A number of patients coming into the office have sheepishly admitted that they don't drink enough during the day--water or otherwise. How much is "enough?"

The Journal of Physiology published this article, which attempted to review the extant evidence for or against the recommendation to drink at least eight 8 oz glasses of water per day. This recommendation is usually accompanied by the declaration that caffeinated beverages and alcohol don't count due to their diuretic effects. Though running into the problem of scant scientific articles, especially those evidence-based, this researcher concluded that for healthy men and women who lead realtively sedentary lives in temperate climates, the so called "8x8" recommendation has not been substantiated by scientific evidence. Note the qualifiers, though: the author acknowledges that adults who have significant disease or predisposition to certain diseases, who engage in vigorous work or exercise, or wholive in hot climates may indeed require 64 oz or more of water intake per day.

Other important points:

• using data from national and worldwide surveys, adequate water intake--via food, cafeinated beverages, and dilute alcoholic beverages (i.e., beer) in addition to water averages about five 8oz glasses per day
• individuals who may require "at least eight 8oz glasses of water" include those predisposed to kidney stones, leading active (more than walking for exercise) lives or living in hot climates
• there may be an inverse relationship between fluid intake and the incidence of bladder cancer, colorectal cancer, premalignant adenomatous polyps, and fatal coronary heart disease with as little as 5 8oz glasses of fluid per day, but specific EBM-valid studies have yet to be done
• the body's innate osmoregulation (via ADH) has been well proven to maintain adequate fluid balance; individuals at risk for overhydrating themselves--and subsequent hyponatremia, etc.,--tend to have other risk factors such as diabetes insipidus or exposure to the recreational drug ecstasy
• one feels thirst when plasma osmolality has increased by about 2%; dehydration is defined as a loss of >3% of one's body weight or an increase in plasma osmolality of at least 5% so the admonition that by the time you're thirsty, you're already dehydrated is not necessarily true

With this information in hand, it should be easier to relieve patients of their guilt about "not drinking enough water."

Someone once told me, "never accept anything someone tells you, always look things up for yourself." In that spirit...

A two week old infant came into the office for a routine exam. During the physical exam, the physician took a look at the umbilical cord stump, said it looked fine, and advised the mother to keep it clean and dry, and to swab it with alcohol each time she changed the diaper. I remember being told while on the newborn service in peds that we no longer advise parents to swab the cord stump with alcohol...and thus arose the question of whether or not to swab?

Alcohol has long been recommended for both dessication and antibacterial purposes. If parents use Google for their information source, they'll find this page in Medline Plus from the NIH, which advises parents to swab the cord with alcohol, emphasizing the importance of squeezing the alcohol around the base of the stump. However, this study from the Journal of Perinatology found that among  infants randomized to either alcohol swabbing or natural drying, none suffered from local infection. Those whose cords were allowed to dry without the use of alcohol actually fell off a few days earlier as well (an average of 13 days postnatally compared to 16 days in the alcohol group.)

So what? So, this is one less thing we have to remind parents to do at their 2 week visit and it's one less thing parents have to worry about when bringing a newborn home.

This week i meet a young couple who just moved here from vietam. They brought in their 4 year old son for a complete physical exam. The little boy's aunt was there too becasue the parents did not speak any english. We did not have any medical record on the son. Therefore, i asked if the parents know if their son got all his immunization, and that he most likely need his final round of shots. The aunt told me that their whole family does not receive immunization because they are afraid to get their children sick. That's right....she believe the shots will make them sick. I found out during the conversation that the whole extended family is has not receive immunoization. The aunt and the parent stated they never receive any, and they are in perfect health. I try to explain to them that icertain immunization may make the child ill for a short while, but it will protect them in the long run. I did not need the aunt to translate the parent's answer, and i knew they were getting upset with me pushing the ideas of shots. And i did not know if teh aunt was really translating my opinions correctly. I ask the parent to atlease think about it and call if they have any more questions.

This trend of non-immunization of foreign children is common becasue of the distrust in the government and not understanding what is immunization. After this encounter, i spoke to many of my other asian foreign patients, and alot of them told me that did not trust alot of their country's government. One asian patient told me "my doctor in china told me not to get my children immunized.

I did a little research and even modern countries (England, France) are having their own problems in gettign parents to immunize their children. The parent in westernized country are not immunizing their children not because of misstrust in their government, but misinformed about vaccine safty. It is very important for physician to educated the parent about vaccines.

 

The other day i was able to assist in a very sensitive procedure, a vasectomy. For those who don't know what it entails i'll tell you.

First step is to find the vas deferens on both sides of the scrotum, make an incision and cleaning them off from their blood supply. because you don't want to bleed into the scrotum it would cause a good deal of pain and brusing. Next you clamp of two parts of the vasdeferens and then snip off the segment in between, we went with a size of 1.5cm, but as you'll see there is some debate as to how much you really need to take. Then lastly you tie off both ends that are left on each side, cauterize them and then tuck them back into the scrotum then suture up the scrotum. The whole procedure takes a little over an hour.

Now cutting the vas deferens and tying off the ends, as well as cauterizing them, you think would be enough to keep the two ends of the vas deferens apart. However, there have been a few report cases of the ends reconnecting, yeah reconnecting. Obviously this poses a problem since you wouldn't have undergone the procedure if you didn't expect it to be a permenant fix. Depending on the article as much as 2% of men undergoing vasectomy could see a failure. The methods for determing failure were based on semen analysis 2-3 months after the procedure, a time legth that was believed to be long enough for the residual sperm to die, or have been removed. The most obvious failure type was not waiting long enough after the vasectomy to resume having sex.

The following articles show some reasons touted for failures of the vasectomy and particularly recanulization. While recanulization isn't the only method of vasectomy failure i thought that was an interesting one.

Some of the ideas believed to be the cause of recanulization are that the size of the vas deferens removed was to small. There are some conflicting studies on this a study out of quebec proved it had no association, while another study stated that a specific   amount of vas deferens should be removed. Another idea was that it had to due with the level of experience that the surgeon perfoming the procedure had. This also was proven not have a strong association. The most interesting reason for recanulization that i read had to do with the sperm forming a granuloma and connecting the two ends of the vas deferens back together. This is quite amazing to think that the sperm themselves build a bridge and actually reconnect their way out.  As you might guess the ones that were most dissapointed by the recanulization were the patients wives, because the most common way to realize that the vasectomy had failed, was.. pregnancy.

A 38 yo female smoker presented for a follow up since she had a flare up of her Ulcerative Colitis (UC). She had been under control but recently had a flare. She went to her GI doc and was told that her recent smoking cessation had caused the flare up. He told her to smoke a few cigarettes a day to control her UC. "What is he doing?!", you might ask.

This article discusses the effects of nicotine on both UC and Crohn's disease. Crohn's disease is known to be a disease of smoker's, where nicotine aggravates the symptoms. UC, on the other hand, is know to be a disease of non-smokers or ex-smokers that quit more than 1-2 years ago. Meta-analysis has shown an odds ration of 2 for smokers vs nonsmokers for Crohn's and an OR of 0.41 for smokers vs nonsmokers for UC.

In addition to being more likely to get Crohn's if you are a smoker, the progression of the disease is worse in smokers. Smoking cessation has been shown to be of benefit in Crohn's patients. But in Ulcerative Colitis, smoking has been shown to decrease the rate of disease and cessation has been shown to worsen the course of the disease. So, ex-smokers that developed UC were told to go back to smoking!

Today, physicians have recommended the nicotine patch, but now to avoid the systemic effects, nicotine enemas are being used to treat the symptoms of UC.They have the potential for fewer adverse effects due to the high first pass metabolism of nicotine by the liver.

Now we can offer the benefit of nicotine for ulcerative colitis without the negative systemic effects of smoking or nicotine itself!

A 52-year-old, Chinese, married, female housewife has had several appointments since I started working at the office for a few reasons.  The main reason is to closely monitor her Type 2 Diabetes.  The patient has a strong family history of diabetes with her mother, father and brother all being affected with the disease.  Therefore, she is quite concerned about it.  However, she is marked in her chart as a "noncompliant" patient.

Culture often plays a big role in how we treat patients.  For this patient, culture dictates her beliefs about medicine to such a strong degree that she has difficulty believing that the medications we give her will actually help her.  Instead, she prefers to use traditional Chinese herbal remedies such as ginseng tea.  Since my Preceptor and many other doctors do not know how to use these "alternative" forms of therapy, this patient and many others are not treated appropriately.

According to the American Association of Family Practice, the active ingredient in ginseng tea, ginsenosides, can be useful in the treatment of type 2 diabetes.  In a study of 36 type 2 diabetics, fasting blood sugars decreased with the use of 100-200 mg of ginseng.  With the 200 mg dosage, HbA1C also was found to decrease. 

Much of the research on ginseng has been done solely on mice/rats.  One study I found demonstrates the efficacy of ginseng on 10 non-diabetic and 9 diabetic volunteers.  The subjects were given 3g ginseng either 40 minutes before or in conjunction with a 25 g glucose challenge.  They found that both the non-diabetics and diabetics had lower postprandial glucose levels (18% and 19% respectively) with taking ginseng 40 minutes before meals.  In addition, type 2 diabetics had a 22% reduction in postprandial glucose when they took ginseng with their meals. 

These results indicate that ginseng may be quite beneficial in treating Type 2 Diabetes.  However, more research should be done using humans to be able to effectively treat our patients.  Physicians should be able to work with their patients in order to create a suitable treatment.  While more research needs to be done on the effectiveness of ginseng, the patient's beliefs should not be discounted since she may be right.  Using current research, I think patients would be more inclined to believe physicians and would be more compliant. 

The patient I encountered was quite highly educated and we found that just being honest about current research on herbal as well as non-herbal medications was more useful to her.  After trying to use ginseng tea and exercise for a long time, she found that for whatever reason it was not working.  My Preceptor offered the option of using insulin since her blood glucose was so high and she has been successful with that. 

Recently, I have been seeing many physicians I work with giving out samples of once daily 5-day courses of levaquin (L-pak) and azithromycin (Z-pak) to treat repiratory infections.

Are these new "fast-food" formulations really effective?

In this article on the intranet, these two treatment options were found to be effective in treating community aquired pneumonia. The macrolide, Z-pak, was less effective in patients who had previously used antibiotics within the past 3 months. In terms of cost effectiveness, these new "paks" should be beneficial since compliance often times dictates the cost of medication. With these 2 treatments, complaince should be quite high since the duration and dosage is minimal. Therefore, patients will only have to buy and take the antibiotic once as opposed to several times in order to treat the infection completely. In fact, the drug remains in the body for about 3-7 days after completing the prescribed course.

This study in JAMA, also through the intranet, investigated the differences between a high versus low-dose treatment of amoxicillin in treating Strep pneumo in babies for 5 versus 10 days. The study found that the high dose, short term treatment was more effective in decreasing resistance (24% versus 32%) and in increasing compliance (82% versus 74%).

Should these be used on our patients?

Resistance is quite likely with the ready-to-use format of the L- and Z-paks, so this is an aspect that should be kept in mind. However, this factor should not discourage their use since physicians should consider resistance when they are prescribing any antibiotic treatment.

Hey everyone.  So here's my cultural issue for posting.  They other day I was giving an annual physical to a middle-aged Japanese woman.  She had emmigrated from Japan to the US about 10 years ago, and married an American born man.  She spoke limited English, and came alone.  I was able to get through most of the physical without too much problem, but I noticed a big problem during the personal questions and domestic violence screening.  Not only was this woman reluctant to talk about her sexual life, but also did not give clear answers to domestic violence questions.  It got me thinking about this woman, and about all the cultural barriers facing her if she were being abused and wanted help.

I found this article here, which talks of some of the barriers faced by Asian and Pacific Islander communities.  Basically, women who emigrate here from these communities face man problems if they try and seek help.  The number one problem is of course language.  But that problem is deeper than one would expect.  Sure, the fact that many do not speak English, and that there are few interpreters is a barrier, but so is prejudice.  There are many people in this world prejudiced against those who do not speak their language.  And perhaps this woman's experience with that type of prejudice translated into her timidness and unwillingness to share about her life with me.

Customs too also play a role, with the rights a woman had back in her native country influencing the rights she may perceive she has here.  While all women in the USA have equal rights as men, not all women who emmigrate to this country have that same viewpoint.  Many countries are more or less patriarchal than here.  This could play a role with the patient I saw as well.

Money and family is also a factor.  This woman married an American, and moved to America for him.  Her family is all back in Japan, and her money is all tied up in her husband.  He is literally her support financially and emotionally here.  And both distance and pride serve as barriers to her reaching out to her family back home if there was a problem.

Basically, what I learned from this woman is that cultural differences between the patient and the caregiver affect the information a provider can gather, and subsequently, the care they can provide.  And we as future providers must keep our eyes open to these cultural differences, and be sensitive to them so that we may truely get to konw our patients so that we may help them.  Incidentally, I got the chance to see this woman again, and the second time she was more open with me, and I was able to find out she was indeed safe at home, and get some of the info I was unsure of before.  But had I just passed her off as being shy, and not thought of the cultural differences between us, I would never have gotten the answers I needed.

We'll since i'm up in Maine and there really isn't much in the way of diversity here. We'll i guess there is some if you consider moose and people diverse. The only real cultural situation that i ran into was a case of prenatal care and her ideas on childbirth.

A few weeks ago my preceptor and i saw this 42 year old women who is going to have a baby in a few months.  Only the thing that separated her from all the other prenatal visits that we have seen is that she is a very strong believer in natural birth, and i don't mean just normal vaginal delivery, i mean no prenatal vitamens, no ultrasound at 18 weeks, and no paps to check for cervical cancer. The only type of care that wanted was to ask the doctor questions, everything else she wanted to either do on her own or via a midwife. She didn't even want to listen for a fetal heartrate.

I was sort of taken back by this i'm so used to people asking what more they can have done medically that this once when soneone didn't want medical help was interesting especially in her case since she is a bit older and therefore carries a higher degree of risk with her pregnancy that she wouldn't want a doctor around was difficult to understand.  So what we did was examine her as much as she would like then consul her on going to the hospital if complications arise during the birthing process and told her to continue with the midwife.
And i know some of you may be thinking that this may be due to her having a bad outcome with a previous pregnancy, but quite the contrary she actually delivered another baby using this method as well. I'm not trying to pass judgement on her, i just thought that it was an interesting approach to childbirth, a very hands off, whatever happens happens approach.

The other day an active 45 year old patient with type 2 diabetes came in for a regular check up. His BMI was 25, his hemoglobin A1C was 6.5 and his blood pressure was well controlled at 112/80; despite this and to my surprise, my preceptor decided to begin the patient on an ACE inhibitor. Knowing that ACEi's and ARBs are common first-line treatment for diabetics with hypertension, I was curious about the indications for  treating diabetic patients with ACEi's and ARBs.

One of the main reasons ACEi's and ARBs are prescribed to patients with diabetes is to prevent the progression of diabetic nephropathy. After searching the literature, I found this article put out by the AAFP in July to answer common questions about the management of patients with diabetic nephropathy. Patients are usually screened for diabetic nephropathy by periodic examination of their urine for microalbuminuria: more than 30mg albumin per 1g creatinine constitutes an elevated level in a one-time ("spot") test; if you're going to inconvenience your patient with a 24 hour collection, you'd look for more than 30mg of albumin per 24 hours to diagnose albuminuria. Two to three positive tests within a 3-6 month period confirms diabetic nephropathy.

How do ACEi's and ARBs fit into this picture? The UK Prosepective Diabetes Study (UKPDS) showed that patients with microalbuminuria can slow the progression of nephropathy and can even help with regression of the microalbuminuria if they

• optimize glycemic control (HgbA1c < 7)
• control hypertension (UKPDS target BP < 140/80; AAFP recommends < 130/80)
• use ACEi's or ARBs

Interestingly, I also came across a meta-analysis of RCTs abstract or comple which looked at the incidence of new-onset diabetes in patients with hypertension or at least one cardiovascular risk factor: the patients in the studies compared ACEi's or ARBs to placebos. The results of the meta-analysis showed that ACEi's reduced the risk of new-onset diabetes by 27%, ARBs reduced the risk by 23%, and the use of either an ACEi or ARB reduced the risk by 25%. (click here for the abstract or here for the complete article, requiring you to log on through the intranet)

But what does all of this mean for the patient we started with? He's already got diabetes, so an ACEi is not going to be preventative in that sense. His Hgb A1C is well below the target and his blood pressure is well-controlled: he appears to be at low risk for diabetic micro- and macrovascular events. Perhaps this was over-aggressive management?

For future patients, however, keep in mind that ACEi's and ARBs are excellent first-line drug therapies for hypertension. Patients with diabetes will benefit from the renal-protective effects and those with multiple risk factors for diabetes may even prevent its onset.

I saw two unrelated patients on the same day with scabies, so I thought that was a sign for my next entry to be about scabies.  The common thing to look for is characteristic rashes between fingers and toes, as well as the wrists and crevices.  We treated these two people pretty much the same way.  Extreme cleaning of the place where they live and a permethrin cream that they apply full body and then wash off 8 hours later.

We all know that scabies is pretty contagious, so we have to treat many exposed people prophylactically.  Here's an article on prophylactic use of ivermectin for scabies.  It seems to work well even though it's not approved in the US, so in the clinic we still prescribed permethrin.  Here's a thorough site on the different drugs used for scabies.  They also show that ivermectin is just as effective for scabies, and for just about the same price.  There are occasions where it would be better to use ivermectin, like in patients who might scratch the cream off or if the cream doesn't work.  They state that the reason it isn't used is because the FDA has not approved its safety for pregnant and lactating women as well as small children.

An aside while I was searching for scabies, I came across this article that shows that scabies will show up positive on an atopy patch test for normal house dust mites.  So if someone comes up positive, you might just want to check out the rash before you dismiss it as atopic dermatitis.

Anxiety is a common condition for people coming into the clinic.  We had a  young girl come in for anxiety attacks with her mother.  Here's an interesting article on childhood anxiety and the association with mom's mental health.  In their study of kids being admitted for mental health issues, 61 percent of the mothers fell under DSM IV criteria for a psychiatric condition.  In our case, the mother seemed to be fine...but then again we didn't really question her as much.

Usually the treatment is cognitive behavior therapy, and according to these guys usually a referral to a specialist.  Here's a an article saying that getting the parents involved with the therapy helps the outcome of the kids.  Given the first article, and how parents usually have a problem, this would probably be better for everybody.  Obviously a lot of a child's anxiety will be influenced by the parent. 

There are other methods to treat this disorder, mainly medications, of which anti-depressants and anti-anxiety meds are both used.  SSRI/SNRI's are used in adults as first line, but there effectiveness in children is still in question.  It seems that SSRI's may cause suicidal thoughts so monitoring is essential.

A 54 yo female who presented this past week with, what to me seemed to be the most unusual symptoms. (I will admit that this shows a void in my educational knowledge, nevertheless.) She said that she had this vague sensation in her legs mostly. Sometimes it would be painful and other times just fatigue like symptoms. The sensation would originate from mid femur radiate distally to her legs and proximally into her hip. NSAIDs did not seem to help and resting did not seem to help. She stated that some relief was gained by stretching her legs. 

As the weather begins to change, more patients will be coming into the office with symptoms of the common cold.  Just as often as you see patients with the cold, you'll hear from people that taking echinacea for the cold will help to relieve symptoms or if taken prophylactically, will prevent rhinovirus infection. Even one of the nurses in my office jumped to tell me "take echinacea!" when I came in sniffling and congested the other day.

Is there evidence for this idea? According this article published in July 2005 in the New England Journal of Medicine, echinacea alone or echinacea in combination, does not have clinically significant effects on rhinovirus infection.  399 volunteers who were challenged with a rhinovirus serotype after being given prophylactic echinacea or placebo showed no difference in volume of nasal secretions, on polymorphonuclear leukocyte or interleukin-8 concentrations in nasal-lavage specimens, or on quantitative-virus titer.  This is one of many articles that actually proves that echinacea is in fact not the wonder herb that many taut it to be.

Last year American spent about $155 million on echinacea. It seems now that that was money ill-spent.  Let's educate our patients and help save them a couple of dollars this year shall we?  

When giving a physical to children for school, I always finish with the Adam's Forward Bend Test to check for scoliosis. One young girl informed me that I didn't need to do this, as she was already told her back was "crooked". Of course I did it anyway, and lo and behold...she did have a slight curvature to her lumbar spine. However, her shoulder blades were even.

The Adam's Forward Bend Test is merely a screening test, so how is scoliosis actually diagnosed? ...by X-ray of course. The degree of scoliosis is actually measured on the film using the Cobb method.

So they have scoliosis, now what? Treatment basically consists of the surgical vs. the non-surgical (which includes orthopedic braces or just observation) based on the degree of scoliosis.

Braces are best for those with curves between 25-40 degrees and substantial skeletal growth remaining. This study shows that a soft brace, although previously described as effective in treating scoliosis is not as good as the plastic thoracic-lumbar-sacral orthosis during the pubertal growth spurt. Most braces do not correct the scoliosis, but prevent further deformity. But this study shows that for infants already diagnosed, corrective plaster jackets can reverse the scoliosis.

This study shows that for those that undergo surgery, dual growing rods are better than a single rod to reduce the degree of curvature.

My patient's scoliosis was very small (5 degrees), so observation is the best choice of treatment for her.

 

Scenario:

A middle-aged man comes to the family practice clinic for a pre-surgical assessment.  He has been experiencing constant tearing and blurry vision in his left eye for approximately 6 months.  Upon inspection of his eye with an ophthalmoscope, it appears as though the conjunctiva on the medial aspect of his eye is growing laterally, covering his eyeball.  He has a pterygium, and because it is causing visual changes he is having it surgically removed.  He is concerned that after the surgery, it may grow back.
 

Does he have a right to be concerned?

According to this author, the recurrence rate after surgery has been documented to be as high as 80 percent.  This patient, therefore, does have a right to be concerned.  There is a possibility of hope on the horizon, however, in the form of Interferon alpha-2b.  In a preliminary case study, this anti-proliferative drug was used topically to treat a recurrent pterygium.  The next step would be to conduct randomized clinical trials, to further ascertain this agent's clinical usefulness.      

34 yo female c/o dizziness, loss of balance when she arises from her bed. She feels nauseous and vomits early in the morning. Previously she mentioned that she had a viral infection and she didn't seek treatment. She also reports that when she turns her head, she feels loss of balance.

What is the diagnosis - Vertigo

What I really liked about is how my doctor during physical exam handled this situation. He spent little bit more time explaining what her symptoms meant, as well as, he assured her that it is quite normal to develop these symptoms after a viral infection.He also spent time rotating her head back and worth entire 360 degrees and he was explaning all his tests. My preceptor followed all the tests mentioned in this article to achieve the diagnosis. 

The doctor suggested that physical therapy might be helpful to her. He mentioned Cawthorne-Cooksey and other exercises might be helpful to promote and develop balance. Now he told her to come back after one month and tell him whether these symtoms continue.

Case: 10 week old male infant returns to the office post UTI and ABX treatment. The patient presents with a slight fever and cough.

Plan: Based on the age, and gender of the patient the etiolgoy of the UTI appears anatomical. In order to assess the situation the attending decides that a voiding cystourethogram (VCUG), and renal ultrasound are necessay. The concern is that the infant is having retrograde urination which can cause kidney damage (primary vesicourethral reflux). A dimercaptosuccininc acid (DMSA) study should be done to rule out pyelonephritis. Additionally, young patients who present with UTIs will need to be on prophylactic ABX treatment until ages 6-8 to prevent further infections. The attending in this situation chose 20 mg/kg Augmentin. Lastly these patients should get annual radionuclide cystography to detect reflux.

A fifteen-year-old came to the clinic for his yearly physical.   He is healthy and reports no medical problems since his last visit.  In 2004, he sustained a concussion while playing football.  A specialist evaluated him at that time.  He wants to return to playing football and soccer.  His mother and the FP wanted to know if he was fit to return to play.
 
While concussions have been rated from mild to severe using a number of scales, none of these scales have been validated.  Most physicians (and some medical societies) maintain that loss of consciousness (LOC) marks the line between mild and moderate concussion.  This article looked at clinical signs used to determine how long an athlete should wait before returning to play (RTP).  It shows that LOC is not the only measure of RTP.  Headache, difficulty concentrating, and retrograde amnesia are all associated with prolonged recovery. 
 
While the linked article is quite clear in its assessments, it was a small study with potentially fatal design.  The researchers sent questionnaires to sports medicine providers.  Each participating physician was allowed to make their own decisions as to when athletes returned to play, making the bias of individual clinical opinion very likely.  None of the patients were followed for sequelae of the physicians decisions.  Finally, the study did not distinguish between pediatric and adult cases of concussion nor did it assess enough female athletes to make gender-specific recommendations. 
 
The current guidelines from the National Athletic Trainers' Association can be found here.  These recommendations include performing baseline or preinjury assessments of cognitive function, postural stability, and other variables (ADHD, learning disability, age, education, etc.).  After a concussion, recovery can be easily assessed by comparing pre- and post-injury scores.  However, the specificity and sensitivity of the recommended assessments is unknown, leaving each physician or athletic trainer to make decisions on return to play based on clinical judgment.
 
In terms of my patient, we decided to consult his specialist before allowing him to return to action.  While the patient has been asymptomatic (no headaches, irritability, nausea, visual disturbances, cognitive problems) for about 10 months, we were uncomfortable with making a decision based on the evidence we could find.  Needless to say, the evidence presented above did little to help us.  Obviously, more research is needed.  Until we have definitive research, we will have to practice based on good ol' clinical opinion.

    For the past few weeks middle and high school aged children have been coming to the office to get required yearly physicals.  During these sessions, it struck me that when questioning the young men about the consumption of alcohol, use of illegal drugs, and safe sex, few (if any) performed regular testicular self exams.  I began to wonder how this ignornace concerning testicular cancer could be so widespread considering it is the most common neoplasm to affect 15 to 35 year old males.

     As I searched for information about the level of knowledge adolescent males have regarding testicular cancer, I learned most young men have few truly reliable sources for information.  One study of Swedish high school men found that the mass media was the main source of information concerning the topic.  Another study of young men involved in the Boy Scouts found that the majority had heard of testicular cancer before, but only approximately 1 in 10 performed regular self exams.

    Perhaps one of the most startling pieces of evidence concerning testicular cancer is it's effect on different ethnic groups.  The previously mentioned study of Boy Scouts found that African American males were less knowledgable about testicular cancer and self exams.  This is striking when viewed in light of the results of these studies (#1) and (#2) which show that both Asian American and African American men present with more advanced disease than White males.  Patient education concerning testicular cancer is not time consuming or difficult.  School physicals represent a time and place where physicians can have a beneficial effect with minimal added effort.

    With the chemotherapy, radiation therapy, and surgical options available to patients that develop testicular cancer, early detection with regular self exams can lead to a near perfect outcome.  Worries about infertility are warranted, but early detection can allow for less toxic treatment leading to greater fertility later on.  Decreased sexual function has not been found to be a side effect of successful treatment. 

    A school physical represents the ideal "teaching moment" for topics like drugs, alcohol, and safe sex.  The exclusion of testicular cancer from the discussion is not only a disservice to the patient, but bad practice.  Since the sources of information are wide and varied, the role of the doctor is critical in educating young males about a very curable disease.

Multiple Chemical Sensitivity (MCS) : Real or Fake

The other day in the clinic I had a patient come in wanting to know if this was the kind of practice that could handle his chronic problems. The patient told us that he suffers from multiple chemical sensitivity and fibromyalgia and wanted to know if my preceptor believed in this diagnosis. 

Multiple chemical sensitivity, also known as Environmental Illness, which is caused by exposure to toxic chemicals in our environment such as pesticides, perfumes and other scented products, fuels, food additives, carpets, building materials, etc. The symptoms of MCS are as follows: difficulty breathing, sleeping and/or concentrating, memory loss, migraines, nausea, abdominal pain, chronic fatigue, aching joints and muscles, and irritated eyes, nose, ears, throat and/or skin. In addition, some with MCS show impaired balance and increased sensitivity not just to odors but also to loud noises, bright lights, touch, extremes of heat and cold, and electromagnetic fields.

Patients with MCS also seem to have a coexistant diagnosis of either fibromyalgia or chronic fatigue syndrome, and they usually suffer from depression, anxiety and somatoform disorders.

As you can see MCS can basically cause anything, which is why there is much controversy over the pathogenesis, diagnosis, evaluation, and treatment of this syndrome.

So if you ever get that patient with a laundry list of disorders that just don't make sense, perhaps it might be MCS.

Lately I've been seeing a ton of UTI's in the office, almost all of which are young to middle aged women, and uncomplicated.  My preceptor prefers to treat using Levaquin as a first line agent, citing compliance, and low levels of resistance as reasons to use over Bactrim initially.  This piqued my interest, as we have always been taught that Bactrim is the first line agent to use.

The usage of Levaquin as a first line agent got me thinking about whether or not the easier dosing of levaquin, combined with the increased likelihood of erradication after initial treatment was worth the increased side effects associated with the quinolones, as well as the chance of promoting resistance to these powerful drugs.

This article talks about using quinolones like Levaquin as first line agents.  It is a link to an abstract, but the full article is available through the intranet.  Basically, the authors agree with my preceptor, and do advocate the usage of quinolones as a first line treatment.  This is because the resistance to Bactrim is pretty high (over 20%) in some areas, and the resistance to the quinolones is low.  Therefore, using quinolones as first line increases the chance of successful initial treatment.  Also, the quinolones used to treat UTIs are renally excreted, and thus highly concentrated in the urine.  This allows them to be very effective at eliminating the bugs that cause UTIs.  By eliminating the bacteria so effectively, resistance is avoided.  Furthermore, as of now, there is low resistance in the community to these agents, although they do admit there is a chance of using these agents more widely will cause increased resistance.  Side effects are also a concern, although Levaquin has a low incidence of many of the common quinolone side effects, as well as the advantage of being able to be used in people with a sulfa allergy.

So the take home message is my preceptor's usage of Levaquin as a first line agent to treat UTIs is indeed supported.  The patient gets a greater likelihood of cure with initial treatment, as well as easier dosing. 

A 57-yr-old patient had entered menopause 10 years ago.  Initially her gynecologist had prescribed HRT to ameliorate her moderate-severe menopausal symptoms.  After 6 years this treatment was discontinued because it was deemed ineffective for this patient.  Moreover, this patient has a very significant family history of breast cancer.  Nearly all first and second degree female relatives on her maternal side have been diagnosed and treated for breast cancer; "In my family, it's not a question of ‘if' but ‘when'".  She has personally experienced benign breast changes and is diligent about SBE's and having mammograms (and now MRI) performed regularly.

During the last three months, this patient has experienced an increase in the frequency and severity of climacteric symptoms, specifically day and night sweats that drench her sheets and leave her exhausted She is interested in trying some alternative therapies and has heard about black cohosh.  So is black cohosh an effective treatment for the symptoms of menopause and is it safe for a woman with a strong family history of breast cancer?

I found several studies (1,2) that concluded black cohosh provides significant relief from menopausal symptoms compared to placebo.  Ho hum...but I also found this study that compared Cimicifuga racemosa (black cohosh) to low dose transdermal estradiol treatment. Granted the study group is small, but I still got excited about the fact that the alternative tx was as effective as HRT for reducing menopausal symptoms, AND that black cohosh alone significantly increased HDL-C.  The authors conclude that this is a safe, effective alternative for patients for whom HRT is contraindicated.

Unfortunately, safety for patients with significant risk for breast cancer is not clear.  I found articles (1, 2) that stated black cohosh does not stimulate estrogen receptors and other articles that state black cohosh interferes with the efficacy of anti-cancer drugs.

Bottom line, given her history and the possibility that black cohosh could adversely affect her current cancer-free state, I'm not comfortable encouraging this patient to use black cohosh.

Case

A four year-old African-American girl was brought to the clinic by her mother three days ago with the complaint of a "dark patchy rash".  These patches were not itchy nor were they tender.  The mother claimed that she first noticed them when the child was an infant but did not think much of it, believing that it would run it's course.  It, however, did not resolve and "became more obvious".  The patient was afebrile with non-contributory vitals.  On physical exam several brown macules of varying sizes were found on the trunk and legs.  They were non-tender to palpation and had no crusting.  Four of these patches (three on the right leg and one on the chest) had round fixed raised nodular masses underneath.  The child also had axillary and inguinal freckles.  Eye exam revealed a thin greyish-white area near the iris.  The rest of the exam was non-contributory.  What is the diagnosis?

Diagnosis and Epidemiology

This child was diagnosed with Neurofibromatosis Type 1 (NF-1) because she displayed at least two of the seven criteria for the diagnosis.  NF-1 is a somewhat rare disease (1/3000 births) which can go unnoticed until a child gets older.  It is an autosomal dominant hemartomatous condition that is due to a mutation in the NF-1 gene.  There is no racial predominance and both sexes are effected equally.  The earliest clinical manifestation (as seen in this case) is "Cafe-au-lait" spots.  Later manifestations that are usually not present at birth or infancy include axillary and inguinal freckles as well as subcutaneous neurofibromas (both however were noted in this case).  There are several other hemartomatous manifestations of this condition including lisch nodules in the eye (usueally detected after the age of 10 in over 90% of patients), optic nerve gliomas, and plexiform neurofibromas that are very deep and can cause bone pain.

Treatment

Treatment is symptomatic and involves management of specific manifestations.  Annual physical exams must be performed in order to note any new or changes in prior manifestations.  Referral to Neurology and Opthamology is also a necessity for management of the neural hermatomas and ocular manifestations.  It is very important for the primary care physician to monitor the patient's blood pressure and developmental milestones as these patients are at higher risk for HTN and ADHD than the normal population.  It is also important to the note the develpment of any new joint/bone pains, scoliosis, and parasthesias that may be due to plexiform neurofibromas.  These as well as other bothersome neurofibromas can be surgically resected, but there is still a relatively high recurrence rate.

With respect to medical therapy, there is no specific medical treatment for this condition.  A variety of anti-neoplastic agents have been used, in particular Carboplatin, with very little success in eradicating optic nerve gliomas.  The National Cancer Institute is about to begin a clinical trial on a new drug (R115777) that has been successful in animal studies in blocking the growth of plexiform neurofibromas.

Impact on Lifestyle

Thus although NF-1 is not necessarily a life-threatening condition and most patients can lead a normal lifestyle, it can be emotionally hard on those with visible manifestations.  It is important for the primary care physician to comfort these patients and monitor them for emotional changes with respect to anxiety or depression.

   I recently had the pleasure of meeting with a 57 yo woman who was coming into the office as a follow up for her Type II Diabetes.  Over the past few years this patient had been placed on Avandia and Metformin, but was still having difficulty achieving her target glycemic control.  She had recently been started on a new medication called Byetta (Exenatide) which serves to mimic a naturally hormone called incretin. 

    Incretin works by improving the glucose-dependent insulin secretion of the Beta cells in periods of hyperglycemia.  Thus, it is able to increase the body's insulin secretion when it needs it the most.  Furthermore, I found THIS ARTICLE which shows that incretin may also increase the sensitivity of the pancreatic alpha cells to the circulating blood sugar level.  The proposed mechanism of action for increasing alpha cell sensitivity is through the Glucagon-Like Peptide 1 (GLP1) receptor.  This is extremely important because if the alpha cells become desensitized to glucose levels they can release excess glucagon which can in turn raise blood glucose levels by activating gluconeogenesis.  Thus, Byetta, unlike other Type II DM medicines, works by acting on both the alpha and beta cells in order to provide optimal glycemic control. 

    One drawback to Byetta is the fact that it is taken as twice daily injections, one in the morning and one at night.  When I asked the patient how she felt about giving herself two injections a day, she replied that "the tip of the needle is smaller than the lancets that I use to prick my finger with everyday".  This is definitely an important fact that could be brought up to patients who are hesistant about giving themselves injections.

    Lastly, Byetta has also been shown to increase weight loss in many patients.  This is extremely useful because the main reason that many of these patients have Type II DM is because they are overweight.  Overally, the patient I saw was extremely happy with how Byetta had worked for her and when I had seen her three months after she first started taking the drug she had already lost 10 lbs!!!

Recently I had to go see a 2 year-old for a WCC. Before going into the room I want to plot this girl on a flow chart, when I realized that the highest weight on the y-axis is 40 lb, while she was 47lb 12 oz!!!!

While seeing this child, me and the resident I was working with, noticed some developmental delays, strabismus, and of course her weight problem. Keeping a somewhat broad differential in the back of our minds (Hunter's syndrome, Hurler's syndrome, and Prader-Willi syndrome to name a few) we began questioning this girl's diet and talking about it with her parents. I should note here that they were suprised that we thought something was wrong with their daughter's weight.

"She doesn't really like friuts and vegetables, but she loves to drink whole milk a lot, and she loves potato chips, fried chicken, and french fries" said her mom, who was a bit overweight herself. This child also does not play outside, but instread watches lots of TV. When we told them that she really needs to cut back on potato chips, her dad jumped in and said "these really aren't bad for you- see it says here- 0 trans fat!" Oh yeah- they had a bag of chips with them in the office, in case this child gets hungry!

I'm sorry but to me this is child abuse!

We ended up spending a good half hour educating them on diet. From what we said, I believe that DASH diet is the best for her, although there is a question of compliance.

Finally, we also sent her to a develpmental phychologist, and decided to get a few test to make sure her thyroid is working properly.

An 8yo boy came for his annual physical exam this past week. As I was doing the routine screening of HEENT, heart, lungs, GI, I came upon what I thought sounded like a systolic ejection murmur. While reporting back to my Preceptor, I proudly reported my findings with concern. My preceptor was quite shocked and asked to take a listen himself, after which he chuckled.  I quickly learned that all of those murmurs from structural defects we learned about are quite rare (1%); while, the "innocent" (normal) murmurs are much more common in children (50%).

Apparently, I am not the only one who struggles with distinguishing between pathologic vs. innocent childhood murmurs. In this "Pediatrics" study, 47 volunteers from Pediatrics as well as Med/Peds residency programs averaged about 57% in diagnosing the correct murmur on models with 1 innocent and 4 congenital murmurs.  Five pediatric cardiology residents averaged 84% in making the correct diagnoses.

According to this article, which was translated from Portuguese, there are several important differences between congenital heart defects and innocent murmurs. The end of the article has very good descriptions of common congenital and innocent murmurs. Some important clues to keep in mind when suspecting an innocent heart murmur are:

• easier to hear in a hyperkinetic circulatory state
• either systolic or continuous murmurs
• never occur alone during diastole
• short duration, low intensity
• no thrills, snaps or clicks associated
• occur in a localized area (left sternal border, supraclavicular, etc.)
• no family history or symptoms of a congenital heart defect
• normal findings on CXR and EKG

Some reasons were identified in the article for the presence of innocent murmurs in kids.  They illustrated how a child has narrower outflow tracts and cardiac structures positioned closer to the thoracic wall, which is thinner than an adults'.  Both structural differences make normal sounds in the heart more easily heard in a child.

I found out that the boy that I had examined actually had "Still's Murmur," which is benign.  This murmur is found in approx. 75-85% of school-age kids, making it the most common innocent murmur.  It occurs at the left sternal border with the patient supine and it may disappear upon standing. You can hear it at the start of systole.

If students and physicians are more astute at identifying murmurs, we will save both the child and the parents much worry about having a potentially fatal heart defect.  In addition, the burden as well as the excessive cost of going through unnecessary tests will be avoided.

            For years, patients with migraines have be forced to medicate and hopefully reduce the incidence and severity of their headache attacks. However, studies testing transcatheter closure of Patent Foramen Ovale's (or PFO's as they will be referred to here on out) have found a siginificant association between closure of a PFO to decreased incidence of migraines with aura. So far migraine sufferers have been limited in what they can take to alleviate their condition. Essentially, their choices have been limited to medical therapy since physicians and researchers have yet to find a physiologic/anatomic cause for ALL migraines.

            Furthermore, with the discovery of this link, researchers have devoted more time to seeing if PFO's are responsible to other conditions. For example, one set of researchers have set out to determine the clinical impact (i.e. what else might PFO's cause) of PFO diagnosis. Clinical impacts range from decompression sickeness in divers to stroke. With regards to stroke, researchers have also shown that PFO's may be responsible to stroke recurrence. In fact, the majority of the patients that had PFO's were found to be at increased risk of recurrence of stroke [along with other factors including: a history of migraine (this paper was from 1996, and only recently has this PFO-migraine link been explores) and PCA infarct.]

            Therefore, it seems to me that those patients who experience migraine's with aura's should be set on a path that helps further explores their migraines and may even lead to relief of such a debilitating condition.

 

 

     The buzz about antioxidants may have peaked several years ago, but patients' interest in these supplements has not faded completely.  In a routine visit, I asked an elderly woman about medications that she was taking, and she stated that she was "taking lots of antioxidants because they are good for you... they can prevent you from getting cancer and heart diseases, and besides it can't hurt, right?"

     Can patients take antioxidant supplements to help prevent heart disease and cancer?   The idea is that antioxidants combine with free radicals so that you have less cellular damage. The main vitamin antioxidants are vitamin E, beta-carotene, and vitamin C.

     The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.   Furthermore, a very recent study showed that adverse effects were common with antioxidant use.  Beta-carotene supplements can hurt patients, as they have been associated with significant increases in all-cause mortality.  

     The American Heart Association reviewed data from 1994-2002 that showed there is no benefit from antioxidant supplements on cardiovascular disease.  They issued a statement last year that says: get the antioxidants from food, not supplements - this means fruits, veggies, whole grains, fish, poultry and lean meat.

     Bottom Line:  We cannot recommend the use of any antioxidant supplements for prevention of cancer or cardiovascular disease.  But, keep in mind that vitamins and supplements can be useful for other purposes like pregnancy, bone disease, as supplements to certain medications, and for other problems.

IN a typical family practice, i have notice that many patients comes in saying they have pain. They always want to know what is wrong with them, and they want a magical pill that will take away the pain. Many physician's common practice is to provide medication for the pain, but what happens when it is chronic pain?

In a study, it was found that two-thirds of the people were on some type of medication for pain. The study was a survey to see what type of treatment people were using for pain. It was also found that 40% of the patients received inadequate pain management. Pain is a real health issue.

Many patient's with chronic pain has also found relief in non-pharmacological methods, which includes physical therpy, massage, and heat. All the listed above are cost benefit, and are successful in relieving pain. They should be suggested first before pills are given.

IF all else failed to control pain, neurostimulation has been consider and suggested to treat chronic pain. Insurance companies are coverig the cost of the device, due to the long term cost benefits. I met a patient, who had chronic back pain for 8 years, and his life has changed after receiving a spinal neurostimulator. He went back to work for the first time in 8 years. Physicians must remember this is a last attempt to control pain!  

 

We had several patients this week with early dementia- both elderly women and an older man with Down's syndrome presented with signs of dementia. With known risk factors like Down's or a family history, the question arose: If a patient has known risk factors for dementia, are there options for prevention? 

What are some Risk Factors?

In addition to some of the known risk factors (head trauma, Huntington's Disease, Down's syndrome, cardiovascular disease, stroke, and others) this study has shown obesity to be a risk factor independent from cardiovascular disease and diabetes that are often associated with obesity. The study looked at 10,276 patients in the Kaiser HMO that were identified between 1964-1973 at the age of 40-45 and were followed at multiple visits to assess for dementia. Both BMI and skin-fold thickness were used to classify patients as obese, overweight, normal weight or underweight. Patients with midlife obesity were 74% more likely to have dementia as compared to normal weight individuals and being overweight in midlife was associated with a 35% greater chance of dementia. It has been postulated that dietary fats and sugars as well as decreased exercise compared to healthy weight patients may contribute to the findings. With an obesity epidemic, this article predicts a 400% increase in the incidence of dementia in the next 20 years.

Prevention

Gingko Biloba, antioxidants and NSAIDs have all been proposed to decrease neuroinflammation and therefore neuronal loss. Statins have also been proposed as decreasing risk, but this study from July 2005 showed no decrease in dementia risk with statin use as compared to never using a lipid-lowering drug.

A new potential therapy, this article discusses the role of minocycline (of the tetracycline family) as a neuroprotective agent in HD, Parkinson's and ALS. It has also been shown in a mouse model for Down's syndrome to improve memory in mice.

Treatment

Once someone is diagnosed with dementia there are treatment options such as Namenda and Aricept, but prevention would be a better option.

The other day while discussing what antibiotic to give a patient with renal failure an interesting and disturbing topic arose.

MRSA (methicillin resistant staphylococcus aureus), which is a nasty critter, and difficult to treat is starting to become more prevalent in the community.  Just recently, there was an outbreak of MRSA seen in an NFL football team, the St. Louis Rams. Football, like other contact sports helps to create an environment where wounds are exposed and the likelihood for infection increased. S.Aureus itself is common to such a contact sport as football, but the MRSA variant is not. Five players tested positive of the 58 players tested, a rate of almost 10%. The source was deemed to be a whirlpool and some taping gel in the locker room.

The fact that 5 players got the infection isn't the really interesting part, the interesting part is that it occurred in the community. MRSA has been seen in hospitals for some time now, but now it is starting to creep out into the community. This is a scary situation because it is quite difficult to treat and requires hospitalization, just imagine if begins to really grow outside the hospital, it could lead to a crisis in the health care system. Even worse is that if MRSA is starting to enter the community, what other resistant bacteria might just be waiting around the corner.

With the increasing prevelence of antibiotic resistant strains of bacteria, it begs the question. Are we properly using antibiotics? It is certainly a debatable subject one that neither side can win, but it if nothing else it should make us stop and think when we hear that those broad spectrums are being offered, might there be a better drug, that isn't going to lead us to further problems down the road with resistance not only in the hospital setting but also out in the community.

A well appearing male came into the clinic the other day to receive injections; we did not conduct a routine physical on the man but my preceptor asked me to take a mental note of the patient.  I was very interested because the man did not appear any different than many of our other patients: a well-built middle-aged man with male pattern baldness.

Our patient was born a female, and in her teens decided that she was more comfortable and identified more with males; she concluded that she was physiologically given the wrong gender.  Ever since, he has received testosterone injections once every 3 weeks and has never missed an appointment.  His work is based on manual labor and he was married in another state approximately ten years ago.  When he returned to New York, the state refused to acknowledge his marriage but he is still romantically involved with his partner.

Our patient suffers from gender dysphoria.  My preceptor enlightened me to the problems that have arisen in his life and to the fact that it is much more difficult for a female turned male to receive support, care and convert his/her body.  Questions, fears and problems have arisen in all spheres of this man's life; anxiety due to family strains, fear of being discovered at work, etc. are a few of the many anxieties which this man deals with on a daily basis.  Similarly, according to this article, there is often some question amongst physicians as to whether the DSM-IV criteria for gender identity disorder are sufficient. 

According to this article, and the HBIGDA Standards of Care (Henry Benjamin International Gender Dysphoria), psychotherapy and hormone therapy are first-line in dealing with issues of gender dysphoria.  This article emphasizes that complications such as estrogen-related thromboembolism or testosterone-induced hepatotoxicity can occur with hormone treatments and patients should be adequately screened prior to initiating treatment.  Testosterone does appear to work well in making the temporary transition for females turned males.  It must be given frequently to maintain its effect and also has the added benefit of helping to prevent osteoporosis in these phenotypic females, as described in this article.

Although the testosterone has been working wonderfully for our patient, he has recently become interested in learning about the next step in changing his physical appearance and genitalia to match his gender identity.  He still harbors fear that he will get a period if he were to miss one of his injections, despite the fact that his ovaries must have atrophied significantly with the long term exogenous testosterone use.  Options for our patient also include hysterectomy, plastic surgery, phonosurgery.

Patients questioning their gender identity are going through a difficult time.  It mandatory that physicians not only be informed of the subject, but also be able to offer unbiased support and a thorough education and review of available options to their patients.  This article demonstrated through clinical trials that gender reassignment is effective and that those who undergo hormone replacement are very satisfied with their life.   

This log was inspired by a patient encounter in which I found my self entirely inadaquate (happens often) to conduct a DM follow up. I realized I did not know how to question and plan long term follow up in these pts. 

So I was doing like my third or fourth pap-smear ever, and the patient was a young lady in her mid-twenties who was very outgoing and very outdoorsy.  During the questioning about her LMP, I asked about any unusual bleeding.  I don't think she really understood the question, or maybe only half heard it, because she answered "No, I use the Diva Cup."  Ok, I had NEVER heard of the diva cup, so naturally I asked, "what's a Diva cup?"

 

Long story short, the Diva Cup is another option for women in lieu of tampons or pads.  Here is a link for the manufacturer's site.  Basically, it is a re-usable silicon recepticle that replaces those other aforementioned products.  In speaking to this patient, this product actually has quite a few benefits over tampons or pads.  Here's a few.

1.  The Diva Cup costs like 30 bucks, and is re-usable, thus becoming cost-saving versus pads or tampons in a short period of time.

2.  The Diva Cup, being re-usable, is very environmentally friendly, something that was very important to this patient.

3.  The Diva Cup is, according to my patient, much more comfortable than inserting a tampon.

4.  It is made of silicon, so you can swim with it in.

5.  It's FDA approved, and approved in Canada as well.

 

So there you have it, another option for women that I personally had NEVER heard of.  For those of you further interested, here's a link to a pubmed abstract of an article that studied if a menses cup is a viable alternative to the traditional methods.  It found that it indeed is a viable alternative.

 

So if you find a patient who is very active, or a patient who finds tampons and pads to be financially burdensome, or a patient who wants to save the environment, or just a patient who simply wants to try something different, go ahead and point them over to that first link, divacup.com.

A 58 y.o male presented for his 3 month follow up for hyperlipidemia. When he was first diagnosed with elevated LDL-C of 187 and a TC of 255 he was prescribed Pravachol. He presented 4 months later complaining of muscle pain and reported that he had stopped taking the drug.

Alternative to statins

He was presented with two options Welchol (a bile acid resin) or Zetia. The patient declined Welchol simply because he knew it would be hard to take 3 tabs twice a day. His next best option: a cholesterol absorption inhibitor, Zetia.

Cholesterol absorption inhibitors were introduced last year. They can be used as monotherapy or in combination with statins. Although statins still remain the first line drug-therapy for reducing cholesterol, these new drugs have not only been efficacious in decreasing LDL levels, but they may help reduce atherosclerosis.

In patients with primary hypercholesterolemia Ezetimibe (a cholesterol absorption inhibitor)  in combination with simvastatin significantly decreased high-sensitivity C-reactive protein (hs-CRP), an inflammatory mediator whose levels correlate with increased coronary risk.

As with any new drug, caution must be exerted until more data is collected on its side effects and it's true efficacy in lowering the risk for CHD.  

 

 

A 29yo female smoker came into the office after being treated in urgent care for a LLL pneumonia. A mother of 2, she had tried quitting before. She was interested in quitting. Nicotine replacement (NRT) is expensive (although she admitted it was cheaper in the long run- as well as healthier than smoking) and wanted to know if her insurance would cover it.  So we set a quit date and agreed to follow up. I would find out what insurance would cover.

Does insurance cover smoking cessation treatment?

I looked it up and her insurance would cover Wellbutrin (not Zyban), but nothing else unless she was enrolled in a smoking cessation program. The physician in the office said that now that nicotine patches, etc are available OTC, insurance won't cover it- the argument being that if they can afford cigarettes they can afford NRT.

Then I found this article- a double blind randomized study looking at the differences when a smoker was offered reimbursement for NRT, counseling and buproprion. (The control group was not offered anything). 10.8% in the intervention group used treatment options with 4.1% in the control group (OR=2.9).  At the 6-month point 5.5% as compared to 2.8% in the control group had not had a cigarette for >7 days (OR=2.3). [The confidence intervals did not cross 1.]

The study was well done, accounting for all participants. Successful cessation was based on a questionnaire and having quit for at least 7 days, which was confirmed by an expired air carbon monoxide level.

As was apparent with our patient, reimbursement for smoking cessation therapy does play a part in a person's willingness to attempt to quit. In the long run it could save insurance companies money by preventing the long-term adverse health effects of smoking.

A healthy 37yo female runner came into the office for a routine visit and brought up an embarrassing problem. She was training for a marathon and during her long morning runs she would get diarrhea in the middle of the run. She would have to stop urgently or need to do laundry later. It happened regardless of what she ate or drank or whether she had a bowel movement beforehand and consistenly occurred after the 7 mile mark.

The question was why is this happening and what can she do to stop it?

I found this review article that presents the problem as a common one- 19-26% of marathon runners experience runner's diarrhea. The real cause is probably multifactorial and the article presents 3 etiologies: 1- Colonic smooth muscle irritation due to a fluid/electrolyte imbalance. 2-Increased secretion of motilin, gastrin associated with high exertional states. 3-Endogenous opioid secretion. Blood in the stool is also not uncommon due to splanchnic ischemia leading to tissue ischemia and necrosis.

Infectious etiologies should not be ruled out and a careful history is important.

What to do?

Cross training and decreasing mileage for a couple of weeks can decrease symptoms. An elemental diet a few days before the longer run, as well as a low fiber diet throughout training can also decrease symptoms. For nonbloody diarrhea Immodium may help, but for bloody diarrhea, running should cease until the cause can be found.

It is also commonly associated with the time of the day. For our patient this was her 3rd marathon and her first time training in the morning. Runner's diarrhea has been associated with the morning and her best treatment option is to switch to afternoon/evening runs.

This week seemed to follow a theme: young patients with viral URI.  I had lost count of the number I had seen, so when a 19-year-old female culinary student with a 2-week history of fatigue, sore throat, feeling hot, and night sweats came in, I expected that she belonged to the same category.  But a bit more history was necessary...  Ibuprophen and acetaminophen had not provided relief, and her condition is not improving.   A number of her co-workers have recently suffered from various illnesses: seasonal allergies, viral URI, and strep throat. The nurse peremptorily performs a rapid strep test; it's negative.

When specifically asked, she acknowledges that her menstrual cycle has been "a bit haywire" the last few months.  Also, she has unintentionally lost about 10 lbs in the last two months despite the fact that her appetite and eating have increased.  She also comments that about a year ago she noticed a sensation of shaking in her legs that has since spread to her arms.  Even her friends comment on her tremor.  No familial hx of similar symptoms. She has palpitations.

She looks exhausted, ready to fall asleep.  Her skin is very warm and moist. HR is 100 bpm.  Lungs are clear.  When checking pulses in her ankles, I can feel the passive tremor, and notice that her right hand also has a passive tremor. When she extends both arms in front of her body at should height, the tremor increases.

The most obvious signs are found on the HEENT and neck exam.  Her pharynx is not injected, but her right eye is distinctly exopthalmic.   Even before palpating for her thyroid, I can see a significant goiter (like this but on the right side)...

Medline provides a great refresher on the S&S, Dx, and Tx of hyperthyroidism.  Merck's page includes a few rarer causes of hyperthyroidism. This patient demonstrates a fairly classic case of hyperthyroidism. 

• Weight loss
• Increased appetite
• Heat intolerance
• Increased sweating
• Fatigue
• Menstrual irregularities
• Goiter
• Weakness
• Clammy skin
• Skin flushing
• Heartbeat sensations
• Hand tremor
• Exophthalmos

She enjoyed a blood draw for TSH and free T4 levels and went home with a ß-blocker, which will not impact her thyroid at all but will likely relieve her cardiac symptoms (even within hours), while we wait for the results.

A large chunk of what primary care providers seem to do is fill out paperwork for sports physicals (aka preparticipation physical exams - PPEs).  While my resident fills out the paperwork, I actually complete the PPE.  After many such visits, I had a talk with a few preceptors and residents.  They all agreed that PPEs are a formality and that we rarely if ever find anything of significance.  We try to assess the athletes' general health, developmental progress, etc.  We also look for musculoskeletal and cardiovascular abnormalities that may limit participation.
 
But are we really finding anything?  Are we missing important findings?  Are we preventing injury or death?  Is there something else we should be doing?  Is there a standardized, detailed PPE?  Is there any evidence that it is useful?
 
Wingfield et al have reviewed the literature and found that while the American Heart Association and other organizations have guidelines for PPEs, there is scant evidence to suggest that anything a PCP regularly does can prevent injury or death.  There is no good way to screen for hypertrophic cardiomyopathy (HCM), the disease that is most noted for killing Hank Geathers.  This disease, as well as many others, tends to be relatively silent and have few clinical signs.  Neither ECG nor echocardiogram nor exercise stress tests can reliably identify HCM or other potentially fatal cardiovascular conditions.  The sensitivity and specificity of these tests is hampered because many athletes have enlarged ventricular walls, sinus bradycardia and other changes that may be considered anomalous in the elderly or obviously ill patient.
 
In terms of orthopedic evaluations, Garrick shows that no physical exam maneuver can effectively predict future injury risk.  While current injuries may be discovered/assessed for severity, there is no way to ensure an athlete's musculoskeletal integrity.  Most of what we do is to simply fulfill an institutional requirement for PPE.
 
Finally, this commentary, by Constantini et al, gives another country's perspective.  Israel has a nationalized, rigid system for the examination of any person participating in organized sport, whether they are children or professional athletes.  Data shows that cardiovascular risks are given too much emphasis, while orthopedic, metabolic, neurologic and endocrinologic features are largely ignored.  It seems that with the lead of other countries, the US should institute exams that include CBC, FBS, and careful musculoskeletal exams.  In other words, when doing a PPE, what we should really do is treat it like any other office visit!  Ignore the paperwork for a moment and ask yourself: what can I do to assess the health of this athlete?
 

Causes and Epidemiology

Nursemaid's Elbow is the most common upper extremity injury in pediatrics.  It occurs when a child (most commonly betwen the ages of 1-3) is pulled upward by the arm (while in extension) in a sudden "jerking" motion.  The articular surface of at the junction of the radial head and capitellum of the humerus is still developing at this stage of life, making the radial head susceptible to subluxation at the annular ligament which fortifies the joint.  This injury is more common in girls than boys and more often on the left side.

Presentation

The clinical presentation for nursmaid's elbow can vary, but almost all have a history of axial traction.  In infants less that 6 months of age, the presentation (aside from crying) often involves a history of the inability to use their arm when rolling over.  In children, they often present with the arm mildly flexed and internally rotated.  On physical exam, the elbow usually does not exhibit any redness or echymoses, but may display mild swelling.  The joint is tender to palpation and passive pronation/supination and flexion to 90 degrees.  Xrays are usually not needed because they are unremarkable.

Treatment

Treatment is rather straightforward and can be performed in the office or over the telephone.  The most common treatment for this injury involves flexion and supination of the forearm while supporting the radial head.  A "snap" or "click" is often heared or felt indicating that the radial head has moved back into position.  I had the pleasure of being able to perform this maneuver last week on a four year-old boy who presented with a classic nursemaid's elbow.  It was not effective on the first attempt but reduction was attained on the second.  Once reduction is achieved, the child was immediately able to use the arm with nearly full range of motion.  If a child in not able to immediately use the arm after treatment, this indicates that full reduction was not achieved and the technique must be repeated.

Since this technique may require repetition in the event that reduction is not attained on the first attempt, new techniques have been utilized by physicians to supplement this standard protocol.  A randomized controlled study was performed that compared the efficacy of Supination/Flexion to Hyperpronation of the forearm and found that hyperpronation was more effective in reducing the subluxation on the first attempt. 

Thus although Nursemaid's elbow is a minor injury anatomically, it is very common and puts children through a great deal of anguish prior to treatment.  Therefore, successful treatment of this injury is very gratifying for both the physician and patient.

A new treatment for Diabetic Peripheral Neuropathy (DPN): Anodyne Therapy

Peripheral neuropathy is a disorder that arises from damage to peripheral nerves in the body. It has many established causes but the most common is Diabetes. DPN can result in two different types of problems: a loss of both sensation and pain, or symptoms of pain and burning.

Treatments

There are several treatments for this condition but no cure. The pain may sometimes be alleviated by analgesics, antiepileptic, antidepressants and in more severe cases surgery to destroy the nerves; however it is often temporary relief.

Anodyne therapy, also known as monochromatic near-infrared photo energy (MIRE), delivers energy to the skin of affected areas. The science behind the energy beams is that it is proposed to effect guanylate cyclase and nitrous oxide release which will relax smooth muscle cells in blood vessels and allow better circulation to the nerves and tissues.

Since this therapy is relatively new it does not have much research support in the literature and its long term efficacy has yet to be determined; therefore it is not covered by insurance companies. However, anodyne therapy does have some advantages that make it an interesting topic to pursue further such as its noninvasiveness, no requirement for medications and potential side effects, and it reported symptomatic reversal of DPN.

Case: A 16 y.o African-American male who looks like he is 35, is 100 lbs. over his ideal body weight, and appears extremely fatigued in the office today due to excruciating pain on his inner thighs. On examination it is determined to be tufted hair folliculitis/furuncles. Immediate relief is brought the patient when warm compresses are applied to the area. We were pleased with the immediate relief of this area, but were concerned about how old this patient appeared for his age. We were also concerned about systemic infection if this folliculitis was not resolved.

The attending physician was concerned that a previous granulosum infection which elicits stress on the body may be involved in precocious puberty. After doing relevant lab work (Cortisol, testosterone, IGF B3) it was determined that there was no precocious puberty indicated. This case reinforced that culture and monetary factors are important to consider in patient care. Recent research has indicated that puberty variations are highly correlated with both environment, ethnic, and obviously genetic factors. Based on my background I did not expect a 16 y.o male to look as mature so it caused me to question ( a good thing), but I should have factored in these other factors.

In treating the folliculitis we prescribed azithromycin for 3 days, and advised the patient to apply warm compresses 3X daily until the pain resolves. Recent research has indicated that rifampicin is also effective against S. aureus involved tuft hair folliculitis.

A recent study conducted by the American Chemical Society found that the biggest source of antioxidants for Americans is from coffee. This study (not available yet) has caused much confusion lately to the patients that I've been seeing in the Family Practice office. Right after I routinely ask about caffeine intake, I have been proudly told by well-informed patients that they drink "a lot" of coffee. Being caught off-guard by this reply, I try to explore why they are so proud to drink so much coffee.

Apparently, many news sources are quite misleading in the manner that they present the results of this recent finding. They seem to indicate that coffee is a good source of antioxidants, 1299mg, with the closest competitor being tea, 294mg. However, you must read the entire article carefully to find the actual results of the study. Instead, they discovered that Americans are putting aside better sources of antioxidants, such as fruits and veggies, and are substituting coffee in their place.

So what should we tell our patients?

While coffee is quite high in antioxidant content, it can be detrimental to the cardiovascular system. A study done in Greece describes the effect of chronic (1 year) coffee intake on the aorta, in particular. Out of 248 participants, 41 with high coffee intake had a 17% higher aortic pulse pressure compared to the 31 non-coffee drinkers. In addition, they also had a 2.4 fold increase in augmented aortic wave pressure compared to the non-coffee drinkers. A stiff aorta, indicated by the increased aortic pressures, could have serious implications to the health of our patients, possibly leading to myocardial ischemia or left ventricular failure.

Therefore, coffee does not seem to be all that great, at least in high doses. While it has much antioxidant value, it also brings with it high cardiovascular risk. Being that heart disease is currently the leading cause of death in the U.S., I would not recomment coffee as a good source of antioxidants. Fruits and veggies, while not quite as high in antioxidants, provide a more balanced source of nutrition.

Seeing numerous pregnant women in our office, I have learned a lot about different complications of pregnancies, as well as numerous differential dx for some common symptoms in pregnancy. Here is one case (short version):

34 y.o. African American female; she is 36w5d; recently, she has had terrible headaches and high blood pressure x 3 days; today she presents with generalized malaise, epigastric pain, mostly in the RUQ, some nausea and vomiting, and still has daily headaches.

DDx: preeclampsia, viral-type illness, TTP, acute fatty liver of pregnancy, cholecystitis, gastritis, and HELLP.

What is HELLP?

Hemolysis, elevated liver enzymes, and low platelet count.

This syndrome is frequently misdiagnosed. Keeping it in the back of your mind is crucial, as it has an associated mortality and morbidity rates of as high as 25%!!!! About 4-12% of patients with preeclampsia develop HELLP, but it can also develop on it's own. Platelet count is believed to be the most crucial test for diagnosis of HELLP. This article will give you more information about the pathogenesis and diagnosis of this syndrome.

Management:

Supportive care is most common management of this syndrome. This includes seizure prophylaxis and blood pressure control. In women who are at term, delivery is the best treatment! Some may also require blood transfusions, as well as corticosteroid therapy.

Prevention:

Although this topic is controversial, I found this article that talks about some preventive methods of HELLP. Even though it may be hard to prevent HELLP, misdiagnosis of it may be deadly!

 

   One of the most common situations a primary care provider is presented with is a patient who comes in complaining of sub-sternal chest pain.  This past week, I saw a 53 year old male who presented after a couple days of intermittent "severe" substernal chest pain.  The man had an 18 pack year history of smoking, slight HTN, and was obese giving him four very important cardiac risk factors (Male >45, smoker, HTN, Obesity).  After hearing this portion of the man's history, myocardial infarction seemed to be near the top of my differential. 

   After more information was gathered from the patient, he stated that the chest pain seemed to appear after large meals and tended to be worse when he was laying down.  He also denied any shortness of breath during or after activities such as walking.  His physical was also unremarkable for any respiratory, cardiac or abdominal pathologies. 

   The pateint was diagnosed with GERD, counseled about avoiding caffeine & cigarettes, and prescribed a PPI.  Furthermore, he was counceled about how best to lower his chances for CAD in the future. 

    I was very surprised when I read this article about how GERD may actually be another risk factor for myocardial ischemia in patients with or at risk for CAD.  The study found that GERD may actually compromise coronary artery perfusion via the esophago-cardiac reflex which in turn will exacerbate ischemia in patients with compromised coronary arteries.  It found that out of 218 episodes of ST depression recorded on 24 hour continuous ECG, that 45% of them were correlated with Pathological Reflux recorded by 24 hour pH-metry. Thus, by treating a patients reflux with a PPI, you may also be lowering their risk of myocardial ischemia. 

Each day a large number of patients visit the family physician's office complaining of  chronic lower back pain, knee pain, and pain at various joints.  We respond by performing a physical exam and depending on the amount of pain they are in, give them medications for pain relief, ask them to utilize physical therapy, or if very severe, refer them to orthopedics for evaluation. 

But many of these patients have already been there and one all that - with no relief.  Chronic joint pain is a prevalent medical problem.  This past week I heard a few patients mention a new therapy they have tried: Prolotherapy.  Most simply, it is an injection therapy of a dextrose solution into the joint that allows ligaments in the joint to be irritated and then grow stronger.

The studies out there regarding prolotherapy are conflicting and often inconclusive.  A hindrance to the control of studies is the lack of consistency in the dextrose solutions used for injection. An article in Spine Journal from may of 2005 presented a critical literature review of prolotherapy for the treatment of  spinal pain.  The authors concluded that there was too much variability in the current literature to make a definitive statement about the benefit/harms of prolotherapy.  However, if you do a quick search of the literature, there are patients who do report pain relief from therapy.  Is this due to co-interventions (as suggested by this cochrane database review)?  Is this the placebo effect?  Is this actually going to appear as a legitimate form of therapy sometime very soon?  Don't know - but I'm itching to find out...

In the meantime, thought I would make my colleagues aware of the method.  Interested to know what you think?

Maybe they've got Fibromyalgia?!

How often do you see a patient complaining of pain? Dumb question I guess, since most people only come to the doctor because they are in pain. However, many times it may become suspicious, when some people who come to you are in constant pain even though they've taken all the pain medication they can take without going comatose. Those patients with generalized chronic pain, they just may have fibromyalgia (not every one is drug seeking for all the cynics out there)

What exactly is Fibromyalgia?

Well just look at the word, it means pain of the fibrous tissues of the body (muscles, ligaments, and tendons). More generally, it is a syndrome of widespread musculoskeletal pain commonly associated with fatigue disorder whose origin is unknown. So how do you identify (much less treat) those persons who have this condition when most of the worlds population can claim they've got myalgias just from a hard days work at the office. This is when we turn to the guidelines for diagnosis and treatment. However, the basic criteria for diagnosis are: 1. a history of widespread pain present for at least 3 months; 2. presence of 11 of 18 paired, bilateral tender points as delineated by the American college of rheumatology. Furthermore, physical exam is not enough to make this diagnosis. In fact, I would say that this is a diagnosis of exclusion merely based on the fact that there are numerous conditions that people could possibly have where they present with generalized myalgias (a differential could include: hyperthyroidism, hypothyroidism, Sjogrens syndrome, SLE, inflammatory myositis, and ankylosing spondylitis, just to name a few).

The daunting differential...

In order to confirm a diagnosis of FM, it is also necessary to rule out anything else that is life threatening. Thus, some diagnostic labs would include: CBC, CMP (a metabolic panel), ESR, liver panel, creatinine phosphokinase. On physical exam, demonstration and examination of all the tender points throughout the patient's body is by far one of the most basic requirements. Finally, FM is commonly associated a multitude of other comorbid conditions. These include(but are not limited to): Irritable Bowel Syndrome, depression, anxiety, and chronic fatigue. Therefore, during the workup of this condition it is necessary to screen for these conditions (especially depression in this setting, considering that these people are in pain for almost every waking moment of their lives).

Theories and therapies

Since FM is such a well known condition with almost no explanation for it, research on the syndrome currently focuses on just determining the fundamental biology surrounding the condition. Examples include: neurobiologic, emotional, and even haemodyalsis. Treatment on the other hand has seen massive advances in recent years with more and more research on pain and analgesia. There are three steps in treatment of this syndrome. First is patient education, help the patient to understand their diagnosis and how it will be treated. The second step is pharmacological treatment. In this case, four separate issues must be addressed: 1. Adequate sleep (TCA's are the first line); 2. Fatigue and depression (if TCA's don't work, second line is SSRI's); 3. Muscle spasms (cyclobenzaprines); 4. Pain control (tramadol is a first line therapy, as an a aside NSAIDS should NOT be used with these patients as this is not an inflammatory condition). Finally, the third step is non-pharmacological treatment. This would include exercise and massage, referrals to sleep centers, and physical therapy.

Last week, a very cute 11 year old girl came into the office, dressed to impress in her sports uniform.  She told us that she had "water on her knees" and that they hurt her whenever she played outside for more than an hour.  Her mother explained that her knees accumulated fluid in the summer when she was playing outside.  The young girl said that her pain was bad enough that she had to stop playing, but usually went away in a few minutes.  Her knees never got red and never hurt at night.  They often got a little swollen after playing outside.  Upon examination, while sitting on the edge of the examining table, the patient's tibial tuberosities appeared to protrude on the anterior aspect.

Osgood-Schlatter's disease is an inflammation of the tibial tuberosity, causing unilateral or bilateral pain and discomfort with use.  Often, the soreness is a result of numerous small stress fractures of the tibia.  The condition most commonly affects young boys and girls, ages 10 to 16 (during the peak of their growth spurt) and they usually outgrow it once their growth spurt has ended.  The condition often runs in families, as was the case with our patient.  Her mother informed us that her father had similar problems as an athlete in junior high school. 

Current standards of care advise physicians to treat the children with the standard "RICE" regimen and advise parents on the use of anti-inflammatories if the pain worsens.  This article suggests that Oscon may be a good treatment option if anti-inflammatories are not sufficient.  Oscon is a compound containing a mixture of selenium and RRR-a-tocopherol; the product was tested on young soccer players suffering from the condition showed promising results, trials testing Oscon did fail to mention if there were any long term consequences or side effects of using this product on children of this age. 

So, if a sporty 6^th grader enters your office with complaints of transient knee pain, a little inflammation, and a bump on his or her tibial tuberosity, think Osgood-Schlatters disease.  Furthermore, if rest, ice, etc. are not doing the trick, move up to anti-inflammatories for a short while and investigate the possibility of trying Oscon. 

Scenario:

A middle-aged woman has come to see her physician.  She has a history of skin-abscesses.  Today she has a brown-raised lump on her chest.  Her physician believes that it is an abscess, and schedules her to have it drained.  Before the procedure, she is given the antibiotic Clindamycin, to help reduce the size of the abscess before drainage. 

While at home:

She has been taking her medication for two days, and is now experiencing severe abdominal cramping and diarrhea.  During the following three days, she has gotten worse.  She now has bloody diarrhea, and severe abdominal cramping. She makes an emergency visit to her physician.

Red flag!

• My preceptor becomes very concerned.  He immediately tells the woman to stop taking the clindamycin, for her stomach illness may be caused by Clostridium difficile, a bacteria which shows high resistance to clindamycin, and may cause "pseudomembranous colitis" (USMLE Step-1 buzz-word!).  This is a severe and life-threatening illness.  He immediately wrote her a prescription for Flagyl a.k.a. Metronidazole, and obtained a stool sample to be cultured by a lab. 

 

• These researchers found that 36% (69 of 192) of C. difficile strains sampled from patients between 1986 and 2001, were resistant to clindamycin.  All strains, however, were found to be susceptible to Metronidazole. 

To avoid the severe sequelae of a C. difficile infection, this patient was treated empirically with Metronidazole (Flagyl).  This may appear to be a "textbook case"; real life, however, reinforces important drugs and the possible severe sequelae of their use.    

Recently i saw a patient that was having problems with urination related to a common condition called benign prostatic hyperplasia. This condition is seen more commonly in older men as the prostate begins to grow and can cause discomfort as it decreases the size of the urethra as it traverses the prostate gland.

There have been many debates about whether or not the PSA is a good assesment tool for BPH and prostatic cancer, and as far as those are concerned i won't touch on that today.

The debate that i will talk about is whether or not current medical treatment with 5-alpha reductase inhibitors such as finasteride, and alpha receptor antagonists such as  are as effective and side effect free as use of an herbal supplement know as serenoa repens extract.  As we all know with the continuing rise of medical expenses and co payments, it will be quite helpful for patients if there are cheaper alternatives available, particularly if those alternatives also provide care with less side effects.

Sexual dysfunction is a common side effect of the 5 alpha reductase inhibitors that is not seen with the use of Serenoa repens, this may help with patient compliance as well, since it is a key reason that men stop taking the medication.

Cost effectiveness. The cost of a month the most commonly used 5-alpha reductase inhibitor is appoximaly $79.99 per month retail. While the cost of Saw palmetto (Serenoa repens extract) is approximate $22.00 per month.  

Situation:
A healthy 19 year old, female, college student came to the clinic to discuss options for contraception.   She has tried the patch and the pill, and didn't like either of them.   Her first method of contraception was Depo-Provera injections, and she liked this best because it was convenient and more reliable.  She had been on it for 6 months before her primary care doctor took her off citing new safety concerns with Depo-Provera.  I was surprised... what were the concerns?

Concerns about Depo-Provera:
In a search, I found out that on November 17, 2004, the FDA and Pfizer released information that Depo-Provera can cause significant loss of bone density if used for prolonged periods of time.  The loss is greater the longer the drug is administered, and the bone density loss may not be reversible after discontinuation of the drug.  The side effect was serious enough that the FDA added a black box warning on the drug package.  

What to do:
Because of the risk of losing significant bone density, it is now recommended that Depo-Provera be used for less than 2 years, and only if there are no other forms of birth control that the patient can take.  It is also recommended that patients who do use Depo-Provera also take calcium and vitamin D supplements.

Caution:
Websites that are updated frequently, like Clinical Pharmacology and UpToDate, contained accurate information listed under adverse reactions.  However, the information is not highlighted in a way that brings attention to this relatively new finding.  Most textbooks and patient information published before November 2004 will still contain the old, false information that there is no danger from injectable birth control pills.  Thus, it would be wise for all physicians and student doctors to know the risk of Depo-Provera and take that information into consideration when counseling patients for birth control methods.

CASE: Today a 46 year old woman comes into the office for a follow up. She is being monitored by he family physician for the pass months due being diagnosised with metabolic syndrome. When speaking to her, she wanted to know what kind of treament is there for her condition.

WHAT is it: metabolic syndrome is a commonly found constellation of metabolic dysfunctions that consist of insulin resistance, hypertension, dyslipidemia, obesity, and endothelial dysfunction, which all leading to accelerated cardiovascular disease.

Treatment: managing the syndrome is really addressing the components that makes up metabolic syndrome. There are many other factors that a patient could address which would make an impact on their condition, such as lifestyle changes. The current study on how lifestyle changes could impact the patient showed that physical activity and weight lost had a greater reduction in the incident of DM type2 compared to medication. Stress also play a role in the syndrome, and reducing the level of stress is a way to reduce neuroendocrine activation.

Scenario:

A mother brings her primary school aged son to her family physician in early July.  She is concerned because her son has four balding, scaling, flaky patches approximately two centimetres in diameter on his scalp.  The physician inspects the lesions, and suspects that they are caused by tinea capitis, a fungal infection.  A six-week course of Griseofulvin, an oral anti-fungal, is prescribed.

8 weeks later..... 

The same mother brings her son in for a follow-up.  She is still concerned, because two of the original four lesions still remain. 

What would you do?

•  According to the authors of "New treatments for tinea capitis", many experts consider a 6-8 week course of griseofulvin to be the drug of choice for tinea capitis.  New evidence has accumulated, however, showing that a 2-4 week course of newer oral anti-fungal agents such as Terbinafine, Itraconazole, and Fluconazole are as efficacious, tolerable, and safe as griseofulvin in the treatment of tinea capitis.  Although not FDA approved for the treatment of tinea capitus, these newer anti-fungal agents are used as an alternative treatment when griseofulvin treatment fails. 
  
• According to the authors of "Griseofulvin versus terbinafine in the treatment of tinea capitis: A meta-analysis of randomized, clinical trials", not only is a 2-4 week course of terbinafine as effective as the standard 6-8 week griseofulvin therapy, but the terbinafine treatment is substantially cheaper (griseofulvin for 6 weeks is approximately $280 while terbinafine for 4 weeks is approximately $145, and for 2 weeks approximately $75). 

Evidence is mounting in favor of newer anti-fungal agents in the treatment of tinea capitis.  The increase in compliance due to the decrease in the duration of dosing regimens, along with their lower costs makes newer agents more favorable clinically.  It may only be a matter of time before newer oral anti-fungal agents become the first line of treatment in tinea capitis.

Background:

A 22 yo female came to the family practice clinic for a routine physical. Upon questioning about her past medical history, she stated that she had been diagnosed with ADHD from childhood and depression from age 13. She was taking concerta (methylphenidate) for the ADHD, however she stated this also helped with the depression, thereby eliminating the need for a second prescription.

Question:

Can methylphenidate be used to treat depression in patients with ADHD?

According to this article methylphenidate alleviated the comorbid depression in those patients with ADHD. So although methylphenidate is primarily used to treat ADHD, it will help with the symptoms of depression for those with a comorbid depression.

Although this will only benefit a subset of patients (those with both ADHD and depression), it will eliminate the need to prescribe an additional antidepressant, which may be contraindicated with the use of methylphenidate (MAOI's for example).

During an afternoon in the prenatal clinic, about half of the patients were unfamiliar with the basics of breastfeeding.  However, when informed about the many important health benefits for their baby and themselves, most showed interest in at least trying to breastfeed.  Breastfed babies have fewer infections, higher IQ's, and lower risk of childhood obesity.  Moms who breastfeed lower their risks for breast and ovarian cancers.  Breastfeeding also provides a considerable aid to losing weight gained during the pregnancy.

The financial savings and convenience of breastfeeding are also noteworthy.  Breastfeeding can save a family between $750-$3000 on the cost of formula alone (depending on the formula that would have been used) during Baby's first year of life.

One woman was particularly concerned about the pain that she expected with breastfeeding and hoped that she could instead "do it through a tube".  Discussing the issues of physical discomfort and how breast pumps work helped allay her fears.

While breastfeeding is touted as "Best for Baby", not every mother can or should breastfeed.  Important contraindications include positive maternal HIV status, use of illicit drugs, and chemotherapy.

Case: M.C. is a 38 y.o. male who presents with DM type 2, HTN, and an angry demeanor. M.C. has a BMI of 48, and is utterly frustrated by his inability to lose weight despite exercise and diet control (he stated he had a cupcake and fried chicken for breakfast). Over the past month he has seen 30 doctors (based on his calculation). This exorbitant number of office visits is part of his pre-surgical evaluation for gastric bypass. By the time all is said and done, M.C. will have had his kidney, heart, liver, and mental functions all accessed. Once cleared by all the various docs he will begin eating optifast protein bars to lose the 40 lbs. required to have the surgery.

Question: With obesity becoming an overwhelming epidemic in our country how well do these patients do post-operation, and how well does the pre-surgery education truly educate them?

This surgery is a last alternative for many obese patients who have lived with serious medical complications throughout life. In order to access how these patients do with this life-altering treatment a new survey was created, which evaluates qualtiy of life, GI symptoms, and other comorbidities. Research found that the survey was validated and ready for use. The information obtained from previous patients will allow physicians to counsel future patients.

However, despite the physicians attempts to educate patients it seems that in many cases it goes in one ear and comes out the other.

If patient compliance and education can improve, then the long-term success of this surgery will dramatically increase. The anatomical success has been high, but it is important that patients comply with the specific diet required for ultimate benefits.

I think it's probably safe to say that even after the first week, everybody has had a few patients being treated for hypertension as well as obesity.  

Here's a study on 12 year olds who have high blood pressures, also looking at how their BMIs correlated with their bps.  Then they followed up after 2 years to show these kids with hypertension at 14.  After all the calculations they came up with an increase in 1kg(2.2lbs) in these kids increased their chance of having htn by 4% by the time those kids hit 14.  Of course having a high bp at 12 directly correlated with having a high bp at 14.  I think its interesting that they considered weight and blood pressures for 12 year olds as independent risk factors for kids developing/still having htn by 14.  

Another study, kind of in the same vein is about a child's socioeconomic status, height, and weight leading him/her to have htn when they're older(60 yo).  They did this study retrospective and they ended up not finding a correlation between socioeconomic status as a kid and htn as an adult.  They did end up with some weird connections.  They say that the taller a kid was, the lower their systolic and the higher their diastolic pressures ended up.  Also that shorter kids ended up having higher pulse pressures.  These guys also connected obesity in particular central obesity to high bp(diastolic).

So I guess what I'm getting at is to help control hypertension in overweight patients, weight control would be beneficial.  Even though those studies focused on kids, the adult patients would probably also benefit.

Case: A middle-aged man came to the office with a history of peptic ulcer disease confirmed by endoscopy (EGD).  His father and brother died of gastric adenocarcinoma.  The patient is worried that he will die soon of cancer and wants to know what we can do.          
Discussion: Recent analysis shows that there are specific cases in which screening for gastric cancer may be effective.  When a strong family history of disease is known, one may suspect either a genetic cause or common environmental exposures.  Unfortunately genetic testing is not currently available to determine the origin of the family history.  Therefore, we must be careful not to exclude genetics as a possibility.
     Infection with H. pylori is another risk factor for developing gastric carcinoma.  Specifically, bacteria containing cag A and some Vac A genotypes are associated with high risk for cancer.  Much like genetic testing for our patient, testing the virulence of H. pylori is not feasible.  It is safe to assume that because he has PUD, he is most likely infected with H. pylori.
           
POEM (the moral of the story): Our patient is at increased risk for stomach cancer.  The combination of PUD and a positive family history should worry us.  He should be treated for H. pylori infection.  However, simply treating the H. pylori infection is not enough.  This patient must be periodically screened by EGD.  Any suspicious lesions must be biopsied.
     Remember, not everyone with PUD needs to be watched so closely.  Only those individuals who are deemed to be at high risk (e.g., family history, previous gastric carcinoma, atrophic gastritis, gastric polyps, Menetrier's disease) should have periodic endoscopy.
 
 

Note: The above link is for the abstract.  The full text may be obtained via AMC's intranet.  Sorry for the inconvenience but this is the only way I could find to link this article.

A 15 yo, white male in good condition presents on follow-up for removal of 2 warts on his index finger and hand.  The diagnosis of HPV was already made due to the presence of the warts.  The standard treatment by my preceptor is removal with Cryosurgery.  This consists of 3 treatments with approximately 10 seconds exposure to liquid nitrogen in order to freeze the warts off.  

 This form of treatment takes at least 4 weeks and can be quite difficult when a patient has bigger, more extensive warts.  Recurrence of the HPV warts can also occur after this quite painful treatment.

Are there any other treatment options for HPV wart removal in this patient?

• Salicylic acid can be used to remove warts in areas such as hands, feet or knees. The patient is responsible for keeping warts clean, lightly drying and applying the acid to damp skin. It involves daily treatments for several weeks.
  

• Cantharidin is a chemical that is applied by a physician and results in blistering off of the wart after 3-8 hours. This treatment may have to be performed more than once and can be painful.
  

• Intralesional immunotherapy is another option for treatment with injections of skin test antigen to Candida, Mumps or Trichophyton.  This form of therapy works by stimulating direct HPV immunity.  Therefore, recurrence of HPV warts may also be less of a problem.  In addition, this treatment is also easier to perform on patients with more wide-spread areas of infection. 

This new immunotherapy treatment seems quite promising for the future of wart removal, a fairly common problem in patients.  A few adverse effects were reported such as edema, erythema and fever.  However, none of the 233 study participants had to leave the investigation due to these events.

In this patient, the treatment of his warts with the skin test antigens seems like a good option.  Since he is in good health and is still young, it would be beneficial to stimulate his own immunity to fight his HPV infection.  For an older patient in poor condition, cryotherapy would be a better option.  

 

 

 

 

 

I noticed a lot of patients coming to our family practice clinic with complaints of migraine headaches. Most of them, if not all, are on some type of prescription medication; however it seems that the actual efficacy of these drugs seem to vary from patient to patient. Most commonly, I have seen Imitrex (Sumatriptan) prescribed for migraines. 

Recently, a middle-aged female patient came to our family practice clinic with a migraine headache that had lasted for 36 hours. For the last 8 years she has had migraine headaches about 1-2 times per week. This is one of the patients who has had little success with Imitrex among other drugs. Since these prescription migraine drugs weren't really working too well for her, I began to wonder what the best non-prescription treatment would be...

I came across this very recent (9/2005) article, which is allegedly the first study to be published which conducted a randomized and controlled head-to-head trial of prescription and over-the-counter (OTC) drugs for migraine. It was found that the combination of acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg was siginificantly more effective than sumatriptan 50mg in the early treatment of migraine. 

The OTC combination was superior in reducing summed pain intensity, quicker response rates, and providing sustained relief.  Another article confirmed the safety and tolerability of the acetaminophen, aspirin, caffeine combination (three double-blind, randomized, parallel-group, single-dose, placebo-controlled studies).

In light of this initial clinical study, one might consider recommending the use of the OTC drug combination (acetaminophen, aspirin, and caffeine) in the early treatment of migraine instead of the commonly prescribed Imitrex.

A young female came by the office the other day in obvious respiratory distress. I was quick on my feet to help her but she told me this is normal for her. I was shocked, she said she was diagnosed with Bronchiectasis some time ago and began to tell me her story.

 

So for all of you I present Bronchiectasis in 2005

 This Disease is an abnormal and permanent dilatation of the Bronchi.  This is not a life threatening disease but it can be a social nuisance, as one suffers from a chronic daily cough with copious amounts of phlegm. However the disease does not stop here, because of the dilated bronchi, the lung accumulates mucus and infections are quite common. These constant infections destroy the structural components of the lung walls and thus a vicious cycle begins with inflammation producing airway damage, then impaired clearance of microorganisms and more infections which lead to more inflammation.

 Causes

  Bronchiectasis can be caused by a wide variety of infectious microorganisms. (which is more common in children, but adults can get too.) Patients can also be predisposed to getting bronchiectasis by various congenital or inherited deficiencies such as an impaired immune system or CF. Other cause include obstruction from foreign bodies and exposure to toxic substances.

Symptoms

Patients usually present with a persistent and recurrent cough with purulent sputum. Hemoptysis is usually present in about half these cases due to the damaged lung walls and usually indicates infection. Although chronic infection is usually present in the lungs the patients are mostly asymptomatic and "feel fine." However they are more prone to developing pneumonia if they are not treated properly.

On Physical exam any variety of crackles, wheezes and rhonchi may be heard.

Treatment

The idea behind the treatment for this disease is to try to allow the patient to live as normal a life as possible. There are various home techniques which one can employ to drain the mucus from the lungs.

Antibiotics are used for acute exacerbations of the disease, but which class and frequency are to be determined by the doctor.

Surgery can also be used to treat the disease but is a last resort and is unadvised in widespread disease.

 

By the way there is nothing like a good Hurricane!

This article gives the same information in children but is the same for adults.

    In an otherwise routine week of patient encounters, there have been a number of office visits for the removal of warts on hands and feet.  In my discussions with the patients, many described the enormous effort they had expended to try and rid themselves of the unsightly growths.  While many had tried over the counter products containing salicylic acid, one of the more interesting options suggested was the use of duct tape. 

    In fact, there is sufficient evidence to suggest that duct tape (or other similar products) have equal effectiveness in removing warts compared to cryoremoval (which is the preferred method at the office where I am located). 

    So who cares and why should you continue reading this?  Having spent a small amount of time in the office with a family practitioner has shown me the value of their time.  A simple, effective, and cost saving measure that can be utilized to remove warts without the need for a visit to the doctor would be a welcome change.  Not only is cryoremoval painful to some patients, but it also requires repeat treatments many times.  If a patient can remove the wart successfully and cheaply at home without the trouble of going to the doctor (possibly more than once), it is my belief that they would choose the easier and least costly option.

    Finally, the burden of wart removal is not causing the very foundation of the health care system to crumble.  However, if patients do not have visit the doctor for minor procedures, it allows the physician to focus on those who might be suffering from serious illness.  A well managed health care system helps both the patient and the physician.   

Although we have been lectured time and time again on the rise of obesity and I have seen it every day around me, I did not fully understand how severe the health implications of the problem are until this past week.  I was astounded at the number of obese patients who came into the office and was equally surprised at the number of obese individuals presenting for diabetes check-ups/ problems.  For most of the patients at my clinic, type 2 diabetes and/or obesity was one of numerous other problems, including heart disease and hypertension.  Type 2 diabetes is the most common form of diabetes, affecting 90-95% of people.  Often, patients with type 2 diabetes also have metabolic syndrome (consisting of obesity, elevated blood pressure, and high levels of blood lipids). 

Although beta blockers are the first line treatment as antihypertensives, this article proposes and supports, through meta-analysis, the use of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to decrease the odds of patients developing type 2 diabetes.  Thus, in many hypertensive patients who have not developed the disease, it may behoove the physicain to prescribe an ACE inhibitor as opposed to a diuretic or beta blocker. 

Patient with type 2 diabetes have an increased risk of developing heart disease, often as a result of their metabolic syndrome.  This article suggests that patients diagnosed with type 2 diabetes can reduce their risk of developing or dying from heart disease by taking an ACE inhibitor.   Patients with type 2 diabetes and hypertension can also decrease the burden on their kidneys by utilizing ACE inhibitors.  Thus, in the face of an ever increasing population of patients becoming obese or developing diabetes, physicians and patients should look to ACE inhibitors or angiotensin receptor blockers (if ACE inhibitors are not tolerated well).  Although beta blockers and diuretics are excellent antihypertensives, many patients may derive alternative benefits from the use of ACE inhibitors.

With one week of FP under your belt, most of you have no doubt had experience with a patient or two coming in with a self-diagnosis and a request for the antibiotics they may have received in the past. Here's my story:

A mother comes in with 2 children. She greets me warmly as I enter the room and tells me that she has a sinus infection; she's used to getting them a few times a year and her symptoms that day are typical.  She asks me for her antibiotics so she can get going.

"Wait Mrs. Smith, how long have you had your symptoms? (She had described them to me as sinus pain, nasal congestion, and a bit of a headache). 

"For about 3 days," she replies.

Well, according to this terrific article, acute sinusitis is often of viral origin but if acute bacterial rhinosinusitis (ARBS) is suspected certain criteria must be met, including the persistence of symptoms for at least SEVEN days (TEN days in children)!! Symptoms should include the following: (1) purulent nasal discharge, (2) maxillary tooth or facial pain (especially unilateral), (3) unilateral maxillary sinus tenderness, and (4) worsening symptoms after initial improvement.  Though sinus radiography is an option, it is not recommended by the CDC and not necessarily a feasible option in the FP setting, esp. with the numbers of patients that come in with the characteristic symptoms.

So my patient, and many others who come into the FP office with sinusitis, don't necessarily have a bacterial infection.  In fact, as the article points out, only about 13% of patients that present with symptoms of a URI have a bacterial infection, yet physicians prescribe antibiotics 98% of the time!  Talk about overprescribing!

So if physicians don't give patients the prescription that they ask for does that mean bad doctor? No, as indicated by this article. What then do we tell the patients?  This is the fun part, since we, the third year medical students cannot prescribe meds anyway.  We can give patients alternatives for sinus pain and nasal congestion relief that may help to "cure" them - all without antibiotics!

This article provides options for the non-antibiotic  treatment of sinonasal disease lasting less than 7 days including:  (1) nasal irrigation (the efficacy of which is confirmed with this article in Larygoscope), (2) inhaling steam and (3) applying moist heat (basically to help break up crust and "gunk").  Other adjunctive therapy is also mentioned.

So next time a patient comes in demanding antibiotics for URI symptoms lasting less than a week, we can be better prepared to educate them about their illness and switch the roles correctly back to doctor and patient.

 

Impetigo is a painful and sad condition to witness, especially when it is a pediatric case.  We all went through the second year infectious disease theme as well as boards and learned about impetigo and how it is a skin infection due to either Staph aureus or Group A Step (S. pyogenes), but I was never aware of the its clinical picture until today.  This condition usually results after inoculation  (ie. by scratching) of the wound by bacteria in the child's surrounding environment.

A mother brought her two year-old African-American daughter to the clinic two days ago with the chief complaint of "boils" on her child's legs, groin, and face that have persisted over the past two months.  She claimed that they were very painful for her daughter and that she would scream and cry whenever anything came in contact with those areas, including her diaper.  She also reported that she tried multiple types of diapers and bath soaps to ensure that it was not an allergic reaction.

On physical exam the lesions were crusty, yellow, and on a red base, thus displaying the classic "honey-crusting" appearance of impetigo.  The raised portions of lesions were not "boils" per se, but rather took on the appearance of large acne pustules and were extremely tender to palpation.  There were several areas of dark scarring from old/healed lesions.  Thus one could argue that this was a case of acne vulgaris, but it was lower on the differential because of the pelvic distribution.

Myself and the resident convened with our attending preceptor to discuss the potential treatments of the patient.  Impetigo througout the years has been rather controversial with respect to treatment interventions.  I found this article from the cochrane database of systematic reviews which involved an analysis of 57 trials involving oral and/or topical treatments of impetigo.  This other article also discusses current recommendations for anti-infective treatment. 

After consulting with the attending physician, we decided to treat the child with Augmenting oral antibiotics for ten days as well as topical Mupirocin 2% two times a day until it clears.  We also referred the child to dermatology for a definitive diagnosis, particularly since the treatment regimens are not defined or fixed.  Finally, it was essential to educate the mother on maintenance of a clean environment.  She explained that she is single, works full-time, and has to raise two other children and thus it is difficult at times for her to maintain a clean environment.  It was at this point that we recommended that the mother contact social services to assist her.  Thus although it is important to treat the current condition, it is also important that healthcare providers do everthing in our power to ensure that our pediatric patients are living in a safe and healthy envronment. 

  Over the course of the past week, the Family Practice office that I have been working with has seen numerous patients presenting with a complaint of a "sinus infection".  Due to the fact that allergy season is upon us, this presenting complain has become exceedingly common. 

   One patient I saw was a 42 yo female that worked full time and also took care of her three kids when she wasn't working.  She presented to the office after experiencing three days of increased pressure and congestion over her maxillary sinuses.  On exam the patient had a temp of 100.1, tenderness over the maxillary sinuses, and erythematous nasal mucosa.

  The treatment for acute sinusitis normally consists of  decongestants and a prolonged treatment of antibiotics such as Augmentin 500 mg BID for two weeks or a ten day regimen of Levofloxacin. 

   When this treatment regimen was proposed to the patient above she asked if there was a less complex regimen of antibiotics that she could take due to the fact that she didn't konw if she would be able to reliably take two pills daily for two weeks with her hectic schedule.

   While most doctors prefer to use an antibiotic treatment like the one mentioned above, I found THIS ARTICLE which compared the efficacy of a single dose formulation of azithromycin vs. a ten day course of levofloxacin to treat adult acute bacterial sinusitis.  The study showed that the novel formulation of azithromycin safe and of equal efficacy as the ten day course of levofloxacin. 

   This new treatment can be extremely useful especially for treating patients such as the one described above that would have difficulty remaining fully compliant to a longer course of antibiotics.

64 yo white female presenting complaining of pain, numbness in her right foot, and weakness distal to the side of entrapment. She complains of inability to walk more than half a mile as well as inability to stand on her feet.

DDx: Mortons neuroma- entrapment neuropathy, includes pressure, friction and ischemia, also known tarsal tunnel syndome. it is also aggravated by walking on hard surfaces, dancing, running.

Management: proper shoes, arch support required. Also in this article it was stated that MR imaging is needed to further evaluate and diagnose this case. Injection of corticosteroids is necessary to relieve the stress, as well as surgical removal in chronic cases.

58 y.o. Diabetic male presents complaining of hand swelling and pain for the past week. He indicates that pain and stiffness are more intense in the morning but improve after 3-4 hrs. The patient is distressed because the pain and swelling are interfering with his work as a chef. In addition, he also complained of pain in both shoulders and elbows that is also relieved with movement. He also has pain in the soles of his feet when walking. He has been taking Aleve in the morning and at night for the pain. The patient denied any constitutional symptoms or the presence of a rash.


On physical examination the following was observed:
- Bilateral and symmetrical swelling of the wrists and all fingers, including MCP and  PIP joints
- Both shoulder and elbow joints are slightly painful with movement, but not swollen.
- Bilateral and symmetrical tenderness of MTP joints.

DDX
Involvement of the MCP, PIP and MTP joints is highly suggestive of Rheumatoid Arthritis (RA). However, peripheral polyarthritis is also common in other rheumatic diseases such as Systemic lupus erythematous, scleroderma, psoriatic arthritis and rheumatoid fever. Other possibilities in the diagnosis include Lyme disease
To diagnose RA the patients blood was drawn to check for: Erythrocytes sedimentation rate (ESR), Antinuclear antibody (ANA) and Rheumatoid factor (RF). In addition, a Lyme titer was ordered.

Literature Review
The patient's urinalysis and previous HbA1c indicated that his Diabetes is not well controlled. Although this patient takes his medications as indicated, he has not tried to improve his diet and does not exercise. I explained to this patient the importance of controlling his Diabetes in order to reduce the risk of cardiovascular disease (CVD). This article explains the link between endothelial dysfunction, atherosclerosis and diabetes.
However, Diabetes may not be his only risk factor. A recent article indicates a fourfold increased incidence of cardiovascular events in RA patients as compared with the general population. RA patients seem to have lower insulin sensitivity and HDL cholesterol concentrations. For this patient modifying his diet is a challenge due to his profession, but an exercise regiment would certainly help as well a regular follow ups to monitor the progression of the RA, his glucose and lipid levels.

It would seem that one of the great things about family practice is the variety of patients that you get to see and manage at the same time. One part of this diverse patient population is pregnant/OB patients. Over the course of this week, I've been witness to countless prenatal exams. As such I began to wonder about the specifics of preeclampsia risk factors, diagnosis, treatment, and possible interventions. The criteria for diagnosing preeclampsia can be found here. But the general requirements are hypertension (>140 systolic or >90 systolic after 20wks of gestation, following normal or low blood pressures early on in pregnancy) and proteinuria (at least 5g of protein in a 24 urine sample, or 3+ urine protein with dipstick on 2 different office visits)

 

Preeclampsia risk factors

Until now, the risk factors that physicians (at least the ones that I have encountered) use to screen patients for possible preeclampsia are nulliparity and family history of preeclampsia. However, in my research I found a systematic review of studies that compiled multiple studies about preeclampsia risk factors and it would seem that there are many others (information on which can be found in most OB patients chart). Some of the more risk factors that were compiled include: previous preeclampsia (with a URR of 7.61), family history (URR = 3.6), nulliparity (URR= 2.35), Antiphospholipid Ab's (URR= 6.12). One of the positives about this study was the fact that it separated and grouped the data into case-control and cohort studies instead of simply combining all the data. Ultimately, the authors delineated the most significant risk factors being: a history of preeclampsia and the presence of antiphospholipid antibodies. Another common risk factor is pre-pregnancy diabetes (a risk factor which is rising in prevalence THROUGHOUT the US) combined with a pre-preganancy BMI of >35 (these combined risk factors quadruple the chance of the patient experiencing preeclampsia.

 

Treatments / Interventions

Currently the most widely accepted treatment for a patient with significant signs of preeclampsia is delivery. I wont go into the specifics, but needless to say severe preeclamptic patients are undergo delivery, while those patients with moderate to mild preeclamptic conditions can often be managed on antihypertensives. An interesting development that would fall under POEM material is that a recently published  systematic review shows that antiplatelet drugs seem to reduce the preeclampsia, preterm birth, stillbirth, and neonatal death. The collective data indicates that simply administering an aspirin-a-day can have a relative risk reduction of preeclampsia of 15% and a NNT of 100. If you look at this from a cost benefit standpoint, treating 100 patients with an aspirin a day can save even just person from going into preeclamptic conditions, this an incredibly cost-effective therapy.

I recently had the pleasure of giving a diabetic f/u to a lady in her early 60's who was quite a character.  She comes in to the f/u in good spirits, appearning quite well, but with a hx. of poor glucose control.  She eats what she wants, is maxed out on glucophage (1000mg 2X Daily) and taking glucotrol as well (2.5mg 1X Daily), and is wondering why her BG is 250 every morning.  The funny thing is she isn't concerned about her high blood glucose, she comes in with a concern that she has recently over the past few months developed hypertension (160/90), and is worried about that.  The high BG and poor control is something she has had for years, and refuses dietary modification, yet she is very concerned about a few months of increased blood pressure.  After talking to her extensively about dietary modification and exercise, I left the exam with a question of my own.  Which is more important, good BS control, or good BP control in type 2 diabetics?  I mean, was this woman correct in being much more concerned about her blood pressure than her sugars?  Not knowing that answer, I couldn't tell her if she should be worrying more about the BP or the fact that she consistantly has an A1C in the high 9's.  So I set out to answer my question, and here is what I found:

 

The United Kingdom Prospective Diabetes Study (UKPDS) is the "largest clinical research study of diabetes every conducted".  Amongst many other studies, it studied the effects of lowering raised blood glucose and blood pressure on the life threatening complications of type 2 diabetes.  That seemed like a good place to answer my question, and it seemed even better after I found a slide presentation that summed up the findings of the study here.  Basically, what they found is while both reducing high BP and high BG had a significant impact in reducing incidence of stroke, microvasuclar complications, and indeed any diabetic endpoint, reducing high  BP alone provides significantly greater benfit than reducing BG alone.  The following is a summary of the stats for those interested (p<0.05).  The percentages are % reduction in relative risk:

 

              BP Control(<140/80)   BG Control(A1C<7.0)

STROKE               44%                     5%

DM ENDPOINT       24%                     12%

MICROVASCULAR  37%                      32%

DM DEATHS          32%                      10%

 

I found that to be incredibly interesting, and even more interesting was the fact that it validated my patient's greater concern for her BP than her BG!!!  However, with everything in this world, these results may be interpreted differently by different people.  So I have included this link for you, which has some other peoples' interpretation of the myriad of conclusions reached in the UKPDS study.  From my own reading of some of the papers, it seems that BOTH BP and BG control are very important, with BP seemingly being more important, and depending on the patient, one may be easier to control than the other.  Obviously if a patient is controlling their BG, try to reduce their BP too, and vice versa.  But if the patient is only willing or compliant in reducing one thing, it would seem that BP reduction is the more important goal in the hypertensive diabetic.

This past week I saw 3 OB patients who came in for follow up visits. Two of the three ladies were smoking through their pregnancy. I also saw 5 ladies ages 17-27 who were currently smoking, and were under the impression that it would not effect their child baring as long as they quit once they became pregnant. Despite knowing many risk factors involved with smoking, altmost 25 % of American women of reproductive age continue to smoke.

I watched many different doctors this week discuss risk factors and smoking cessation with their patients. I realized that smoking is a huge problem in this community, and decided to do some research on risk factors assoiated with smoking, as weel as different smoking cessation methods, and their success rates.

One of the articles that I found, discusses that women who smoke during child baring age are at risk for infertility, placental abruption, low birth weight of their baby, preterm premature rupture of membranes, placenta previa, and spontaneous pregnancy loss. Although much of pathophysiology is not clearly understood,  many of these effects have to do with impaired fetal oxygen delivery, as well as carbon monoxide exposure.

However, the problem of smoking cessation still exists, and I found that most doctors still remain uncertain what the best approach to these patients would be. There is much talk about different methods of smoking cessation, but no clear number one choice. One thing remains clear is that the patient has to be willing and wanting to quit before any smoking cessation would work. Thus I thought it is very important for us, students who have more time to interview and talk with these patients, to have facts about risks associated with smoking so that we can get our patietns to start thinking about quiting, and then have different information about smoking cessation methods that seem to work best.

The article mentioned above lists three recommendations for smoking cessation during pregnancy that were released by the United States Department of health and Human Services. One of these recommendations states that pregnant women who were offered extended or augmented psychosocial intervention did significantly better then those who were were simply adviced to quit by their physician. Meta-analysis found abstinence rates to be 16.8 versus 6.6 percent. Another recommendation says that pharmacotherapy should be considered whenever a pregnant women is unable to quit, and the risks of smoking outweigh those of pharmacotherapy.

Although nicotine replacement therapy might work great for many smokers, it is not recommended for pregnant women, as it results in a state of sympathetic activation.In animal studies it increased vascular resistance and reduced uterine blood flow.

Another option, that can be used with pregnatn women, is sustained release bupropion. It showed to have higher abstinence rates when compared with a placebo, or a nicotine patch. It is NOT known to be a teratogen or have any adverse fetal effects. It is a class B drug.

I also noticed that many times it is difficult to initiate such conversation with a patient, and get them to the point where they are thinking about quitting. So, I found something called the 5 A's (ask, advise, assess, assist, and arrange) method that is menat to be used for pregnant patients. It should help you obtain smoking history information from your patient, as well as progress through this portion of the interview in a logical manner.

Some other methods that I saw/heard doctors use include making a jar where the patient would put the same amount of money that he/she spends on cigarettes, so that they can see how much they can save by not smoking. It adds up to a couple of thousand dollars a year, depending on how much they smoke; showing pictures of babies born with defects from smoking to motivate them to kick the habit; and cutting the cigarette in half, to get your patients to cut down.

What the future holds:

There is some new research that shows promising effects of Rimonabant, an antagonist of central cannabinoid type 1 (CB1) receptors, on smoking cessation. Rimonabant appears to decrease nicotine addiction while hyperactivating the endocannabinoid system and the mesolimbic dopaminergic neuronal pathway.

I hope that this information was useful and that you will now be able to get all your patients to quit smoking :)

A pleasant 56yo woman with type 2 Diabetes, hypertension and hyperlipidemia presented to the office for a follow up. She was previously on Lipitor, but she decided to stop taking it 2 months ago because it was giving her a stomach ache every time she took it. Someone mentioned to her that Red Yeast Rice can help control cholesterol. She brought a bottle of the natural supplement to the office with interest in starting it in place of the Lipitor.

What is Red Yeast Rice?

Red Yeast Rice is rice that is fermented by red yeast (Monascus purpureus). It has been used in Chinese medicine for thousands of years to treat "circulation problems" and more recently to treat high cholesterol. It is also a dietary staple in some Chinese, Japanese and Asian American communities.

What does it do?

I looked it up on the Natural Medicine section of MicroMedex and found that the active ingredient is lovastatin. I found this study comparing one formulation to placebo. The study was a prosepctive, double-blind randomized trial. The patients received blood tests for LDL, HDL, total cholesterol and triglycerides at baseline, 8,9,11 and 12 weeks. They also received dietary couseling on a healthy heart diet and filled out food frequency questionairres at several points to determine changes in diet. The results showed a statistically significant difference (p<0.05) for a decrease in LDL, total cholesterol and triglycerides with no change in HDL. The study was well done and appears valid. The study was funded by Pharmanex (who also manufactured drug for the study). A better study would be one comparing red yeast rice to a pharmaceutical statin.

Should patients use Red Yeast Rice?

Since the active ingredient is a statin, they should work. However like all natural supplements, they are not regulated by the FDA and another study looked at the differences between the formulation proven effective in clinical trials to other formulations. They found significant differences in active ingredients between the 9 formulations tested.

The cost was ~$35 for 60 tablets at a local health food store (potentially more expensive dep on insurance/co-pays) and the side effects of liver and muscle toxicity are the same as with other cholesterol lowering drugs.

Our patient....

Our patient's cholesterol had gone up significantly since stopping the lipitor, but the physician said that she could try the Red Yeast Rice for 4 weeks. If there was no improvement at that time she recommended that the patient return to the lipitor or another statin.

CASE: A young health athletic young man came in today complaining of extreme sweating through out his entire body even when he is directly in front of the air conditioner for the pass year. He stated that the sweating could start at any time even during in his sleep. He said it is very annoying, and his employer has started to comment on his condition better he could not meet with clients. He wanted to know if there are any treatments for the condition because it is affecting his life.  

Dx: There is no test that could directly diagnosis the condition, and the first step in the evalution is the exclusion of other causes of excess sweating. There are many medications that could cause this condition and must be ruled out, such as diuretics, antihypertensives, antidepressants, etc.

Treatment: There is no clear explanation for the sudden dysfunction of the nervous system, and the current treatment is with botulinum toxin or surgery in extreme cases. The botulium toxin is only useful in treating focal hyperhidrosis. The surgerical treatment requires the resection of T2 and T3 ganglion.

In the study which involve the T2 and/or T3 resection, it was found that if both T2 and T3 were resected the recurrence rates of sweating is only between 0-3%. If only the T2 or T3 ganglion were resected the recurrence rate of sweating was between 100% for T2(only) and 90% for T3(only). The study had a follow up period at 1 and 2 years.

The other day i saw a patient that had a history of ingrown toe nails. The first time the patient had problems they were treated surgically with a removal of the parts of the nails that were ingrown. To be able to prevent the nail from growing back the sides of the toe needed to be cauterized. Unfortunately, this did not permenantly help the pateint, since they had to return to see us. This time we tried a different approach, which involved removal of the entire nail. We also decided that we should try a different method to stop it from reoccuring by using phenol to destroy the tissue and hopefully prevent it from growing back. Both procedures also required that the patient undergo a digital block.  

Recently there has been some evidence that a new method using lasers.The procedure has shown some promise helping to reduce the pain asssociated with removal of the ingrown toe nail, also it may help reduce swelling and help provide a quicker healing time. This procedure may help to reduce the pain for the patient. Hopefully this may be a new method to permenently prevent patients from having to come back for repeat procedures. 

Saw apatient named mrs smith who works as the secretary for the manager of the price sbhoppper in Slindanes and she was swimming a lot and she had ear pain.

(just kidding)

So I looked this up and it helped treate her.