Working in the family practice office, I see a lot of women getting papanicolaou smears for cervical cancer screening.  However, some doctors use a lubricant on the tip of the speculum and some doctors prefer not to use it.  I also remember a doctor from the last rotation, who prefers not to use the lubricant for the pap smear because of the debate on the possible contamination of the pap smear sample. 

However, one doctor that I worked with in the past week told me that the debate on the contamination of the sample by the lubricant has been resolved.  As my research results showed, she said the lubricant does not interfere with the pap smear result.  She also considered a patient's comfort as the most important reason for the use of the lubricant.

Most textbooks on gynecology written in the past (prior to the publication of these studies), state that no vaginal lubrication should be used for pap smears in fear of adversely affecting the result.  One Ob-Gyn website by a medical school, copyrighted in 2001, also recommends the same, showing how pervasive this belief was prior to these studies.

In order to elucidate the possibility of interference with the interpretation of the pap smear, investigators in this study collected pap smear samples from 182 patients, using a speculum with a water soluble lubricant or a speculum with water only.  Next, they sent the samples for analysis to cytotechnicians and pathologists who were blind to the cohort and to whether or not they were part of the study.  According to the result, 2.1% in the lubricant group and 2.2% in the no lubricant group had unsatisfactory result, showing no significant difference between the two groups.

FYI: Unsatisfactory samples refer to smears that are "unsatisfactory for evaluation" : samples that have scanty cellular material or obscured by inflammation, blood, or debris so that more than 75 percent of the cells are uninterpretable.

Another study published in the same issue of the same journal also found no difference in the pap smear results between the two groups.  This study analyzed over 8000 samples and found the rates of unsatisfactory sample in lubricant and no lubricant group to be 1.4% and 1.3% respectively.  They also investigated the rates of high-grade and low-grade squamous intraepithelial lesions and benign cellular changes in the two groups and found no significant difference.

I could not find any study that associated the use of a lubricant with misleading or incorrect results(the authors in above studies could not either).  One website mentioned the use of a lubricant has been discouraged ‘traditionally'.

I also could not find a study that investigated the level of pain and discomfort associated with a lubricant use on the exam.  However, if there's a possibility of decreasing pain and discomfort associated with the exam, why not use it?  Many women avoid pap smear because of the pain and discomfort despite its proven effectiveness for cervical cancer screening.

54-year-old R.S. came into clinic for a routine annual check-up.  With no major complaints and an unremarkable physical examination, my preceptor was finishing up the appointment by going over health maintenance issues.  When he got to screening for prostate cancer, he recommended a digital rectal exam (DRE) but not a PSA test.  Why not the PSA test?!!!  It was time to investigate!

Prostate specific antigen, or PSA, is a protein produced by the prostate that may be found in low amounts in the blood of healthy men.  The amount of PSA in the blood normally increases as a man's prostate enlarges with age.  It may also be found in an increased amount in the blood of men who have prostate cancer, benign prostatic hyperplasia, or an infection of the prostate gland.   There is no specific normal or abnormal PSA level.  However, the higher a man's PSA level, the more likely it is that cancer is present.  But because various factors can cause PSA levels to fluctuate, one abnormal PSA test does not necessarily indicate a need for other diagnostic tests.  When PSA levels continue to rise over time, other tests may be needed. 

I found one study that looked at the pros and cons for all types of screening for prostate cancer for the U.S. Preventive Service Task Force.  Their literature evaulation found that the benefits of screening for prostate cancer cannot be well determined (i.e. decreased mortality), although the risks of prostate cancer screening are known (i.e. erectile dysfunction, urinary incontinence).  This would suggest that all types of general screening for prostate cancer is unwarrented.  Not quite satisfied since I wanted to look at the validity of specifically PSA test for prostate cancer screening, the search continued...    

Another study used a case-control format to evaluate the correlation between serum PSA and prostate cancer in 21,387 men in the Finnish Cancer Registry.  The sensitivity of PSA to identify cancer was 44% and specificity 94% with the clinically common cutoff of 4 µg./l.  The sensitivity increased to 86% if only cases occurring in the 5 years after the sample drawing were considered.  Patient age at the sample drawing affected the validity. The sensitivity was 93% and specificity 96% at the cutoff of 4 µg./l.  if only those men younger than 65 years at the time the sample was drawn with a lag of less than 5 years were included.  All men younger than 65 years with cancer in 5 years after the sample drawing had PSA greater than 2.5 µg./l., indicating 100% sensitivity, while specificity remained at 91%.  The authors concluded that although serum PSA is a valid test for screening prostate cancer, routine testing with PSA is not justified until an effect on mortality can be demonstrated.

In conclusion, since there is no direct evidence whether or not early detection and treatment of prostate cancer reduces mortality because randomized clinical trials to address this question have not been completed, it seems PSA testing should not be used for routine screening.  PSA screening can cause harm by producing false alarms, inducing anxiety and the treatment of early disease whichwould not otherwise have become a problem.  But even though evidence does not yet support population screening for prostate cancer, there is considerable demand for the PSA test amongst men worried about the disease.  Therefore, presently the role of the general practitioner is to inform men of the PSA test and provide high quality information regarding the test so that they may make their own decision.

Hi, just in case my links don't go through, I've included a list of resources at the end of my blog... :-)

One of my more exciting patients last week was a man with a painful perianal abscess.  (Click here for a picture of one (5).) We consulted with a surgeon, who made an incision in the abscess to drain it.  The surgeon then left it open, filling it with a strip of thin cotton gauze which was to be removed the next day. 

The surgeon remarked that no special antibiotic ointment or care was needed because "wounds around the anus don't get infected, despite all the schlong that passes by."  Actually, he went on to say that no open wound ever gets infected, and that in his opinion, antibacterial ointment is no more effective than Vaseline.

Unfortunately, I couldn't find any articles specifically on whether or not an incised perianal abscess would get reinfected without an antibiotic ointment.  However, the review articles on treatment never mentioned using one.  Instead, postsurgical treatment often consists of rinsing with seltzer water after having a bowel movement. 

I did find one article (6) comparing various antibiotic ointments with Vaseline.  It was a double blind randomised controlled trial.  Basically, 465 patients who presented to the ER within 12 hours of sustaining a wound (and who weren't immunocompromised, pregnant, taking antibiotics, etc.) were randomly placed in groups.  Patients either received an antibiotic ointment or Vaseline after the wound was cleaned, debrided, and sutured as needed.    The result was that patients given antibiotic ointment had a lower rate of wound infection than patients given Vaseline.  

Weaknesses in the study (7) included subjective measurements of infection, patients were responsible for their own wound care, and the fact that every wound was initially treated differently.   According to doctors at Best Evidence Topics, there wasn't enough evidence to change our current practice of not using antibiotic ointment on wounds to prevent infection.

Another randomized, double-blind, prospective trial compared white petrolatum with bacitracin ointment.  In this study, 922 patients were enrolled, with a total of 1249 wounds.  "Thirteen patients developed postprocedure infection (1.5%), 9 (2.0%) in the white petrolatum group vs 4 (0.9%) in the bacitracin group (95% confidence interval for difference, -0.4% to 2.7%; P=.37)"  Although the authors found do difference in wound healing and concluded that white petroleum is as safe and effective as an antibiotic ointment, their own study does show a lower rate of infection when bacitracin ointment was used.  However, 4 patients treated with the ointment developed an allergic reaction to it, whereas none of the petroleum patients had an allergic reaction.   
The bottom line on all this?  It seems as if the consensus is that we don't need to use antibiotic ointment after wounds are treated, unless a large multicenter study is performed that proves otherwise.     

For your Interest, Some Perianal Abscess Info:

"A perirectal abscess is a collection of pus in the deep tissues surrounding the anus. By contrast, a perianal abscess is a shallower collection of pus under the skin surrounding the anus."  (3)  It is believed that a perianal/rectal abscess occurs when one of the mucous-secreting glands inside the anus gets blocked up.  The duct gets infected, swells and bursts, creating an abscess.  This abscess then tracks to the surface, where it presents as a fluctuant mass just under the skin.  Apparently, you can get an idea of how deep the abscess is by where it presents on the anus.  (For a diagram, click here and scroll down.)

Treatment:
These abscesses usually form inside the rectum, then track to the skin, so it is rare to find a truly superficial perianal abscess.  Ultrasound, MRI, or CT can be used to track the depth of the abscess, which often forms a fistula.  Basically, the abscess should be incised and drained.  However, it should not be tightly packed, since the gauze can become a hotbed of new infection and can cause sepsis.   If it were closed by stitches, pus would just form in the wound and recreate the abscess. (4)   

Reference List:

1.  http://www.emedicine.com/emerg/topic494.htm
2.  diagram:  http://www.emedicine.com/med/topic2733.htm#target1
3.  http://www.emedicinehealth.com/articles/20221-1.asp
4.  http://www.emedicinehealth.com/articles/20221-7.asp
5.  http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-2070454759
6. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7606610
7. http://www.bestbets.org/cgi-bin/bets.pl?record=00352
8.  http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8805732

An article which has good info on wound healing with topical ointments, but is not available online, is:  J Fam Pract. 1997 Jan;44(1):26-7

This site is a great source for this topic.  I would have been linking the same site too many times throughout the blog.

Just about every other patient I see has diabetes.  Within the past two weeks, none were referred to the nutritionist, nor were they asked about podiatry visits nor was diet mentioned.  On Friday, I saw a 41 year old woman who developed type 2 diabetes about 1 year ago.  Her diabetes is diet controlled.  I asked her about her diet, which she told me she has started to eat all the things she had stopped eating and from looking in her chart, she had regained the weight she had lost after her first and last visit with the nutritionist. 

She gained the motivation to change her diet after meeting with the nutritionist 6 months ago.  She regained the weight, because she had lost the motivation to eat a proper diet.  I suggested another visit with the nutritionist since this is what had motivated her to lose some weight in the first place.  She told me that she had already seen the nutritionist, I convinced her to go to the nutritionist again (scare of meds/insulin :) )  Surprisingly, I precepted the patient and told the doc that I think the patient should see the nutritionist again and the doc's response was what the patient had said, "She already saw the nutritionist."

The effective most successful management of diabetes requires teamwork.  Back in the days, the traditional or consultative approach, where the doctor was the leader and had the say so was used.  Today, the interdisciplinary or integrated team approach has been proven to work best in the management of diabetic patients and any patient with a chronic illness.  The basic team should include physicians, nurses, medical assisstants, dieticians, social workers and behavioral scientists specifically trained in the area of interest.  It takes a well collaborated  team effort to appropriately manage these patients.  Team members need to understand the disease process fully, understand the management approach, respect each other's point of view and role and they MUST COMMUNICATE.  They don't have to agree with each other, but they must all communicate regarding the patient.

A large part of managing diabetes well is educating the patient.  The linked article provides result from a study, which showed that the educated patient is able to better monitor blood glucose levels and make better decisions regarding their health.  The patient who was previously mentioned with diet controlled diabetes should spend most of her time with the nutritionist.  The physician may be the team leader, but he or she does not have to be the one to spend most of the time educating the patient after the initial visit.  These patients may spend upto 60% of the visit with the nurse or whoever is able to educate them.  Each team is designed according to the specific needs of the patients.  This does not happen in this clinic.  The nurses do the routine stuff (BP, RR etc), that's it.  I haven't heard anyone ask about the diet nor money for the proper foods nor support systems.

We should all try to remember to utilize the resources that are available to us as doctors.  A team approach to applicable patients may help to decrease our workload while providing the best possible care for our patients.

A young guy (mid 20's) presented this week with generalized anxiety d/o exacerbated by sleep disturbances, tension, and restlessness. Having tried more conventional treatments such as benzodiazepine and SSRI he was wandering the efficacy of phytotherapy such as kava kava (piper methysticum) which he read on the internet could be of some benefit. What was I supposed to tell him??

The first article that I came across seemed to be in favor of using Kava Kava extract for sleep disturbances that are associated with anxiety disorders. The study only used 57 patients (a small number I thought) 34 of which were assigned to take the extract while 23 were placed on the placebo. Both groups showed sleeping improvements but the Kava Kava group had a more pronounced improvement. The study claims that administration of kava increases deep sleep periods but unchanges REM sleeping periods unlike psychopharmacological agents used for anxiety which suppress REM sleep and prolong REM latency period. Patients taking Kava tolerated the treatment well without any adverse side affects. Patients with anxiety disorder claimed that being on the KAVA improved their overall well being and reduced their anxiety in part by the normalization of their sleep. The authors of this study supported the use of Kava for its affectivity but also for its lack of dependency creating potential.

In another recent article the role of Kava was assessed in patients with anxiety. This study lasted for 4 weeks and included 50 patients with non-psychotic anxiety (DSM-III-R criteria). Anxiety levels were measured using the Hamilton Anxiety Scale (HAMA). This study concluded that a lower dose of Kava 100-300 mg/day can be efficacious for anxiety treatment while a higher dose can be comparable to benzodiazepines. The authors in this study pointed out that patients tolerated the drug well and that Kava has minimal drug interaction with other drugs. Therefore this study also supported a trial use of Kava in patients before beginning them on habit forming sedative psychotherapy.

However, not everyone is supportive of the use of Kava Kava in the treatment of anxiety disorder. An Article (cannot link to OVID article) published in 2004 in Current Opinion in Psychiatry (VOL 17(1) pp49-52) reviewed recent developments in the research of generalized anxiety d/o and stated Kava Kava, although well tolerated, is not superior to Placebo. This information is important to keep in mind when we are educating patients about what we can realistically expect from a treatment such as Kava Kava.

Lastly, it is important that we educate our selves and our patients about the potential side effects to the medications we prescribe them. A publication in JAMA pointed out the potential association of Hepatic toxicity with the use of Kava Kava containing products. Patients with pre-existing liver disease or are at risk for liver disease are advised not to use Kava products. Some countries such as Germany, Canada, Australia and France have restricted use of Kava based on its potential for hepatotoxicity.

In conclusion we should not negate our patient's request for alternative medicine especially if we are not educated about the particular remedy. For my patient Kava may be a good choice to begin with because he did not want to resort to benzodiazepines for initial treatment. As long as the patient is well educated about the possible risks and benefits of the treatment he should be able to exercise his autonomy.

Recently, due to the massive recall of the incredibly popular drug Vioxx, many patients have expressed their concerns about other potential side effects that perhaps have not yet been discovered about the other cox-2 inhibitors. In many cases, patients have become reluctant to try other drugs that are in the same family as Vioxx, and have instead opted for the more traditional NSAIDs. For most, the change in treatment has been well tolerated, however for others, the side effects from non-selective NSAIDs including gastric ulcers has forced them to stop treatment. Curious as to what else could be done for these patients, I decided to do some research and across an interesting fact- "Tumeric is a natural cox-2 inhibitor!"

Tumeric, which comes form the root of the Curcuma longa (a leafy plant in the ginger family), is a popular spice that is extensively used in Indian and Southeast Asian cooking and is what essentially gives curry it's yellow color. Since 600 BC, tumeric has not only been used as a flavoring and a dye, but has also been used for medicinal purposes. Throughout Asia, the spice has been consumed to treat stomach and liver aliments and has also been used externally to heal sores.

Recently, there has been much interested in tumeric and it's natural abilities as an anti-inflammatory agent. One particular literature study concluded that after the research and review of a large number of studies, tumeric (curcumin) demonstrated to be safe in six human trails and has demonstrated anti-inflammatory activity by inhibition of a number of different molecules that play a role in inflamation, including cox-2.

In the clinic this week, I saw many patients concerned about hyperlipidemia and heart disease. Many of them already on appropriate lipid lowering medications, wanted to know what more they could do to maintain their health. One women specifically asked about the benefits of garlic as a supplementation to her normal diet. I had always heard that garlic had a laundry-list of benefits - but this came from my grandmother who also swears by knocking on wood and spitting in the presence of a black cat. So, I decided to do some investigating for myself and this is what I found:

The use of garlic in medicinal practice is evidenced throughout history. So much so, that garlic is commercially available in a variety of supplementation forms from raw to tablets. Garlic and garlic supplements have been used over the years for hyperlipidemia, antiplatelet and procirculatory effects, anticancer and chemoprotective properties, and for immune-enhancement among others. An article on the Historical Perspective of Garlic and Cardiovascular Disease examines the contradictory results of medicinal garlic use. It discusses studies demonstrating that garlic can normalize plasma lipid levels, increase fibrinoltyic activity, inhibit platelet aggregation, and reduce blood pressure and glucose. However, it also introduces studies that have shown garlic to be entirely ineffective. The article concludes that despite conflicting studies, garlic supplementation does positively contribute to the prevention or delay of cardiovascular disease. As for the scope of medicinal benefits with garlic, more extensive studies are required. 

Another article examines garlic's function in preventing H. Pylori and other bacterial infections. Some interesting findings include: 1) raw garlic juice was found to have anti-microbial properties against several intestinal bacteria in humans, 2) garlic may be effective in strains of bacteria that demonstrate resistance to antibiotics, and 3) garlic may even prevent toxin production by certain miro-organisms. Because garlic has been shown to work synergistically with antibiotics, the article suggests the need for further study to test whether in combination they may be effective in the eradication of resistant or difficult to treat bacteria.

Yet another known benefit of garlic, is immune enhancement and anti-tumor effects. The mechanism proposed to explain this effect states that garlic is an antioxidant that stimulates cytochrome P450 and as such can detoxify carcinogens. Furthermore, garlic's function as an immune stimulator may contribute to its effects in inhibiting the growth of cancer and decreasing the risk of malignancy. Unfortunately, the article that I found in support of this was performed as an animal study. However, its significant findings may be an encouragment to begin clinical studies.

So, in conclusion, grandma may have been right all along. Garlic may indeed have a variety of significant medicinal benefits to decrease morbidity and mortality. As such, the literature supports its use as a supplementation in our current diets. However, although studies have demonstrated its beneficial effects, the literature unanimously agrees that further investigation must be done to support incorporation of garlic as a mainstream medicinal therapy. Nevertheless, it may be worth noting that the garlic we use today on Halloween to keep the vampires away might be useful tomorrow to keep the doctors away.

This past week, a 72 year old man came in for treatment of several actinic keratoses on his ears.  My preceptor used a liquid nitrogen spray to freeze the keratoses and thus kill the precancerous lesions.  As a demonstration of what this process feels like, she froze a small spot on my hand.  Trust me, it stings pretty badly for a while.  Not only can this procedure be painfully, it leaves an area of hypopigmented skin after healing.  I wondered whether there is another treatment method that would be equally effective, but without the pain or potential disfiguration.

In a review (full text) of various treatment methods for actinic keratosis, cryotherapy with liquid nitrogen spray was considered the gold standard of treatment.  Cure rates for this method were reported to be as high as 98.8%.  The use of topical 5-fluorouracil was considered as an alternative treatment.  Cure rates for this method were as high as 93%, however treatment was highly dependant on patient compliance.  Many patients are unable to tolerate the side effects (burning, pain, and itching at the site of application) and therefore fail to apply the topical cream daily, reducing efficacy.

A study (full text) comparing the therapeutic results of cryotherapy (liquid nitrogen) with the reported results of 5-fluorouracil,  found that the cryotherapy treatment demonstrated superior efficacy in preventing recurence of the lesions.  This study found a 30% recurrence after 3 years with the use of cryotherapy compared to a 75% recurrence after 3 years in a similar study employing 5-fluorouracil.

Though the initial treatment of actinic keratosis with cryotherapy can be painful, the literature I reviewed suggests this is still the best means to treat this condition.  Take home message- wear your sunscreen!

Hydrotherapy (exercise in a pool) is said to reduce oedema, initiate pain relief and reduce load and damage on joints.  So is this true?

Abstract

Full text

This single blind, three arm, randomized controlled trial compared hydroptherapy resistance exercise program with a gym based resistance exercise on strength and function in 105 patients >50 yo who have osteoarthritis (OA) of knee and hip.  Both groups had 3 exercise session a week for 6 weeks and at 6 weeks a blinded physiotherapist assessed outcomes (muscle strength dynamometry, 6 min walk test, WOMAC OA Index, SF-12 quality of life, Adelaide Activities Profile, & Arthritis Self-Efficacy Scale). 

Both gym and hydrotherapy exercise programs improved physical function.  GYM was BETTER at building MUSCLE STRENGTH and HYDROTHERAPY was BETTER for an AEROBIC work out.   The gym is recommended for those who want to improve joint stability and increase shock absorption around affected joint.  For those with very painful joint, hydrotherapy is better because it decreases the burden of weight bearing during exercise.

The gym program had a higher intensity exercise than recommended by American Geriatrics Society and were NO ADVERSE EFFECTS, NO INCREASE IN SYMPTOMS, NO DISEASE ACCELERATION, NO INCREASE IN PAIN (even in severe OA and with joint replacements).   DO RECOMMEND EXERCISE and a heightened intensity will have increased benefits in muscle strength.

As we as all know Vioxx was recently taken off the market in light of new evidence that found that patients who took the drug had an increased risk for cardiovascular events including heart attacks and strokes. The alarming pattern surfaced halfway through an unrelated 3 year study that was looking at Vioxx and colon polyp prevention. Researchers found that heart attacks and strokes had occurred at a much higher rate among the roughly 1300 volunteers on Vioxx (3.5%) than among the 1300 taking a placebo (1.9%).

With the exact mechanism of as to why Vioxx causes cardiotoxicty still unknown, patients and physicians alike have been left to wonder if perhaps some of the other drugs that are in the same family as Vioxx are not dangerous as well. Pfizer, the manufacturer of the other two major Cox-2 inhibitors Celebrex and Bextra, have been quick to claim that their products have been thoroughly tested and showed no evidence of any correlation between their products and cardiac damage. However, the company has just announced that in light of this new finding with Vioxx, they will begin another 2 year study of their Cox-2 inhibitors at the beginning of next year.

When Cox-2 inhibitors were first introduced, they were hailed as a miracle drug because unlike older NSAIDs, they were able to selectively hone in on Cox-2, the enzyme implicated with inflammation, but largely avoid Cox-1, the enzyme which protects the stomach from gastric acids. As for now physicians are left to make the decision of whether to keep their Vioxx patients on another Cox-2 inhibitor or to change them to other NSAIDs such as Naprosyn and Arthrotex, have been around for a long time and are tested and true but many patients have problems with these drugs due to their nonselectively, i.e. stomach ulcers.

Familiar case: Pt with a viral URI looking for antibiotics... reassure the pt it will pass, increase hydration, get some rest, gargle with warm salt water, and treat symptoms with OTC med PRN.  Right? 

Wait, don't forget about the cold-eeze zinc lozenges.  This randomized, double-blind, placebo controlled study looks at the effects of zinc when given within 24 hours of onset of cold symptoms.  Participants were 100 employees of the Cleveland Clinic who developed cold symptoms within the past 24 hours.  Half received a zinc lozenge every 2 hours while awake and the other half received calcium lactate pentahydrate lozenges (placebo). 

There was a significant reduction in the zinc group in time for complete resolution of symptoms (median, 4.4d vs 7.6d) and duration of cough (2.0d vs 4.5d), headache (2.0d vs 3.0d), hoarseness (2.0d vs 3.0d), nasal congestion (4.0d vs 6.0d), and sore throat (1.0d vs 3.0d).  There were no significant differences in duration of fever, muscle ache, scratchy throat, and sneezing. 

Possible adverse effects of zinc include nausea and bad taste (I can attest to the nausea part, may want to stay away from zinc if already nauseated or hungover).

Mechanism of action is unknown, but possible theories include inhibition of the formation of viral capsid and coat proteins, stabilizing and protecting host cell membranes, and induction of certain chemokines.

In the office we saw many patients of all ages who complained of sleep problems ( insomia).  Mainly they complained of not being able to fall sleep, and laying awake fr at least an hour before falling sleep.  Patients are first encouraged to improve their sleep hygiene before considering medications.

I wanted to look at the effectiveness and the safety of long term use of zolpidem (Ambien).  As you may remember, benzodiazepins (BZ) work on the GABA receptors. They can decrease REM sleep therefore they do not produce quality sleep and  produce tolerance and rebound axiety and insomnia.  In addition daytime performance and cognition are also decreased by BZ.

Therefore, zolidem and Zaleplon (sonata) are preferred for insomnia since they are selective for BZ type 1 receptors so that they are not effective for treatment of anxiety or seizure disorders. Zolpidem (Ambien) is in the class of imidazopyridines, structurally unrelated to BZDs.
Zaleplon (Sonata) is in the class of pyrazolopyrimidines, also structurally unrelated to BZD.  The half-life of Zolpidem is 2.5 hrs with a peak at 1.6 hrs, and Zaleplon has a half-life of 0.9-1 hr with a peak of 0.9-1.5hr. 

Here are some of my findings in terms of how to use and usefulness of Ambien:

• One study showed that even if it is not taken every night it helps improve sleep latency, number of nighttime awakenings, and increase amount of sleep.  They found no tolerance or rebound insomnia.  I also found other studies to support these findings.  Therefore it is not necessary to take Ambien every night and t s better to perscribe it prn.
• Study showing That insomniacs have a higher cyclic alternating pattern (CAP) on EEG than controls and that there was a significant decrease in CAP and increase in the quality of sleep with the use f zolpidem.
• Study showing that Ambien has similar effect n sleep pattern as BZ (dec REM, inc spindle frequency).  However these effects were mainly seen in the first four hours of sleep and they found no residual effecs on psychomotor performance in the morning.
• A site explaining sleep meds.  They feel that Ambien and Sonata "may be less likely than benzodiazepine medications to disrupt natural sleep rhythm patterns (called the rapid eye movement [REM] ratio). Disruption of REM sleep may make sleep less restful".  These meds are great to take after failing to fall sleep since they wear off fast.
• www.Ambien.com.  Claims no disturbance of sleep architecture (no dec in REM).

   

AA came in for a follow up visit for his hip pain.  He had been suffering from severe hip pain for several months now and the results of his imaging were in.  His scan noted avascular necrosis of the femoral head.  How could a 40 year-old man with no history of trauma or corticosteroid use develop avascular necrosis?  He had no other medical problems and he had never been on meds.  While looking through his chart, I found that he had a history of alcohol abuse.  When I approached my preceptor with this little bit of information, he decided that this was the most likely cause of his condition.  However, I was a little interested to see if alcohol use could really be the cause of avascular necrosis in an otherwise healthy male. 

In this article, several risk factors for non-traumatic osteonecrosis were explored, including alcoholism.  The authors conducted a review of 524 studies on osteonecrosis.  In one study of 57 patients, 29% of patients were found with alcohol-associated osteonecrosis of the femoral head and 12% with idiopathic osteonecrosis.  Another study compared 112 patients with nontraumatic osteonecrosis of the femoral head and no history of systemic steroid use.  The study found an elevated risk for regular drinkers and a dose-response relationship for alcohol intake.  This article also noted another study showing that patients with alcohol-induced osteonecrosis are significantly older than patients with idiopathic osteonecrosis, are usually men (97%), and present with collapsed femoral heads.  How can drinking a six-pack a day possibly cause my patient to develop avascular necrosis, you may ask...   Well, alcohol appears to compromise blood flow through fat embolization or fat hypertrophy.  This can cause cell death by its direct toxic effect on osteocytes and other marrow elements.       

This case showed me the importance of exploring the risk factors for our patients disorders.  Only then will we be able to gain better diagnostic skills and hopefully help our patients by early detection.      

Mrs. Jones, a 60 year old woman, came to the office complaining of arthritic pain.  She recieves corticosteroid shots in her knees every three months.  The shots relieve the pain for two months.  She wanted the doctor to prescribe an arthritis medication for the last month until time for another shot, because she was in intense pain.  The doctor ran out of the door and returned with a bottle of Glucosamine Chondroitin.  Dr. Emeny described the supplement as a miracle drug.  The doctor had been taking it for a herniataed disc.  She told the patient that there was a woman who had so much arthritic pain that she could hardly walk.  After taking the supplement for two months the patient could run five miles?

I found this article in The Lancet, which completed a double-blind placebo study that researched the effects of Glucosamine Chondroitin on osteoarthritis.  The symptoms of pain and decreased function improved by 20-25%.  The supplement was found to decreased the progression of osteoarthritis.  At this time the mechanism of action is unknown.

Early last week we had a 52 year old women who came in with a history of high cholesterol.  She was taking Lipitor, which was managing her cholesterol well, but she really didn't like taking the medication.  She ate a healthy diet and excercised regularly, but that didn't help lower her cholesterol.  She just had a genetic predisposition for high cholesterol.  She came into the office and said she had heard half a teaspoon of cinnamon a day can help lower cholesterol.  I had never heard of this, but my preceptor said he had heard of this.  He didn't feel very optimistic about her trying this, but we decided to conduct an experiment of our own since our patient did not like taking Lipitor.  We drew blood from her that visit to get a lipid panel, and then starting that day she would stop taking Lipitor and start taking half a teaspoon of cinnamon a day, and we would then take another lipid panel measurements her next visit.

I was curious to see what literature was out there concerning cinnamon and cholesterol.  A lot of the hype about cinnamon came from a study done by Tufts University, which found that cinnamon not only lowered total cholesterol, and LDL it also lowered triglycerides and glucose levels.  As noted in this article the research on cinnamon hasn't been as rigorous as the research on statins.

Some other studies supporting cinnamon is this article, which shows the multiple benefits of cinnamon in lowering glucose in type 2 diabetes as well as lowering cholesterol.  This is another article which explains the biochemistry behind how cinnamon works to lower cholesterol.

I think there isn't any harm in trying cinnamon with someone who has high cholesterol.  Although, it is still to early to use cinnamon as a substitute for statins. 

I hurriedly gave my preceptors my visually-interpreted results of the urine dipstick test of the 9-month-old pregnant young woman whom I had just examined. A decision was quickly made to treat the patient for bacteriuria because as my preceptor said, "she is symptomatic and the urine is positive (1+) for nitrates." The attending that day said that it was imperative to treat in this situation in order to prevent a UTI. Patterson et. al. state that "the prevalence of asymptomatic bacteriuria is 4-7% in pregnancy, when it can progress to symptomatic UTI, postpartum UTI or pyelonephritis." [Patterson et. al., Detection, significance & therapy of bacteriuria in pregnancy. Update in the managed health care era, Inf. Dis Clin N Am 1997; 11:593-608] "Untreated bacteriuria during pregnancy has been shown to be associated with low birth weight and premature delivery." [Romero et. al., Meta-analysis of the relationship between asymptomatic bacteriuria and preterm delivery / low birthweight, Obstet Gynecol 1989; 73:576]  The resident proceeded to give the patient the script for the antibiotic she should take right away. Results of a urine culture were not yet available. I wondered about the reliability of the urine dipstick test reult when coming to such a decision to treat in this case.

I found an article which helped to me to understand why family practitioners might place so much imoprtance on the urine dipstick test. This article is actually a meta-analysis summarizing the available evidence in this regard which has been compiled from 70 studies performed during the last decade (1990-1999). The 70 studies come from 18 countries and are published in 7 languages. Inclusion and exclusion criteria were specified in the selection of studies. Inclusion criteria were as follows: publications selected had to be centered on the diagnosis of bacteriuria or UTIs, had to investigate the use of the dipstick tests for nitrites and/or leukocyte esterase, and had to present emprirical data. 3 reviewers worked independently to assess the methodological quality of chosen articles. Potential sources of heterogeneity, such as setting, level of care, population sampled and urine collection & analysis procedures, were taken into consideration. Data on sensitivity and specificity were drawn from each of the studies and were combined after being subjected to natural logarithmic transformation.

Results of the meta-analysis suggest that overall, the test for nitrites had its highest accuracy in certain populations, namely, pregnant women, urology patients and elderly people. In elderly patients alone, the test for nitrites reached a high sensitivity and, whereas in pregnant women sensitivity was lowest. This was consistent with the results reported by Patterson (see above citation). The pre-test probability was also shown to be higher in family medicine or primary care studies as compared to studies done in hospitals. This was attributed to the fact that family doctors use the dipstick more to diagnose an infection once clinical signs and symptoms are noted, whereas doctors in the hospital use the test to screen patients to makre sure they don't have an infection.  

Last week I encountered a 65-year-old man being seen in the office for hypernatremia discovered during a routine physical.  His sodium level was 165 mEq/L, distressing due to the high mortality rate of this extreme of an increase.  The man had no complaints and no associated physical findings.  However, this man had the mental capacity of a 7-year-old and was previously diagnosed with schizophrenia, being treated with Lithium among other agents.  Given the narrow therapeutic range for Lithium and the fact that this patient was also being treated with loop diuretics, which can increase the risk of lithium toxicity, we began to think about Nephrogenic Diabetes Insipidus secondary to lithium therapy.

This case illustrates how very important it is for us to be aware of the issues associated with the drugs we are prescribing especially in cases where our patients cannot be advocates for themselves through voicing complaints.

As this study points out, many problems develop from chronic usage of lithium.  As such it is an iatrogenic illness, occurring in patients such as the one I encountered who have identifiable clinical risk factors: nephrogenic diabetes insipidus, older age and impaired renal function.  It is important for us to be aware of all effects of therapies we initiate as well as all the interactions possible.

A patient in his mid-30's came to the clinic to get a mole in his back checked.  He was very concerned that the mole has been getting bigger and darker in the past several months and that it might be melanoma.  Although my preceptor said it was likely to be a benign nevus based on the ABCD criteria, she could not rule out melanoma completely.  She scheduled for dissection and biopsy of the lesion on the following day to rule out melanoma.

The ABCD criteria for diagnosis of melanoma refers to checking Asymmetry, Border, Color and Diameter of a suspicious skin lesion or nevus:   

A - Asymmetry (melanoma lesion more likely to be asymmetric)

B - Border irregularity (melanoma more likely to have irregular borders)

C - Color (melanoma more likely to be very dark black or blue and have variation in color than a benign mole, which more often is uniform in color and light tan or brown)

D - Diameter (mole <6 mm in diameter usually benign)

According to this study which examined 195 cutaneous pigmented lesions in 186 patients, the ABCD criteria can serve as a valid clinical guide to distinguish melanoma from benign nevi.  The investigators imaged the lesions using telespectrophotometric system which included a special camera that provided imaging of moles at different wavelengths.  Next, they analyzed images of melanoma and other lesions according to the ABCD criteria.  The result showed that all the variables(ABCD) showed statistically significant (p < 0.05) differences between melanoma and other lesions; especially, reflectance(C) showed the most significant difference between the two groups[melanoma vs. others], p < 0.0001.

Another study investigated enlargement(E) of the lesion as one of the screening criteria for melanomas.  They found adding ‘E' to the ABCD criteria made the screening more sensitive and more specific.

However, a recent study demonstrated that the ABCD criteria are not absolute.  As much as 38% of melanomas they studied were less than or equal to 6 mm in diameter; it may be necessary to biopsy a lesion to rule out melanoma, even if it doesn't fit into the ABCD criteria. 

If you want to learn more about diagnosis and management of melanoma, click here.

In this randomized trial, ribavirin was added to interferon in hopes of a better response in those who did not respond to interferon alone. The following two regimens compared were: (1)6 MU alpha-interferon for 6 months and 3MU, both doses given 3x/week subcutaneously and (2)1.2 grams of  ribavirin for 2 months followed by the 12 month course of interferon as described above, during the first 2 months there is concurrent treatment with ribavirin.  Improved aminotransferase activity was more commonly found in the combo group (53%) than in the interferon group (26%).  HCV RNA was undetectable by PCR in 25% of those in the combo group and only in 7.7% of those in the interferon group.  The histopathology (necrosis and degeneration) of those in the combo group was improved in comparison to the interferon group (69% vs. 36%).  However, none of these improvements were maintained. 
It seems that adding ribavirin to interferon treatment is unnecessary based on this study.  Although initial findings are encouraging, most of the improvements are not sustained past 6 months post treatment.  Ribavirin costs $$$20,000/ 4 months.  I would say stick to interferon. 

The Family Practice doctors in Nebraska tend to deliver a lot of babies compared to back east. In fact, the F.P. residents are required to "catch" a certain number of babies during their Ob/Gyn rotation. One morning, labor progressed faster than expected and the baby's head was halfway out of the mother by the time my resident and I arrived. The rest of the baby followed quickly, leaving a 2nd degree laceration through the vaginal wall. The resident told me afterward that fast deliveries are more likely to cause vaginal tearing, and that normally he would have applied pressure on the baby's head during delivery to ease it out more slowly.

Unfortunately, there does not appear to be much (if any) research on preventing vaginal tears by delivering a baby slowly. Part of the reason for this is that a prominent doctor in the 1920's declared that the 2nd stage of labor, where the mother "pushes" was harmful to both mother and child. Thus for many years the standard of care was to perform an episiotomy and use forceps to help speed delivery. (There is LOTS of evidence that episiotomies actually cause worse tears and higher morbidity than natural tears, but that should be the subject of another POEM... :-) )

An article on Dr. Spock's website (http://www.drspock.com/article/0,1510,4453,00.html) claims that "the best protection [against tearing during childbirth] is a slow, controlled birth, with a practitioner experienced in avoiding laceration and episiotomy." Another article by an M.D. (http://www.fisher-price.com/us/babygear/article.asp?c=bg_labor&artid=114712) also claimes that a slow delivery, especially in a woman with pliable skin, allows the perenium to stretch around the baby's head without tearing. Likewise, the antidotal evidence of midwives (related on http://www.gentlebirth.org/archives/perinealProtection.html) seems to support a slow, controlled delivery to protect against tearing during birth.

The bottom line on all this seems to be that the practice of obstetrics is changing, with fewer episiotomies being performed in favor of a slower, more natural childbirth. There are many benefits to surviving labor & delivery with an intact perenium, including a faster recovery, and we should investigate methods of doing so more thouroughly as a profession.

For more information about interventions during the second stage of delivery, visit http://transitiontoparenthood.com/ttp/parented/laborbirth/interventions.htm

For more information on preventing perineal tearing, look for Midwifery Today Int Midwife. 2003 Spring (65):10-3. Everything you need to know to prevent perineal tearing. Bruce E.

Sure, metformin is one of the premiere oral hypoglycemic drugs used to treat diabetes mellitus, Type 2 (DM 2).  It is effective only in the presence of insulin and its major effects are to decrease hepatic glucose output and increase insulin action.  As a result of the improvement in glycemic control, serum insulin concentrations decline slightly.  But when an obese teenager came in to clinic and was found to have a fasting glucose of 111 mg/dL, I was surprised that the resident would prescribe metformin.  According to diagnostic criteria for diabetes, this patient did not have diabetes.  The resident explained that the metformin therapy could help prevent the progression to diabetes.  I decided to investigate. 

The Diabetes Prevention Program (DPP) was a major, randomized clinical trial aimed at discovering whether either diet and exercise or the oral diabetes drug metformin (Glucophage) could prevent or delay the onset of type 2 diabetes in high-risk individuals with elevated fasting plasma glucose concentrations and impaired glucose tolerance (IGT).  The answer is yes.  In fact, the DPP found that over the 3 years of the study, diet and exercise sharply reduced the chances that a person with IGT would develop diabetes when compared to placebo. Metformin also reduced risk, although less dramatically.  The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively.  The DPP resolved these questions so quickly that, on the advice of an external monitoring board, the program was halted a year early.

Since diabetes is a main cause of kidney failure, limb amputation, heart disease and new-onset blindness in American adults, it makes sense to try to prevent diabetes.  Patients, who are increased risk of developing diabetes, include: 

Therefore, these patients may benefit from metformin therapy to prevent progression to diabetes, as was seen with the DPP study.

I've noticed that a lot of the elderly patients at the clinic are complaining of problems falling asleep.  Some were newly diagnosed and others were previously diagnosed, but had stopped taking their medications and are interested in restarting their sleeping pills.  In every case, the resident or attending did not hesitate to prescribe sleeping pills, always Ambien, without exploring other options. 

Cognitive Behavioral Therapy (CBT) is one method that has been reported to be effective in relieving insomnia or problems falling asleep.  CBT incorporates the recognition  and challenging of negative thinking prior to falling asleep and changing behaviors that prolongs falling asleep, these are referred to as sleep hygiene.  One study concluded that CBT is more effective than sleeping pills.  Patients responded faster and the effects were longer lasting than sleeping pills.  Patients who were treated with CBT were falling asleep without problems a year later as opposed to those who were treated with sleeping pills and had to experience their side effects and also rebound insomnia upon withdrawal of the pills.  One main disadvantage of CBT is that it is widely unavailable to patients.

I tried to find other ways of safely and naturally treating insomnia and basically all natural methods that involved no meds recommended changing sleep behaviors, or changing the atmosphere of your bedroom.  Relaxation is key.  There are other natural medications available.  They are inexpensive, but they aren't regulated.

I think that doctors shouldn't be so quick to prescribe meds as soon as the patients hint at sleeping problems.  More time should be spent exploring other natural treatments, then use meds as a last resort. 

Background:  Warts are benign proliferations of skin and mucosa caused by human papilloma viruses (HPV). Currently, more than 150 types of HPV have been identified. Certain HPV types tend to occur at particular anatomic sites; however, warts of any HPV type may occur at any site. The primary clinical manifestations of HPV include common warts, genital warts, flat warts, and deep palmoplantar warts (myrmecia). Warts are transmitted by direct or indirect contact, and predisposing factors include disruption to the normal epithelial barrier. Treatment can be difficult, with frequent failures and recurrences; however, many warts resolve spontaneously within a few years.

Question: To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

Answer: Simple topical treatments containing salicylic acid have a therapeutic effect.

Discussion: Systematic review of fifty randomized controlled trials for efficacy of local treatments for cutaneous warts to clear warts and adverse effects such as irritation, pain, and blistering. The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model. Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy no significant difference in efficacy was demonstrated. There was no consistent evidence for the effectiveness of intralesional bleomycin. There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 15/40 (38%) respectively, odds ratio 6.67 (95% confidence interval 2.44 to 18.23), random effects model. Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy. Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments.

Conclusion: The treatment of cutaneous warts lacks the valid evidence to come up with the logical bases for treatment. Placebo preparations had a significant positive outcome in treating cutaneous warts. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and some evidence that it is only of equivalent efficacy to simpler, safer treatments. Dinitrochlorobenzene appears to be effective but there were no statistically significant differences when compared with the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

Shoulder pain is a common complaint of many patients presenting to their primary care physician.  The etiology of this pain is varied, including tendinitis, impingement syndromes, and trauma (rotator cuff tears, dislocations, etc.).  In this past week, I saw 3 people who presented with shoulder pain from different causes and each received the same treatment, a steroid injection to the joint space around the most tender region of the shoulder.  According to my preceptor, this is a common means with which to deal with shoulder pain in the primary care setting.  However, my text pointed out that the evidence for the efficacy of steroid injections in most cases of shoulder pain was sparse at best.  Plus, steroid injections are not without risk, having the potential to introduce an infection to the joint, or inadvertently injecting a tendon, resulting in atrophy and possible rupture.  So what is the evidence to support corticosteroid injections for shoulder pain?

A Cochrane Review of corticosteroid injections for shoulder pain looked at 26 studies comparing steroid injections with physiotherapy for treatment and relief of shoulder pain.  In general, this review did little to either refute or support the use of steroid injection, as the studies reviewed were small and employed very different methodologies.

Another study of 207 patients with unilateral shoulder pain presenting to their primary physician sought to compare physiotherapy with corticosteroid joint injections.  This study found that both treatment methods attained a similar outcome with a successful outcome in 60% of the physiotherapy patients and 53% of those receiving the injections.  The difference between these results was not statistically significant.  The injection group, however, required more follow-up with their physicians, increasing their workload.

A third study had results that conflicted with those of the above study and review.  Here, 77% of patients receiving a steroid injection had favorable outcomes compared with 46% of those undergoing physiotherapy.

What should we make of all this?  It is obvious that while steroid injections have become a staple in the treatment of shoulder pain in the primary care setting, little definitive evidence exists to support its use.  More studies are needed to elucidate whether this should be the primary means of treatment.

A common complaint seen at the clinic this week was back pain. Although the age presentation varied from young adults to the elderly, the setting from acute to chronic, and the etiology from work injury, to sports injury, to "I don't know what happened...but my back is killing me." - the requests were all the same "doctor, please do something to ease my pain." I was surprised to find that for many of these patients, my preceptor recommended a course of acupuncture therapy. Like the patients, I too wanted to know - can acupuncture really help relieve back pain? So, after some searching, this is what I found. 

In support of acupuncture, I found a blinded placebo-controlled study that randomized patients to receive acupuncture (either manual or electro-stimulation) or placebo for the treatment of low back pain. Patients received one treatment a week for eight weeks and an additional two treatments in a follow-up six months later. Assessments done at one and six months found an improvement in 14-16 of 34 patients in the acupuncture group and only 2 of 16 in the placebo group. Criteria for assessing improvement included a decrease in intensity of pain, a decrease in the need for analgesics, as well as a significant improvement in return to work and quality of sleep. Thus, the authors concluded that acupuncture is effective in the long-term pain relief of nociceptive low back pain.

Still not entirely convinced, I continued my search until I found an article that hit a bit closer to home as it discussed acupuncture as a treatment for the high incidence of back pain (over 80%) in nurses. Surprisingly this back pain was anything but benign as it resulted in the loss of more than 150 million working days per year. Furthermore, many of these nurses did not respond to prior attempts for treatment using medication, bed rest, physical therapy, chiropractics, and surgery. The article gives a nice summary of the philosophy of acupuncture and Chinese Medicine as well as references to various studies that demonstrate the effectiveness of acupuncture in the treatment of back pain.   

In conclusion, although the verdict may still be out for many of you, the literature I found seems to support the use of acupuncture for the treatment of nociceptive back pain. Just something to keep in mind for the future, when after hours and hours of being on our feet, our posture begins to sag and our backs beg for some relief. Before you reach for those NSAIDs or decide to tough it out and tolerate, you might just want to give acupuncture a try.

Whether we will become Pediatricians, Family Practice Doctors, Psychiatrists or perhaps even others, we will undoubtedly hear these words come out of parents' mouths..."(insert name) just won't sit still and never pays attention!!....I don't know what else to do!" For many of these kids, discipline is the main problem, for others, however, a true diagnosis of ADHD may be in order. For many of these parents, Ritalin, the mainstay of ADD/ADHD treatment for years is the obvious answer, for others, however, the idea of their child being on an amphetamine-like stimulant day after day leaves something to be desired...could that something be Strattera?...The first non-stimulant medication approved for the treatment of ADHD. This article makes a preliminary comparison between Ritalin (methylphenidate) and Strattera (atomoxetine) in treatment of ADHD in school-aged children.

After an evaluation and drug washout period, patients were randomized to open-label treatment with either Ritalin or Strattera for 10 weeks, with weekly visits.

Clinical Assessment: The primary measure of symptom response was the investigator-rated ADHD RS, an 18-item scale in which each item corresponds to one of the 18 DSM-IV symptom criteria for ADHD, based on an interview with a parent. A parent-rated version of the ADHD RS, identical in structure and content to the investigator-rated version, was also administered.

 A previous study has shown that Strattera is efficacious and well tolerated. The results presented here provide preliminary evidence concerning the magnitude of response compared withRitalin. Among children with DSM-IV-defined ADHD, similar reductions in ADHD symptoms were seen in both the Strattera and Ritalin treatment groups. For both drugs, inattentive and hyperactive-impulsive symptoms responded to treatment, and parent reports were consistent with investigator assessments.

Overall, this study was well-done. One important limitation however, is that the study was not double-blinded. Therefore, parental and investigator expectations may have altered the results. I would still definitely use Strattera in my practice, especially for those parents who are adamantly opposed to having their children treated on an ongoing basis with stimulant medication.

This week in the office, we've seen many patients who are asking for flu vaccines in light of the shortage that has ocurred due to the contamination of Chiron's supply.

This puts us in a tough spot.  We bought our vaccine from Aventis.  So we have enough for now - but it may not last.

The CDC has released spankin-new guidelines that show who should get a flu vaccine and who shouldn't:

Everyone in this group should seek vaccination:

• People 65 years of age and older
• Children ages 6 months to 23 months
• Adults and children 2 years of age and older with chronic lung or heart disorders including heart disease and asthma
• Pregnant women
• Adults and children 2 years of age and older with chronic metabolic diseases (including diabetes), kidney diseases, blood disorders (such as sickle cell anemia), or weakened immune systems, including persons with HIV/AIDS
• Children and teenagers, 6 months to 18 years of age, who take aspirin daily
• Residents of nursing homes and other chronic-care facilities
• Household members and out-of-home caregivers of infants under the age of 6 months (Children under the age of 6 months cannot be vaccinated.)
• Healthcare workers who provide direct, hands-on care to patients

So many of the healthy adults who are seeking vaccine do not qualify for a flu shot.

Yes - you've seen it advertised, so I know you're thinking about that new cool stuff called Flumist.  Does it work?

Well, yes.  But it's awfully expensive.  

In our practice, we have implemented the CDC guidelines and will not be giving out our vaccine to people who are supposed to get it.  Flumist remains an alternative for healhty adults and kids over five.