Thursday, September 19, 2013

Is the risk of Stillbirth higher with home births vs. hospital births ?

According to the October issue of the American Journal of Obstetrics and Gynecology, the risk of stillbirth is 10 times higher for homebirths.

Researchers at New York-Presbyterian Hospital and Weill Cornell Medical Center, who analyzed data on more than 13 million US births. It is the largest study of its kind, the study's results were confirmed by analyzing birth certificate files from the National Center for Health Statistics to evaluate deliveries by physicians and midwives in the hospital and at home from 2007 to 2010.

The primary outcome measure was the Apgar score: Appearance, Pulse, Grimace, Activity, and Respiration. The researchers looked at Apgar scores of 0, neonatal seizures and neurological dysfunctions. The Apgar test is a screening assessment that quickly studies the health of a baby 1 minute and 5 minutes after being born. If a baby has a 5-minute Apgar score of 0, it is considered stillborn, but the researchers say that 10% of these babies survive.

The Apgar test is usually given to a baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Sometimes, if there are concerns about the baby's condition or the score at 5 minutes is low, the test may be scored for a third time at 10 minutes after birth.
Five factors are used to evaluate the baby's condition and each factor is scored on a scale of 0 to 2, with 2 being the best score:
  1. appearance (skin coloration)
  2. pulse (heart rate)
  3. grimace response (medically known as "reflex irritability")
  4. activity and muscle tone
  5. respiration (breathing rate and effort)
Doctors, midwives, or nurses add these five factors together to calculate the Apgar score. Scores obtainable are between 10 and 0, with 10 being the highest possible score.


- Babies born at home were nearly 10 times more likely to be stillborn.
- The risk of stillbirth increased to 14 times for firstborns.
- Babies born at home were also almost 4 times more likely to experience neonatal seizures or         serious neurologic dysfunction compared with babies born in hospitals. 

The study associated risk with the location of a planned birth, rather than the credentials of the person delivering the baby. When a child is born at home, typically there is only the midwife or doctor to address any unpredictable circumstances that arise, but in the hospital, a team of specialists can be mobilized in seconds if needed. Also excluded from the study were so called "taxi-cab" births where no Doctor, mid-wife or specialist was available, premature or multiple births, prenatal care and the effect of insured vs. uninsured mothers having home births due to cost.

Thursday, July 18, 2013

Prescription Opioid Use for Low Back Pain associated with Erectile Dysfunction.

Prescription Opioids for Back Pain and Use of Medications for Erectile Dysfunction. 

Spine: 15 May 2013 - Volume 38 - Issue 11 - p 909–915. Deyo, Richard A. MD, MPH*; Smith, David H. M. PhD, RPh; Johnson, Eric S. PhD; Tillotson, Carrie J. MPH; Donovan, Marilee PhD, RN; Yang, Xiuhai MS; Petrik, Amanda MS; Morasco, Benjamin J. PhD§; Dobscha, Steven K. MD§


It is said that most healthcare decisions in families are made by women. This is what I hear day in, day out, in my private practice. "Doc, I wouldn't be here if it weren't for my wife". In fact, many of my male patients initial appointments are made by their spouses.

Low Back Pain Statistics: 
  • Low back pain is the single leading cause of disability worldwide, according to the Global Burden of Disease 2010.
  • One-half of all working Americans admit to having back pain symptoms each year.
  • Back pain is one of the most common reasons for missed work.  In fact, back pain is the second most common reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.
  • Most cases of back pain are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.
  • Americans spend at least $50 billion each year on back pain—and that’s just for the more easily identified costs.
  • Experts estimate that as many as 80% of the population will experience a back problem at some time in our lives.
Prescription Opioid Narcotics, also known as "Pain Killers" are on the rise. These are available by prescription only and are also readily available on the street. Common Opioid Narcotics: Morphine, Codeine, Hydrocodone, Oxycodone, Methadone, Fentanyl, etc.

Initially intended for acute trauma, post-surgical pain and for terminally ill cancer patients, opioids have since been prescribed for chronic non-cancer pain conditions, without medical evidence that these powerful narcotics were either effective or safe for use in the long-run. The result is that we have a rapidly escalating epidemic of death and addiction, and pain patients with often reduced pain relief and various side effects over time. 

A recent article in the journal Spine found an association between usage of Opioids for pain relief and increased use of those patients for medications for Erectile Dysfunction and Testosterone Replacement Therapy.

In this study, there were 11,327 males with a diagnosis of back pain. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% confidence interval, 1.03–2.43), even with adjustment for the duration of opioid therapy.


Spinal Manipulation vs. Diclofenac for Acute Low Back Pain

Spinal High-Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain: A Double-Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo

Spine, April 2013;38(7):540-48.

Von Heymann, Wolfgang J. Dr. Med*; Schloemer, Patrick Dipl. Math; Timm, Juergen Dr. RER, NAT, PhD; Muehlbauer, Bernd Dr. Med*

 A recent article in Spine Journal, one of the most renown Scientific Journals for Spinal Disorders, compared the effects of Spinal Manipulation, high velocity low amplitude thrust, vs. Diclofenac in a Double Blinded RCT.

Diclofenac is a common NSAID (non-steroidal Anti-inflammatory) drug taken to reduce inflammation and as an analgesic.

A total of 101 patients with acute low back pain, defined as less than 48 hours in duration, were recruited from 5 outpatient clinics. The subjects were randomized to 3 groups: (1) spinal manipulation and placebo-diclofenac; (2) sham manipulation and diclofenac; (3) sham manipulation and placebo-diclofenac.

Thirty-seven subjects received spinal manipulation, 38 diclofenac, and 25 no active treatment. The placebo group with a high number of dropouts for unsustainable pain was closed praecox. Comparing the 2 active arms with the placebo group the intervention groups were significantly superior to the control group. Ninety subjects were analyzed in the collective intention to treat. Comparing the 2 intervention groups, the manipulation group was significantly better than the diclofenac group (Mann-Whitney test: P = 0.0134). No adverse effects or harm was registered.

Conclusion. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.

Thursday, January 31, 2013

Going off the grid: cancelling cable TV.

Cable TV: The "Heroin" of the entertainment world.

This is a departure from the usual Blog posts on Health & Medicine but I felt compelled to share my experience of cancelling cable.

When we think of Comcast, Xfinity, AT&T, Astound and all the other cable providers out there, it is definitely a love/hate relationship. The first image that comes to mind is:

In our household, we have the TV on as background noise most of the time. I'll admit, I use to be addicted to Hardcore Pawn, American Pickers, the Doomsday Preppers, etc. Most of the time, I would watch a movie on Cable that I have either seen multiple times before or already own because it was familiar.

Then it dawned on me. Cable TV is stressing me out. How ? Ever notice the bottom third of your TV, also known as TV real estate:

We are bombarded by advertising throughout the TV show/movie, commercials, etc. Even the streaming news stories constantly alerting us of terrorist threats, mass shootings, political tit for tat fighting, etc. This begs the question, why is Cable not paying me to watch this crap ?

My cable/internet bill started at $90/month, crept up to $160 - $200/month and now I was told I would have to commit to a 2 year contract to have my bill reduced for the first 6 months after which the price would increase in months 6-12 and then again from months 12-24. Oh yeah, I would also be forced to sign up for their "triple play" or bundled package forcing me to sign up for their VOIP phone service (which you would need to rent their special router).

So I researched an OTA (over the air) antenna option. What I got was mass confusion. UHF/VHF ? Indoor antenna vs. outdoor antenna. Where to mount. Where to point.

Luckily, we live in the Bay Area close to the San Francisco, San Jose and San Mateo broadcast towers. Since we rent, an outdoor antenna was out of the question and we decided to purchase an indoor antenna.

After some research, we decided on the Mohu Leaf Plus. This was about $60 - $70 on

Next, we had to find out how many channels we would be able to pick up. These web sites give you an idea of how powerful an antenna you need, indoor vs. outdoor and where you should point your antenna:

Antennaweb or TV Fool

Living in the Bay Area, we were able to pick up most of the major networks, PBS, and the local stations. We get about 27 channels, 5-10 Latino stations and about 5 various Asian networks.

Next, we decided that we would "stream" our movies and network TV shows. The two major players out there are: Hulu Plus and Netflix. Each cost about $7.99/month. Since we already have a huge collection of movies, we decided to go with Hulu Plus. In general, Hulu Plus has newer network TV episodes and older movies. Netflix generally has newer movies and older seasons of network TV shows.

Now, you need to be able to "stream" these from a device. Most Bluray players, Playstation or Wii devices allow you to do this. Smart TV's do as well. We purchased a WD Live which is similar to a Roku as our streaming device. We opted for the WD Live since it could play ALL out the codecs (mp4, avi, mkv, etc.) that our movies are stored as.

Of course, we had to keep Comcast internet, which is costing us $49.99/month and adding Hulu Plus is an additional $7.99/month.

We have literally thousands of DVD's, movies and TV shows purchased from iTunes. What do we do with these ? We bought a Network Attached Storage (NAS). Think of it as a mini home server. We can store up to 8 TB of media. So by using a program called Handbrake, we were able to convert all of our DVD's (that we purchased) to a digital format to store on our NAS.

Using our NAS to stream our movies, WD Live to stream Hulu Plus and our Mohu Leaf antenna for our local stations and major networks, we found that not only do we NOT miss Cable TV, we watch quality TV and movies. Also, I attributed a lot of stress to the advertising and the constant "doom and gloom" that our news stations put out. Our bill came down from $200/month to about $57/month.

So, we're taking the money that we are saving and putting it into mutual funds for our sons college fund, using the time to watch quality TV/movies and maybe even doing something constructive with our time like writing this blog article.

Saturday, January 26, 2013

For Neck Pain, Chiropractic Spinal Manipulation (Adjustments) superior than Medication, for both short and long term relief.

Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Gert Bronfort, DC, PhD; Roni Evans, DC, MS; Alfred V. Anderson, DC, MD; Kenneth H. Svendsen, MS; Yiscah Bracha, MS; and Richard H. Grimm, MD, MPH, PhD.

For Neck Pain, Chiropractic Spinal Manipulation (Adjustments) yielded superior results than Medication for BOTH short and long term Neck Complaints.

A study in the Annals of Internal Medicine found that Chiropractic Spinal Manipulation yielded superior relief in BOTH the short and long term, for neck complaints.

This exciting study was featured in The New York Times.

A large group of adults, 272 in all, were recruited and were diagnosed with acute or sub-acute, neck pain emanating from the spine and/or associated soft tissue structures. The objective of the study was to compare Spinal Manipulation Therapy, Medication and Home Exercise with Advice for acute and sub-acute neck pain in both the short and long term. This intervention lasted for 12 weeks.

The results suggested that Spinal Manipulation had statistically significant results over Medication at 8, 12, 26 and 52 weeks with pain being the main outcome studied.

Good news for Acute Low Back Pain sufferers, more room for improvement for patients with persistent Low Back Pain.

Back pain improves in first six weeks with treatment but lingering effects at one year. 

A large study published in the Canadian Medical Association Journal (CMAJ) found that for people presenting with Low Back Pain, symptoms will improve within the first 6 weeks but disability may linger for 1 year.

Researchers from Australia and Brazil examined data from 33 studies (11,166 participants) to understand the clinical course of pain and disability in people receiving care for low-back pain. Researchers were able to study the effects of treatment on patients presenting with acute low back pain and with patients presenting with persistent low back pain. 

At one year, the patients who initially presented with acute low-back pain still experienced some pain and disability but it was minimal; the typical improvement in pain intensity was about 90%

In contrast, those who initially presented with persistent low-back pain experienced moderate levels of pain and disability at one year; the typical improvement in their pain was only about 50%.


Dr. Rommel Hindocha, D.C. is the clinic director at Peninsula Spine & Sports Rehabilitation, located in San Mateo, California. Dr. Hindocha treats acute low back pain stemming from: muscle strains, ligament sprains, joint dysfunctions, sacroiliac joint disorders, non specific low back pain and mechanical low back pain.

Friday, January 25, 2013

Who is to Blame for Spine Care Costs in the US ?

Who is to Blame for Spine Care Costs in the US ?

Where the United States Spends Its Spine Dollars: Expenditures on Different Ambulatory Services for the Management of Back and Neck Conditions. Spine: 01 September 2012 - Volume 37 - Issue 19 - p 1693–1701. Davis, Matthew A. DC, MPH; Onega, Tracy PhD; Weeks, William B. MD, MBA; Lurie, Jon D. MD, MS.


Back and neck conditions are associated with considerable costs to the US economy both due to direct expenditures on their management and indirect costs from losses in productivity.
  • Between 49% and 70% of all adults will experience a back pain episode during their lifetime, and, at any given point in time, 12% to 30% of adults have an active back problem.
  • Back pain is the second most common reason adults consult a primary care provider, following upper respiratory tract infections.
In recent years, prevalence and costs for spinal conditions has significantly increased in the United States despite the little change in outcomes for these individuals suffering from these conditions. It is estimated that approximately $90 billion is spent on the diagnosis and management of low back pain, and an additional $10 to $20 billion is attributed to economic losses in productivity each year.

Therefore the purpose of this study was to examine the US expenditures (costs) on common ambulatory health services for the management of back and neck conditions (spine conditions) for:
  • Medical Care.
  • Chiropractic Care.
  • Physical Therapy. 
Study Design:

A Medical Expenditure Panel Survey (MEPS) from 1999 - 2008 was utilized. Data from US adults 18+ was used with sample sizes for the MEPS during these years ranging from a low of 23,565 individuals in 1999 to a high of 37,418 individuals in 2002; response rates ranged from 56.9% in 2007 to 66.3% in 2001.

Results of the Study:

In 1999, 11.9 million adults had an ambulatory visit for a primary diagnosis of a spine condition. This number increased approximately 15% during the study period to 13.6 million in 2008; however, with population growth, the proportion of all US adults reporting a visit for a primary diagnosis of a spine condition remained constant at approximately 6%. 

Number of visits per specialty:

Medical Care: The mean number of ambulatory visits to medical physicians for a primary diagnosis of a spine condition fluctuated between approximately 2.9 and 3.7 visits per year from 1999 to 2008.

Chiropractic Care: The mean number of visits for chiropractic care fluctuated between 7.2 and 9.3 visits per year.

Physical Therapy: There was more variability among adults utilizing Physical Therapy, the mean number of visits per year ranging between a high of 11.4 in 2002 to a low of 6.8 in 2005.

Annual Expenditures / Costs per Specialty:

Medical Care: The mean inflation-adjusted expenditure increased by 95% (from $487 in 1999 to $950 in 2008). The Mean specialist care costs ranged from approximately $800 in 1999 to more than $1,200 by 2008.

Chiropractic Care: The mean expenditure varied much less, fluctuating between a low of $473 in 1999 and a high of $662 in 2007.

Physical Therapy: The annual inflation-adjusted mean expenditure per user on physical therapy peaked in 2002 at $1543 and apparently contracted thereafter; however, the confidence intervals for physical therapy were large, implying considerable variation in expenditures among physical therapy users.


According to our estimates, the total annual expenditures on medical care for the management of spine conditions has grown significantly in recent years, whereas expenditures on chiropractic care and physical therapy have not experienced the same growth. Our study suggests that this growth in medical care is primarily due to increases in expenditures on Specialty care services (expenditures on primary care physician services were remarkably stable during the 10 years we examined).  Specialty care services include: Orthopedists / Orthopedic Surgery, Physiatry / Physical Medicine & Rehabilitation, Neurology and Neurosurgery.

Dr. Rommel Hindocha D.C. is the clinic director at Peninsula Spine & Sports Rehabilitation, located in San Mateo, California. Dr. Hindocha also practices at San Francisco Multi-Specialty Medical Group in San Francisco where he enjoys working with his Medical Specialist counterparts. In his San Mateo practice, Dr. Hindocha specializes in chronic back and neck pain, including: Sciatica, Hernaited Discs, Spinal Arthritis, Degenerative Disk Disease and Spinal Stenosis.