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This week's questions:
1:22 - What is your opinion of free public access to research articles?
3:13 - I was wondering what the cognitive symptoms of mild, moderate and severe dehydration were.
3:59 - I got my flu shot yesterday, and, curiosity and a Google search lead me to a report saying the 2015-16 cycle has been 60% effective. Is that good? Seems less than impressive.
5:01 - Why most universal health care coverage don't cover teeth? Treating my cavities is part of my health as much as treating the flu isn't it?
5:50 - Is there any good research on (moderate - heavy) weightlifting increasing bone density? And if it is, is this possibly a good way to decrease bone fractures in the general population?
6:43 - How do they make glasses for babies? I have to read a tiny line to get glasses but they make them for babies?
8:05 - Are all prenatal vitamins created equally? Some are $5, some are $20. What's the difference?
8:58 - I've had a cough going on 3 months now. All the doctors find is I have low potassium in my blood work and nothing on my xrays. Should I go to another hospital for their opinion?
9:46 - Advice on how to explain to friends/family that they don't know how to treat themselves better than their doctors do?
10:29 - I move all the time for school/work, so I'm constantly changing healthcare providers and I don't have a regular physician. How am I supposed to keep track of my medical history?
11:20 - For an otherwise healthy person, is there any good reason to endure a headache as opposed to knocking back some paracetamol/ibuprofen/aspirin?
12:18 - What is Tetralogy of Fallot, my nephew has it and nobody can explain it to me very well.
14:58 - Do antibiotics applied to the skin have the same effect as those ingested? I regularly treat skin infections this way. Should I stop?
15:43 - Olympics in Brazil, should it be cancelled because of Zika?

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[Intro Music]

I'm told we're live at Healthcare Triage. Sorry we're late [sighs], we've had a day here. Um, script misplacement, running out of-- ah, you don't want to hear it. Let's get -- let's just get going. Anyway, Healthcare Triage Live. Support us on Patreon if you can. That's all we'll do. Here we go.

Christina L., "What is your opinion of free public access to research articles?"

So, so funny you mention this, 'cause, um, Austin Frakt and I have actually talked about doing an up and back on this to, to post in The New York Times, 'cause, 'cause there's a good debate here. So, lot of people think all the research should be free, should be posted in online access journals and everything's fine. I buy that argument when the research is funded with public money, 'cause the idea that money should fund, uh, should fund the research but than everybody can't go look at it, public money, that doesn't seem right. Um, on the other hand, there have been changes so that that already does happen. Sometimes, there's just like a year lag or something until the stuff is public, but even then, I, I don't know...

 (02:00) to (04:00)

Problem is that it costs money to do the publication, the journals, and everything else. It costs money for the infrastructure to publish, to do the peer review, and the way they often get paid is by subscriptions. Um, otherwise, it's often by advertisements. But then everybody argues that's a conflict of interest, 'cause if a drug company's paying the journal maybe their more likely to, you know, publish positive stuff for that kind- that drug company. So, a simpler way is often to do subscriptions. That, of course, forces people out, but we have to pay for this somehow. So, I don't have a good answer. One is open access journals, which require basically, when I want to publish an open access journal, I have to pay. But, you know, where do I get that money as a researcher? Therefore, only like rich researchers, rich universities can do it? What if I conduct good research on a shoestring, and I can't afford the open access payments? Then, then-- So, this is not the easiest question in the world. I'm sympathetic to the arguments. I get why we should have research open. I'm in favor of everyone being able to see everything. I do not have an easy answer about how we should pay for that, and I think that the people that call for "everything should be free and open to everyone" have got to grapple with that and come up with some sort of solution with real world money that would allow that to happen.

Gideon Taylor asks, "I was wondering what cognitive symptoms of mild, moderate, and severe dehydration were?"

[Taps on desk]

I wish I could remember these off the top of my head. I would say probably that mild dehydration shouldn't have much cognitive symptoms. I mean, dehydration, first of all, when we use it clinically is severe. I mean, like you're talking like five to ten percent of your body weight of water gone. Like, that's real dehydration, and so that, we, what we call dehydration is not really dehydration. If you're seeing cognitive response, like problems, that's dehydration. Get, you know, call the doctor or, you know, call, you know, get, get them to the, get them help. That's real dehydration. There's probably a scale or a system to figure that out. I wish I knew it off the top of my head, um, but we could go look that up.

Megan Jacquelyn, "I got my flu shot yesterday, and, curiosity and a Google search lead me to a report saying the 2015-16 cycle has been 60% effective. Is that good? Seems less than impressive."

 (04:00) to (06:00)

It's... [sighs] that's such a great question, and it's a complicated answer. I-- This is the thing, if I, if we wanted to be boring, I could literally go read you a blog post I wrote last year which discusses this exact thing. And, if you will tweet me, I will send you the link to that post. Sixty percent effectiveness is not terrible. It's better than you'd imagine, um, but it's not perfect. The number needed to treat, even when you're down at 60 percent, though is still in like a reasonable range. It's not like the hundreds, or even thousands, that I think we see with some drugs that we use. Um, it is effective. It's not as effective as we would like, but it is effective. And, that sixty percent effective doesn't mean that like you got a sixty- or forty percent chance of getting the flu. The numbers and the math are complicated, and you should go look at my post or you should tweet me and I will absolutely send you there.

Garents the Kid, "Why most universal health care coverage doesn't cover teeth? Treating my cavities is part of my health as much as treating the flu."

Yeah, yes. I don't know, cause we're idiots in the United States sometimes and we don't consider things that are like the common sense health to be there. For kids, it's law that there has to be in the exchanges some dental coverage offered. You know, cavities are the number one chronic disease in childhood. Just are. We don't seem to care. Um, even when those dental plans are offered, um, they are not often, you know, affordable for everyone. Um, and, we, we used to do this with mental health, too. We use to think that, like, mental health wasn't health; therefore, we didn't really cover it. Laws changed, now it is. I expect some day we'll get there with dentistry and teeth health as well, but we're certainly not there yet.

Sentius Dayus, "Is there any good research on moderate on heavy weightlifting increasing bone density? And if it is, is this possibly a good way to decrease bone fractures in the general population?"

No, as far as I know there isn't.

 (06:00) to (08:00)

This is the thing, you can actually prevent accidents and falls with moderate or mild, you know, very low levels of activity.You don't need to be a heavy lifter to get improvements in the chance of, like, falls and fractures. Actually, just strength, you know, just muscle-- you know, just some training often helps. We've covered this actually, cause they even looked at vitamin D, then they looked at mild exercise. I covered this in a piece I recently wrote. In an episode I think we really did recently, a news episode on vitamin D. You know, exercise will help the elderly prevent falls and fractures, but, you know, vitamin D doesn't. Um, but you don't have to do, like, moderate to heavy weight lifting. That's probably overkill, and not necessary for most people.

Terrytown, "How do they make glasses for babies? I have to read a tiny line to get glasses, but they make them just for babies?"

OK, so a couple things here. One, you don't have to read a line in little kids, they can do symbols. So, you don't have to have a letter to do a test, you can say triangle, square. So, you can get low. Babies, on the other hand, one of two things can be happening. One is they can do reasonably good refraction tests these days just with machines, um, where they can just sit you down, have you look in a thing, and actually just tell what your refraction is. The other thing is that you should know, not all babies are being corrected for like twenty-twenty vision. Sometimes, when we're doing baby stuff, it's to stre-- you know, to make one eye, because eyes are not equal, um and that's one can be more developed than the other, and we basically screw up, or sometimes even patch, the strong eye to make the weak eye work better to bring it up. That's sometimes you're able to, ambylopia, things like that. Um, or we could be correct -- creating, or changing something else. My son, Jacob, had to wear glasses when he was little, because, um, he had an, originally an asymmetric red reflex, but basically he had some kind of differential thing with his eyes, and they needed to correct it. Um, and he doesn't wear glasses now. He outgrew that problem. It wasn't for he couldn't see twenty-twenty, it was for something completely different. Um, and then so, then it's necessary, necessarily to measure the perfect refraction, and try to get them to twenty-twenty.

 (08:00) to (10:00)

Christina L., "Are all prenatal vitamins created equally? Some are five bucks, some are twenty bucks. What's the difference?"

Fifteen bucks. You like that? Um...

[Laughing off camera]

No. Most of the time as long as you're getting the complete set and folates, you're good, and I don't know what they're putting into that extra fifteen bucks, except probably expensive urine. Um, but if the five dollar one doesn't have the folate, then I would be concerned, 'cause that's what you're - that's often what we're really talking about. Um, so talk to your doctor about what they think the difference is, certainly. And, if it doesn't sound right, email me or, you know, send me a tweet, and I'll try to look into that specifically for you. But, um, you usually, with respect to vitamins, this is what I talk about all the time, when you're talking about taking a multivitamin, which most people don't even need, you know, the cheap one by the barrel at Costco is all you need. Anything else you take above that is you're just peeing it out, doesn't make a difference.

Jonathan Vinnelli, "I've had a cough going on three months now, and the doctors find I have low potassium in my blood work and nothing on my x-rays. Should I got to another hospital for their opinion?"

I'm not going to give you medical advice, dude. Plus, it's like I don't know why you're going to a hospital, um, instead of a doctor's office. Maybe you just meant another clinic. I also don't know what blood test they're doing for your cough. I mean, there's lots of things that could be cough, and I'm not giving you medical advice, but lots of things could be cough. An allergy could cause cough, asthma could cause cough, you know, uh, reactive airway dis-- which is really just saying asthma another way could cause. So, it's not necessarily going to be something that's gonna show up in x-rays, or it's not going to be an infection. So, they need to work that up properly. You should talk to your healthcare provider about the differential diagnosis of cough. What else it could be. Three months seems like a long time.

Alexis Is Peachy, "Advice on how to explain to friends/family that they don't know how to treat themselves better than doctors do?"

Yeah, say that? Um, although I would also say like what are they treating? If it's a cold, doesn't matter.

 (10:00) to (12:00)

You know, symptomatic care is all you need to do, there's nothing to treat. If they're treating chronic diseases or real medical problems, then I might want to check in with a healthcare professional. Um, but in general, that's what doctors are trained to do, and if you're not going to trust them, OK, uh, but there's a reason that I, you know, graduated in the twenty-fifth grade to do what I do today; took a fairly large amount of schooling to get the knowledge I need to do this, and I would hope that most other doctors have learned something along the way as well.

Nick Sullivan, "I move all the time for school or work, so I'm constantly changing healthcare providers and I don't have a regular physician. How am I supposed to keep track of my medical history?"

Well OK, in an ideal world, first of all, there would be electronic records so this wouldn't matter, but it's probably a good idea to get your doctor, when you leave them, for them to give you a print out or summary of your medical record. Um, they may charge you a couple bucks for the xeroxing, but they'll do it. Um, and then you carry it for the next one. I used to just keep, I mean I have ulcerative colitis so I knew I had like some history that needed to be maintained. I had a file and I just kept it, and every time I went to a new doctor, I'd give them the file. Sometimes they'd update it. I had many copies of it. Unfortunately, we live in a world where individual patients have to do this for themselves, and, in an ideal world, this would be done for you by some sort of EMR or anything else. But, that's the good way, uh, to do it.

Megan Jacquelyn again, comma, says "For an otherwise healthy person, is there any good reason to endure a headache as opposed to knocking back some paracetamol," Tylenol for Americans, "ibuprofen, aspirin?"

No. I mean, why, why would you want to tolerate pain? I mean you don't want to get addict-- I should say addicted even though it's not addiction-- You don't want to overdose on these things. Um, you certainly don't want to be drinking a lot and using Tylenol, cause liver problems can be an issue. Um, you don't want to take too much ibuprofen, cause it can have chronic GI, or stomach, issues and pain and bleeding. But, no, if I have a headache, I absolutely take medication for it. Now, if you have tons of headaches, you want to talk to your doctor, 'cause if it's chronic that could be a reason for something in the long term.

 (12:00) to (14:00)

But, for an acute headache, local-- then absolutely, no reason not to treat it. Uh, if it's the worst headache of your life, super severe, you should call and get real help, but again, for a mild headache that you're having at home, why would you suffer? I can't think of a good reason.

Tivapox asks, "What is Tetralogy of Fallot?" uh, "my nephew has it and nobody can explain it to me very well."

So, Tetralogy of Fallot is a complex congenital heart defect. So, some babies are born with it, and it has basically four features. The first is a ventricular septal defect, and that's usually pretty large. What that means is that there is an opening between the two ventricles. So, remember the heart, we're going way back here. The heart, two atriums, two ventricles, the blood comes from, uh, let's say, comes from the body and it goes into the, oh my god this is where I'm going to kill myself right here, the right ventricle and then it's pumped, I mean the right atrium. Then, it's pumped into the right ventricle, then out to the lungs, where it gets oxygenated. Then, back to the left atrium, then to the left ventricle, then out to the body. So, the two ventricles, one of them has oxygenated blood and one of them does not. A large ventricular septal defect means that that blood is mixing. So, the blood that's getting out to the body is not as oxygenated as you would like. That's defect number one. Defect number two is pulmonary stenosis. The, uh, the vessel that's going from the heart to, to the lungs is narrowed, and it's much harder for it to get the blood out there. That's a problem. Three, right ven-- you get right ventricular hypertrophy. So, it's-- the heart has to work so hard to push the blood through that narrow ventri-- the, that narrowed pulmonary stenosis, the pulmonary artery, that it gets enlarged. Because if the muscles working so hard it gets bigger, cause muscles, that's how muscles work; when you work your muscles, they get bigger. So you get right ventricular hypertrophy cause it's gotten too large. And finally, you have what we call an overriding aorta. The aorta is suppose to just sit over one of the ventricles. So, pure oxygen, you know, blood coming-- fully oxygenated blood is coming out.

 (14:00) to (16:00)

The overriding aorta is sort of covering both ventricles, sort of, so again you're getting this mix of oxygen. So you got, again, four problems: the large VSD, the pulmonary stenosis, the right ventricular hypertrophy, and the overriding aorta. All four of those, unfortunately, leave it so that the blood coming out of your heart is not as well oxygenated as you can like, and with various problems and things that occur, you can get cyanotic and have problems. So, they have to do surgery for the most part, uh, to fix that, and it's complicated and I think if I remember, there's a few steps. They do some right after birth, but depending upon, a lot of times it depends on the surgery and how bad the pulmonary stenosis is, uh, on how, how many different-- Now, we've improved, obviously, the surgery quite a bit in the last few decades, but it's a serious problem. It's usually diagnosed in utero, and they want to fix it soon after birth.

Uh, let's look at the time. We've got time for one more question. Sebastian-- actually maybe a few more. SebastianP2Scan, "Do antibiotics applied to the skin have the same effect as those ingested. I regularly treat skin infections this way. Should I stop?"

Well, they don't have the same effect, 'cause, obviously, one is on the skin and one is ingested. So, when you take something, ingested, it's going everywhere. When you put it just topically, it's just treating that. In general, you want to treat topically when you can, because, of course, do as little as possible and it gets little side effects and the infection only needs-- So, if you can treat it locally, that's, that's great. Sometimes you can't get rid of skin infections with the topical, and that's when you have to go to the oral antibiotics. But, if you can treat it topically, that, that seems totally reasonable. Of course, I never give out healthcare advice on Healthcare Triage. You should talk to your doctor.

Last question. Jen4f, "Hi Dr. Carroll. Olympics in Brazil: should it be cancelled because of Zika?"

[Laughing] Somebody wrote yes. I don't know if that's part of your question of not. I don't know. That is such a great question. The problem is that it's like I don't know how we're going to-- you know, there are lots of other places where, I mean, the United States, Zika is becoming more and more prevalent.

 (16:00) to (17:46)

We're getting panicked about it here, too. I don't have an answer for you. I can't run the numbers and do the calculation. I know that if my wife were pregnant with, with a, with one of our babies right now, I'd be concerned about sending her to a Zika endemic area, because the risk of infection is reasonably pretty high, this thing seems easily transmitted, and, you know, pretty benign. It's one of those kinds things for other people, and the risks of, of, ah, this seems like a, you know, a risk, a real problem. We're not sure what it is and I don't have all the answers. So, I personally would panic, but, you know, on the other hand, I don't know if we cancel the Olympics. People have trained their whole lives, you know, there's a lot of economy and everything that goes into s-- I don't know. I wish I could answer for you. I'm sure we're going to see a lot of articles and discussions about it, and when other people have done analyses and there's stuff that we can compare and analyze and talk about, it might make a good episode for Healthcare Triage.

Thank you everyone for tuning in for a shortened, but excellent, I hope, uh, episode of Healthcare Triage News. Ah, again, support us on Patreon if you can, You can always get merch, You can check out the Facebook page, facebook-com-- Tune in Fridays for news, Mondays for the episodes. Lots of exciting stuff coming up in the future. Thanks for your support.

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