s life. This is often compounded by an uncertain economy, with jobs in the balance and companies struggling. Can U.S. HealthWorks make a difference in these patients’ lives, as well as the health of their companies?


Nothing will take the place of excellent medical care and genuine empathy, but U.S. HealthWorks goes a step further by providing a level of occupational expertise critical for these patients and their employers.

Over the last seven years as a physician at the U.S. HealthWorks clinic in Lynwood, Washington, numerous examples come to mind:

Early Intervention and On-Site Help
In the spring of 2009, Frank came in with a back injury, suffered while lifting a case of soda. His back spasms were so severe that he was doubled over in pain and unable to straighten up. We fast-tracked him that day for a chiropractic adjustment, as well as physical therapy, and soon thereafter he was able to drive home much relieved. Frank was evaluated the following day by our physical therapist, and it was obvious that his early intervention and therapy accelerated his recovery and return to work. This shows how fortunate we are to have on-site physical therapy, chiropractic care and massage therapy. Our focus is not only on acute rehabilitation, but also on returning workers to their jobs quickly, safely and with a lower risk of injury recurrence.

A Helping Hand
Salvador, a Spanish-speaking patient, came to us with a nail embedded in his left hand that occurred while he was installing a roof. His trusting eyes could not conceal the fear of losing the use of his hand and his livelihood. As we guided him through his x-rays, injections and wound management, he was reassured with the help of our experienced Spanish translator. He was back to full duty after only a week, and we were thankful that we could provide skilled, efficient and cost-effective treatment for his injury.

Understanding Workers’ Compensation
Then there are patients like Greg, who suffered from a severe eye injury after being struck by a rock at work. He required same-day emergency care and multiple specialist follow ups. His claim, however, was subsequently rejected on a technicality. Thankfully the situation was later corrected, as was his vision. Intimate knowledge of workers’ compensation laws and communicating with claims managers and company contacts are things that greatly benefit our patients and their employers.

Getting Back to Work Safely
Thanks to our relationship with hundreds of companies, we were able to help patients like Louis, a laborer whose wife was expecting a baby in the same month as his injury. He was facing a loss of income after he fell off a truck on the job, but once we contacted his employer per our usual protocol, we were able to discuss his injuries and an appropriate modified position for him. He started a light duty job with his employer the next day. Louis, like most of our patients, was able to work and continue treatment of his injuries simultaneously, resulting in improved short- and long-term outcomes for him and his company.

U.S. HealthWorks provides outstanding occupational care, and that can make a difference to the hardworking people that need our help. Rewards in my position are many. I count among my favorites the firm, thankful handshake of Vincent, a landscaper whom we discharged after successfully returning him to his job from a serious knee injury. He left our clinic trailing fresh dirt from his work boots and a big smile on his face.

Sunshine 101

Summertime. The kids are off, the pool is warm and the sun is working overtime, at least if you live in Phoenix, Arizona. I daresay we may very well be the sunshine capital of the country. Our newspapers don’t list minutes of peak sun exposure to sunburn – we list seconds. Perhaps a bit of an exaggeration, but we know sunshine in the desert.

Before we get into the latest anti-aging/fountain of youth/magic sunblock, we need to talk about sunburn a bit.

The sun is a great big natural nuclear reactor up in the sky. Interestingly enough, the earth quakes (sun quakes) and tidal forces on the sun are literally off the Richter Scale, but the sun seems to tolerate them and should for a couple more billion years. The sun puts out radiation that they don’t make sunblock for, but by the time that radiation reaches earth, it has been reduced in intensity about 10 zillion percent. What is left is a mixture of X-rays, ultraviolet, visible light and infrared (heat) radiation. Most of the X-ray radiation is dispersed in the atmosphere. We are big fans of the visible and infrared radiation (think of a lizard sitting in a sunbeam). The ultraviolet we deal with less elegantly than the infrared.

sun shadephoto © 2007 .D.B. | more info (via: Wylio)

Ultraviolet light is broken up into 3 kinds – A, B and C. They do this to confuse people and make it seen complicated. UVA is the closest to visible light; it passes most easily through the atmosphere and won’t give you a sunburn. UVA is used in tanning beds and photo therapy. Photo therapy is when you go to Hawaii because you’re depressed (and try to deduct it as a medical expense).

UVB is shorter and higher energy. The ozone layer absorbs much of it, but we get enough at the surface to still get a pretty good sunburn. UVC is entirely absorbed by the atmosphere, and a good thing too, because it is germicidal and could wreak havoc with the microbes and ecology of the world – not to mention, you could watch your skin age.

The problem with ultraviolet radiation is it damages the skin. Excessive exposure over a short time results in the well known sunburn. This is a first-degree burn to sun-exposed skin. Anyone who has ever had one can appreciate just how much skin you have. It’s the largest organ on the body, and it is well supplied with nerves, particularly pain fibers. Hydration and ibuprofen are the way to go with the usual sunburn. A really severe sunburn needs hospitalization with IV hydration and serious pain meds.

But skin is damaged by sun exposure, even if there is no visible sunburn. Ultraviolet radiation penetrates surprisingly deep into tissue, damaging cellular DNA and elastin. DNA damage is usually repaired successfully by healthy cells. Rarely, the cell is repaired incorrectly but goes on and multiplies. We call that cancer.

UV radiation also breaks down the elastin in the skin. The elastin gives the skin its tone and support. Damage to the elastin leads to premature wrinkling and aging of the skin – a fate worse than death, according to some.

Sunblock is a recent development in society and has become an essential accessory on the equipment list for outdoor activity. There is little doubt it is generally effective at lowering UVB dosages, which reduces the more common kind of skin cancer and skin aging. Beyond that, sunblock is widely misunderstood. When was the last time you read the instructions on a sunblock bottle? Although it is counterintuitive, it doesn’t block the instant you smear it on. We think of them as paint. Smear them on and instant shade. They actually bind with elements in the skin to become effective. This takes time. In general, sunblock needs to be applied 15 or 20 minutes before sun exposure for peak effectiveness.

Then there is that whole Sun Protection Factor (SPF) number. There is a complicated formula to calculate the protective value of a sunblock. I have been known to stand in front of the sunblock display and carefully consider my outdoor activity and which to buy among 15 different brands, claims of waterproof/sweat proof/anti-aging and SPFs from 15 to 60. A frustrating experience and a waste of time. Buy your favorite smell, nicest bottle or least expensive as long as the SPF is 15 or greater.

The SPF factor is almost irrelevant. The SPF value of your sunblock is the least important ingredient in whether you get a sunburn. The dirty truth: sunblock only protects you for about 2 hours. Sunblock loses effectiveness with time, water, sweat, dirt and sun exposure. If you apply SPF 15, you will block about 90% of UV radiation for 2 hours. If you apply SPF 50, you will block 95% of UV radiation for 2 hours. After 2 hours, you are on your own. High SPF numbers wash, sweat and bake off just as fast as low SPF numbers. You really can’t get longer protection from higher SPF numbers.

The next common sunblock operator error is not using enough. Too thin of a layer will not protect you fully. That means you need to use an ounce. What is an ounce? Fill up a shot glass. That’s a lot of sunblock!

Sunblock also has an expiration date on it. Don’t count on full 2-hour protection if the bottle is expired.

Keep in mind, that the best sunblock is not portable shade. It is hard to beat shade. There is a reason the outdoor workers in Phoenix wear long pants, long-sleeve shirts and hats, even in the summer. Clothing does not lose its SPF factor for years. You can even be one of those funny people who carry umbrellas on sunny days when shopping.

Summertime is a great excuse to be outdoors doing active, fun things. A little preparation will allow you to avoid a sunburn and play another day.

Take care,

Dr. B