Family Medicine Notes

Posted by Jacob Reider, MD at 01:02 PM | Permalink

Posted by Jacob Reider, MD at 01:35 PM | Permalink

"For younger women who have had at least two normal annual screenings, the Task Force found no evidence that annual screening achieves better outcomes than screening every 3 years."

While this isn't really news (the data to support this recommendation has been around for quite a while), it's an 'official' guideline that supports what many of us have been doing for years.  The 37 year old mother-of-two who is monogamous and has no history of abnormal pap smears does not need to be screened annually.  Now I can point to this report when I discuss screening options, since this is always a shared decision anyway.    

Posted by Jacob Reider, MD at 10:53 AM | Permalink

Posted by Jacob Reider, MD at 10:07 AM | Permalink

Treatment of the Ingrown Toenail

The ingrown toenail (onychocryptosis) is a condition commonly encountered in primary care. The principal problem usually involves the erosion or puncture of skin on the lateral border of the great toe. The disorder can be stratified into three stages of severity. Stage I is defined as erythema, swelling and tenderness along the lateral nail edge. Increasing tenderness, and a bulging of the lateral nail fold over the nail plate is characteristic of Stage II. This stage also usually involves infection and abscess, and can be quite painful. As granulation and subsequently epithelial tissue covers the nail fold and of the lateral nail plate in Stage III, drainage of the abscess is restricted. Stage III will often become a chronic condition in which the presence of pain, erythema, and infection waxes and wanes every few weeks.

Ingrown toenails are rarely described in cultures where shoes are not worn, and the relationship between shoes and this disorder are well established, as Joseph G. Richardson described in 1905:

The feet are subject to many diseases, but the most common ones … ingrowing nails … are due to neglect of a few simple rules which nearly all adults know. Fashion decrees that certain shapes must be worn and the poor foot, willing to toil and bear, is pressed and pulled out of shape by misshaped shoes. [1]

Prevention if the problem should be the physician’s first course of action. The modern version of Dr. Richardson’s “few simple rules” is summarized in table 1.

Treatment

Several strategies are successfully employed for treatment of ingrown toenails without surgical intervention. The rationale for all of these methods is to separate the nail from the lateral nail groove, allowing injured tissue to heal, while encouraging the nail to grow normally.

The most common procedure, often attempted by patients before presenting to the physician, involves the placement of a cotton pledget into the lateral nailbed, and (if possible) under the offending nail edge. Combined with good nail care, proper trimming, and minimized pressure from shoes, this method is often effective for stage I and Stage II nails.

For advanced stage II and Stage III, the flexible tube procedure [2], performed under local anesthesia, involves advancing a 2mm lengthwise-incised flexible plastic tube over the lateral nail edge. The tube is fastened with wound closure strips (eg Steri-Strip™ 3M corp, dkfkdj), and the toe is then washed daily with a cleaning solution until the nail plate grows out normally, and erythema subsides.

An alternative to plastic tubing is a procedure described by Lazar [3] in which the toe is soaked and cleaned, then treated with EMLA cream. When adequate anesthesia is achieved, the nail fold is cleaned thoroughly, debrided, and the granulation tissue is cauterized with silver nitrate. A wound closure strip is then introduced diagonally under distal corner of the nail, advanced proximally, and left in place. (See figure X) The following day, the toe is soaked once again, and a new wound closure strip carefully inserted. The patient then repeats this process daily until the toe is healed (average 5 weeks).

Unique solutions without sufficient clinical evidence of success include cryotherapy of the granulation tissue along lateral nail border, and a metal spring that is glued to the nail plate, which pulls the nail edge upward. [4]

Surgical Intervention

Most authorities agree that Stage III requires surgical intervention. There is much disagreement, however, regarding the appropriate procedure. Many methods and techniques have been described in the literature. Techniques published in the 1920's are still being used.

Most of our experience involves some minor variations to the procedure described by Pfenninger [5]. After the risks (see table 2), alternatives, and benefits of the procedure are discussed with the patient, and consent is obtained, The patient is placed on the table supine with the ankles extended beyond the tabletop. The toe is painted with a betadine solution.

A digital block is performed using 5-10 ml of 1% xylocaine solution without epinepherine: A 25 or 27 guage needle either 1-1.5 inch is used. Pain associated with injection of xylocaine can be diminished with the use of buffered xylocaine, or EMLA cream applied to the injection site 2- 30 minutes prior to the procedure. A wheal is raised at the base of the toe on the dorsal surface and 1-2 ml of anesthetic is injected in the area of the extensor digital nerve. The needle is repositioned and advanced towards the plantar surface with 1-2 ml injected in the area of the plantar digital nerve. The procedure is repeated on the corresponding site on the opposite side of the toe. (see figure Z) We allow 5-15 minutes for the anesthesia to reach full effect, often seeing a quick "urgi" visit before returning to complete the procedure.

A rubber band, small Penrose drain, or the cut of a rubber glove digit may be placed at the base of the toe and used as a tourniquet. To use the cut end of a glove digit, first cut off the tip of the digit, and then cut the remaining piece off of the glove. Place this piece around the toe as far proximally as possible, and roll the distal cut end of the rubber proximally. This device can be twisted and looped over the end of the toe once or twice to obtain the appropriate balance of fit and comfort. In our experience the procedure also works well without the tourniquet. Keep in mind however, that if a phenol nail matrix ablation is planned it must be done in a bloodless field, as any blood will dilute the phenol resulting in a higher rate of nail growth recurrence.

The nail is loosened from the bed by using the flat pointed end of a scissors or “anvil style” nail splitters designed for this procedure (e.g. catalog #243 – Universal Foot Care, Northbrook, IL). The instrument should be pointed at a slightly upward angle just under the nail surface to avoid lacerating the nail bed. This is a complication of the procedure and may require closure with suture if severe. The instrument is introduced at the hyponychium and pushed back to the nail fold. For a partial removal loosen the lateral 25% of the nail. A scissors works well for nail loosening in younger patients. Patients with thicker, or damaged nails may require a thin periosteal elevator to help avoid laceration of the nail bed. The scissor or nail splitter is then used to cut the nail along the margin that has been loosened from the distal tip back to the nail fold. The nail piece to be removed is grasped medially with a hemostat or needle driver, and the nail is removed with an upward twisting motion in the direction of the affected side. After the nail is removed, granulation tissue should be excised by silver nitrate cautery, trimming with a scissors, or scalpel.

The exposed nail matrix may be ablated by various methods. We use Phenol ablation, but techniques using laser, radiofrequency, and surgical excision have been described. An 88% Phenol solution is placed on a cotton swab. The bottle of phenol should be kept in a dark place, with exposure to light minimized, as light will significantly diminish the effectiveness of the phenol. Old or light-exposed phenol will be yellow or brown, and fresh phenol will be clear and colorless. Replace the bottle every one to two months.

The swab should be soaked but not dripping, and placed in contact with the nail matrix under the proximal nail fold. We have found that fine tipped, calcium alginate (Ultrafine Calgiswab, Inolex Corp.) or dacron swabs (Spectrum Laboratories, Inc., Los Angeles, CA) on the end of a fine, flexible metal wire are optimal. The swab should remain in contact with the nail matrix for 1-2 minutes. The surrounding normal tissue may be coated with petroleum jelly prior to the application of phenol as a protective measure. Simple nail avulsion combined with phenol ablation is more effective at preventing symptomatic recurrence than avulsion without phenol. [6] Patient satisfaction is greater with the phenol procedure despite a small increase in the number of postoperative infections. We have had success with both procedures. When not performing a phenol ablation we have the patient put a small amount of cotton or a small piece of waxed dental floss under the leading edge of the nail as it grows out to prevent recurrence. This material can be left in place until it falls out, and then simply replaced.

Total nail removal is probably only necessary when the granulation tissue blocks drainage on both sides of the nail. If this is the case the nail may be totally loosened, cut in half and removed in two pieces by the procedure above. An alternative procedure for total nail removal is described by Birrer et al.: [7] an elevator is used to free the proximal nail fold and once it is completely free the elevator is used as a lever to pry the proximal portion of the nail away - revealing the matrix.

Aftercare

Most importantly, do not forget to remove the tourniquet, as this can cause necrosis and loss of the toe! The patient can’t feel the toe, and may not be able to distinguish postoperative pain from ischemia in the hours following surgery – especially if the toe is covered with a dressing. Subsequent postoperative care involves applying a non-adherent dressing to the nail bed with a gentle compression dressing over the top. The foot should be elevated as much as possible for 24 hours. The dressing can then be removed and warm water soaks started. Pain control is usually adequately achieved with Ibuprophen or Acetaminophen. It may be necessary to limit weight bearing and wearing shoes for 2-3 days after the procedure. Shoes with an adequate toe box to allow the toes to assume a natural position should be worn. The nail typically grows back in 3-6 months.

Reimbursement

Many payers will refuse payment if a bill is submitted for payment of CPT 11730 (Removal of nail plate) in the absence of an ICD-9 code and appropriate documentation in the chart that the ingrown nail is painful or infected. The procedure may otherwise be considered cosmetic. ICD-9 729.5 (foot pain) will serve this purpose.

Tables

Table 1

Caption: Prevention of ingrown toenails

Wear shoes that fit properly. Tight shoes can press on the toenails, causing them to become ingrown.
Trim nails squarely across the top. Nails that are trimmed into the corners are more likely to become ingrown.
Nails should not be cut shorter at the edges.
Keep your feet clean and dry.
Wear clean socks

Table 2

Caption:

Risks of partial nail avulsion with or without phenol matrixectomy

· Assess general risk to each patient in the context of their medical condition: age, associated illness, allergies, anticoagulant/aspirin therapy and anxiety

· As with any surgical procedure, there is risk of bleeding or infection.

· Even if matrixectomy is not to be attempted, damage to the nail matrix may occur – resulting in potential changes to the appearance of the nail.

· If phenol matrixectomy is to be performed, there is a slightly increased risk of infection, and injury to the surrounding tissue due to the caustic effect of phenol on healthy tissue.

Figure x

Figure Z .

. (we’ll need to work on this . . it’s supposed to be a digital block)

References

1. Richardson, JG, Ford, WH, Vanderbeck, CC. Medicology. New York: University Medical Society; 1905:1084-1085.

2. Lazar L, Erez I, Katz S. A conservative treatment for ingrown toenails in children. Pediatr Surg Int. 1999;15:121-2.

3. Schulte KW, Neumann NJ, Ruzicka T. Surgical pearl: nail splinting by flexible tube--a new noninvasive treatment for ingrown toenails. J Am Acad Dermatol. 1998;39:629-30.

4. Http://www.nailease.com. Haelan Medical Corp., P.O. Box 907 , Midvale, Utah 84047, USA.

5. Pfenninger JL, Fowler GC. Procedures for primary care physicians. . Mosby-Year Book primary care series. St. Louis: Mosby; 1994.XXX-XXX

6. Rounding C, Hulm S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. 2000;2.

7. Birrer RB, DellaCorte MP, Grisafi PJ. Common foot problems in primary care. . 2nd ed. Philadelphia: Hanley & Belfus; 1998:XXX-XXXX

-----------------------------------------------------

Online Resources:

Patient Information:

· FamilyDoctor.org

http://familydoctor.org/handouts/208.html

· ThriveOnline

http://www.thriveonline.com/health/Library/sports/sport67.html

Provider References:

· Emedicine

http://emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&;topicid=593

· Podiatry Channel

http://www.podiatrychannel.com/ingrowntoenails/

· American College of Foot and Ankle Surgeons preferred practice guideline

http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00852

· Primary Care Online (free access – registration required)

http://www.primarycareonline.co.uk/clinical/minorsurgery/ingrowing.htm#ref1
Learning Objectives

The reader will understand methods of prevention of Ingrown toenails.

The Reader will be able to describe the stages of severity of ingrown toenails, and describe conservative treatment options for each.

The reader will understand the proper technique for performing partial nail avulsion with phenol matrixectomy.

QUESTIONS

1) Ingrown toenails can be prevented with:

a. “Buddy taping” the great toe to the 2nd digit prior to sporting activities.

b. Wearing snug shoes.

c. Cutting the nail corners square and long.

d. Cutting the nail short, with special attention to trimming deep into lateral and medial corners

e. Keep feet moist and soft – apply skin softener if necessary to great toe.

2) Stage II ingrown toenails:

a. Absolutely require surgical intervention to prevent long-term complications.

b. Always involve both medial and lateral nail edges of the affected toe.

c. Are often very painful, but can be managed conservatively with wound-closure strips, small plastic tubing, or cotton pledgets.

d. Never require antibiotic treatment.

e. Will resolve spontaneously in 2-3 weeks.

3) Partial nail avulsion with phenol matrixectomy:

a. Is performed under local anesthesia using EMLA or TAC.

b. Requires that a tourniquet always be used, or uncontrolled bleeding is likely to occur.

c. Is performed with 1% or 2% xylocaine with epinephrine.

Posted by Jacob Reider, MD at 10:20 AM | Permalink

Posted by Jacob Reider, MD at 05:44 AM | Permalink

A nice Algorithm for the treatment of sinusitis.  Trouble is .. how to diagnose it?

As our friends across the pond remind us:

The clinical bottom line is that we don't have adequate diagnostic methods.

Tonight (this morning) I'm up finishing off a review of the literature for fpin on sinusitis. 

Alas, Medscape's review of sinusitis is written by a specialist - and is nearly 5 years old.  Specialists think differently about things  .. yet in fact the see less of this than we do.  Sinusitis accounts for roughly 1 million office visits a year in this country - most of them to primary care physicians.  We're the experts .. not the "experts."

Physician specialty is associated with differences in the evaluation and management of acute bacterial rhinosinusitis.

Otolaryngologists use more health care resources to diagnose and treat ABRS than primary care physicians despite an absence of evidence that such tests and treatments lead to better outcomes.

Writing the "Clinical Inquiry" has been MUCH harder than I anticipated.  I know the literature well, but it's been quite hard for me to 'find my voice.'  I think I'll stick with the less formal writing on the medlog. 

Posted by Jacob Reider, MD at 04:49 AM | Permalink

The SQLserver worm is now well documented.

This server seems to be holding up just fine.  We do use SQLserver for OnCalls, and the Docnotes website lives on one of the OnCalls servers.

The OnCalls SQLservers were fully patched, but I spent some time today making sure that I had installed the most recent service packs (SP3 just was released three days ago) to all of the servers.  Everything's nicely buttoned down, and we had no downtime aside from a few reboots today for my service pack installations. 

I use sitemeter to track traffic on docnotes.  While I do have the IIS logs, sitemeter is easier.  You can see in the graph above that I had tracking off for a few weeks.  The sitemeter server that tracks docnotes seems to have been down yesterday.  No hits at all on the 25th. 

Posted by Jacob Reider, MD at 12:34 AM | Permalink

This study, published last year, reminds us of something the pharmaceutical representatives are always hoping we'll forget.

CONCLUSIONS: Patients treated with a first-line antibiotic for acute uncomplicated sinusitis did not have clinically significant differences in outcomes vs those treated with a second-line antibiotic. However, cost of care was significantly higher for patients treated with a second-line antibiotic.

Posted by Jacob Reider, MD at 10:03 PM | Permalink

ARGO, N.D., Jan. 16 — Josiah Flatt, like about 60 percent of other newborn American boys, was circumcised soon after he was born here, in the spring of 1997. Two years later, his parents sued the doctor and the hospital.

They did not contend that the circumcision was botched or deny that Josiah's mother, Anita Flatt, had consented to the procedure in writing. They said, instead, that the doctor had failed to tell them enough about the pain, complications and consequences of circumcision, removing the foreskin of the penis.

It's now well established that circumcision is not medically necessary.  I don't do them.  This causes some trouble for me, as I have to buy my partner lunch sometimes if she has to come in to the hospital to do one for me. 

But if my job as a physician is to do only medically necessary procedures -- I just cant see how performing circumcisions is indicated.   Indeed, one of my concerns is that most parents do not receive adequate information to make the decision.  When I round with the residents in the hospital -- they all anticipate that I'm going to "try to talk the parents out of circumcision."  In fact, that's not my goal.  I do want to make sure that they understand that it's an optional procedure.  Very often, no one has told them that.

The fact that it is also a quick procedure that generates revenue for physicians and hospitals cannot be left out of this equation.  When (not if) insurance begins to curtail the compensation -- I'll bet we'll see the circumcision enthusiasm from both physicians and hospitals wane. 

Posted by Jacob Reider, MD at 12:13 PM | Permalink

INteresting post today in Lagniappe on research in psychopharmacology:

"In other words, we're like the drunk looking for his keys under the streetlight, because it's too dark over there where he lost them."

Posted by Jacob Reider, MD at 11:44 AM | Permalink

On the Medscape Technology & Medicine Home Page, there's a list of medical weblogs (scroll to the bottom of the page) .. hmm ... are weblogs useful and/or interesting to physicians?  Hard to know.  I've been getting more (mostly positive)feedback about this weblog lately ..

In the midst of a few changes to the structure of the templates I use for Docnotes, I turned off the tracking of my 'hits' for the past month or so.

Just turned them on again last week .. and I'm surprised to see that this site now gets about 200 unique visitors a day.  I don't know how many of these visitors are physicians .. how many are not.   I'll bet medscape would like to know.  Their viability (and the viability of many otehr sites like theirs) relies on consistent traffic.

Let's think about that for a minute.  What do physicians do?

• See patients
• Write notes
• Answer phone calls from patients and other physicians
• Look up information (patient related)
• CME
• Make phone calls to patient and other physicians
• Take call
• Go to the hospital

So if I want to capture the physician's eyes .. I want to provide something that the physician wants/needs. 

• Messaging.   No -- not e-mail.  Secure messaging.  Medscape is one of a small number of sites that a majority of physicians have registered for.  If I could securely correspond with patients (perhaps through a WebMD view?) and physicians (through a medscape view) .. I'd be happy.  Yes.  Other companies (relayhealth, mdhub, aboutmyhealth) have developed infrastructure to do this, but they lack the membership.  I had a long talk this week with someone from RelayHealth.  She called me because I'm one of the top users.  (That's odd - I don't use it much.  I probably get two or three messages a day.)  They're thinking about enhancing the service.    It doesn't need enhancement.  It needs focus.  I use 1% of the features - message from patient to me -- and back.  That's it.  (more on this later .. off to see patients now) ..

Posted by Jacob Reider, MD at 11:18 AM | Permalink

Hot off the press:

LOS ANGELES (AP) - Cedars-Sinai Medical Center, the largest private hospital in the West, is suspending use of a multimillion-dollar computerized system for doctors' orders because physicians complained it was endangering patient safety and required too much work.

The computer software was designed to reduce medical errors, allow doctors to track orders electronically, and warn them about dangerous drug interactions and redundant laboratory work.

Since it debuted in October, however, the Patient Care Expert program, dubbed PCX, has been plagued with problems, many doctors said.

"The PCX system is presenting too many safety issues in the care of our patients," cardiologist Dr. Mark Urman said. "The only logical, prudent and safe thing to do is to put it on hold until it can be made better."

Interest in computerized physician-order entry software accelerated in 1999 after the Institute of Medicine concluded that up to 98,000 patients die annually in hospitals from avoidable medical errors.

A 2000 California law requires hospitals to implement formal plans, including new technologies, to eliminate or substantially reduce medication-related errors by Jan. 1, 2005.

Most hospitals buy a commercially available product, but Cedars-Sinai decided to create its own, following the example of other major hospitals such as Brigham and Women's Hospital in Boston and Latter-Day Saints Hospital in Salt Lake City.

Estimates of the system's cost have gone as high as $34 million. Hospital officials have said that estimate was too high but they declined to provide a precise figure.

This week, Cedars-Sinai suspended the ordering system after more than 400 physicians confronted hospital administrators during a tense staff meeting Friday. The doctors voted nearly unanimously to urge the hospital to halt the system until the problems are fixed.

Posted by Jacob Reider, MD at 03:54 PM | Permalink

Better than the Rolling Stones  .. the COLOSSAL COLON TOUR may come to a city near you sometime soon.

The AAFP has a nice handout on Colon cancer screening.

Posted by Jacob Reider, MD at 09:38 PM | Permalink

More from the Wall Street Journal.  This time, it's an article about the table PC. 

My cousin works for Microsoft, so I got to try one of these things out last November for a few days.

It's not bad.  We may try one for the office in the next few days.   Using the computer in the office is hard -- I don't like turning my head away from the patients to enter notes -- or even retreive data.

Posted by Jacob Reider, MD at 09:28 PM | Permalink

Things Worth Considering.  A new medical weblog. 

Welcome

.. added to medlogs

Posted by Jacob Reider, MD at 01:28 AM | Permalink

From across the pond:  Electric toothbrush not better.

But at least I can get my kids to brush at all!

Posted by Jacob Reider, MD at 12:21 AM | Permalink

A nice review on Medscape (Free - login required) of ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial).  Since the press has gotten-hold of the results, I've had several patients ask to be treated with thiazides.  

Some useful Hypertension resources:

ALLHAT slides from HypertensionOnline.org

A great article on Secondary Hypertension from American Family Physician

C-Reactive Protein and Ischemia in Users and Nonusers of ß-Blockers and Statins Published in Circulation this week.  I ordered my frist CRP this week in a man with borderline hypertension, borderline LDL, and is a former smoker.  He really doesn't want to take medications.  I suppose a low CRP would reassure me, and a high one may help me decide to start him on something.  b-blocker?  statin?  thaizide? 

Posted by Jacob Reider, MD at 12:09 AM | Permalink

Cheaper than a month of Prozac:

"HealthEngage Depression is designed to help you manage depression, bipolar disorder or a similar condition with ease and flexibility. "

So I downloaded the Windows version just to see what this was.  11MB .. and their server's kinda s-l-o-w.

Speaking of slow.  The  install is slow.  The software is slow .. and I'm not sure that anyone who isn't ... um  ... slow would ever want to use this software.   It's supposed to remind the user to be positive, take their medications, eat right, etc.

I'd rather have Microsoft 'Bob' around to cheer me up. This software gets two thumbs down.  Depressing

Posted by Jacob Reider, MD at 10:30 PM | Permalink

Posted by Jacob Reider, MD at 10:06 PM | Permalink

I referred a patient with epiphoria to an opthalmologist about 2 weeks ago.  I wasn't sure what was causing it, and I hoped that he could figure it out.  It wasn't disabling .. but it was annoying. 

Last week, I got a cordial letter from him that mentioned that she had a vasovagal episode during his exam, and that she declined nasolacrimal duct irrigation.

and .. as Paul Harvey says ... now for the rest of the story ...

Here's an excerpt from her version.  

... Out of nowhere, slowly but with ever-increasing speed, I become Juliet after drinking her poison. I begin shaking. My vision is clouded with angry, furry, marching black clouds. My hands join my eyes in the heavy slump of the numb.

"I don't feel so well," I manage to whisper, whimpering like a 4 year old. "I'm very dizzy."

Instantly I am in a sweat and begin to swoon. I ask for the garbage can and lean over it quickly, ropes of my instantly saturated hair hanging limp against its blessed coolness.

....

When the doc returns, he smiles vaguely as though nothing has happened. I survive the eye dilation drops easily enough because this time I suggest that he kindly explain to me what he is going to do before he does it.

After this he flatly states that next on the agenda of fun-things-to-do-in-the-doctor's-office is a procedure they like to call STICKING A NEEDLE IN YOUR EYE. "I'll inject saline into your tear duct opening,” he explains, “and if you can't taste the saline, I'll know the duct is blocked."

One of these things is not like the other ...

We make judgments about the skills of our specialist colleagues based on the letters they write to us .. and the reports we get from our patients.   Recall that our patients don't care how much we know until they know how much we care.   It's not enough to just care.  Patients needs to KNOW we care.  Can't convey that by speaking in tongue and treating the patients like cattle.

Posted by Jacob Reider, MD at 01:33 AM | Permalink

A few weeks ago, Richard Winters wrote about the "Death Talk." He wrote about talking with the family of a deceased patient. 

Richard works in a Emergency Department.  I'm a family physician. 

So we see the death of our patients in different ways. 

Yet he's right about the need to undersand what the other person is thinking, and what they understand.  This is necessary with all physician-patient(or family) interactions.  I usually ask patients what they know about something before I launch into a long blab blab blab about something.    I usually do this.  Last week, I saw a type 1 diabetic patient who has seen an endocrinologist for 10 years.  She's doing very well now -- sans endocrinologist.  When we first met, I made some assumptions about her level of understanding about diabetes.    I didn't aske her what she knew .. I just assumed.

Turns out that she didn't know much at all about diabetes,  She knew WHAT to do, but not why.  Once I learned what she knew (and what she didn't) .. I was able to help her understand more completely how her diabetes could be managed.

Posted by Jacob Reider, MD at 12:59 AM | Permalink

Dr Centor has a well done discusssion of diabetic retinopathy screening today on Medrants.  He's also coined a good mnemonic:

FLECKS represents a checklist that we must consider every time we have a patient encounter with a diabetic patient:

• Feet
• Lipids
• Eyes
• Control
• Kidneys
• Shots (immunizations)

Posted by Jacob Reider, MD at 09:07 PM | Permalink

One of the ways that I learn about what readers seem to like is by looking at my "referrer logs."

Most of the traffic that comes to this site is coming from search engines.  Google is clearly #1. 

(I recently discovered froogle.  It's for buying stuff ... seems to work pretty well).

The most commonly searched-for item since November is Strattera (sometimes incorrectly spelled Stratera or Straterra in the search engine queries  The correct spelling is with TWO t's and ONE r).  I wrote a quick note on this medication last fall.  Since many people seem to be looking for information in it, I'll provide a little more insight into Strattera.

Atomoxetine (Straterra) is a nonstimulant treatment for ADD/ADHD.  It's the first medication that is indicated for the treatment of ADD/ADHD in children and adults.

Mechanism of action

A selective inhibitor of norepinephrine reuptake. 

Indications

Indicated for the treatment of attention-deficit/hyperactivity disorder in patients six years of age and older.

Dosage Forms

It's available as capsules in 10 mg, 18 mg, 25 mg, 40 mg, and 60 mg strengths.

Dosage

For children and adolescents weighing up to 70 kg, the initial dose should be 0.5 mg/kg per day. 

After at least three days it can be increased to a target daily dose of 1.2 mg/kg per day in one or two daily doses.  The maximal daily dose for these patients is 1.4 mg/kg.

For children and adolescents over 70 kg and adults, the initial dose is 40 mg per day.  This can be increased after a minimum of three days to a target dose of approximately 80 mg either as a single dose in the morning, or in two evenly divided doses.  After anther two to four weeks it can be increased to a maximal dose of 100 mg per day for those who have not achieved an optimal response.

Here's a little table that I made that may help with Strattera dosing:

Elimination

Hepatic metabolism primarily by CYP 2D6.  Patients taking inhibitors of this enzyme (paroxetine, fluoxetine, or quinidine) should have the dose adjusted.  The initial dose is 0.5 mg/kg daily for children and adolescents up to 70 kg, but the dose should only be increased to 1.2 mg/kg daily if symptoms fail to improve after four weeks and the initial dose is tolerated.  For children and adolescents over 70 kg and adults, the initial dose of 40 mg should only be increased to 80 mg if symptoms fail to improve after four weeks of treatment and it is well tolerated.

Administration

Can be given with or without food.  Should be reduced to 50% of suggested for those with moderate hepatic insufficiency, and to 25% for those with severe hepatic insufficiency.  Can be discontinued without tapering.

Adverse Effects

The most common adverse effects observed in clinical trials included dyspepsia, nausea, vomiting, fatigue, decreased appetite, dizziness, and mood swings.  Increases in blood pressure and heart rate have been observed.  MIld weight loss and slowing of growth have been observed, and patients should be monitored. 

Drug Interactions

Should not be used with MAO inhibitors.  Inhibitors of CYP 2D6 can increase the serum concentrations of atomoxetine.  Common examples include paroxetine, fluoxetine, and quinidine.  Atomoxetine does not significantly interact with CYP 1A2, CYP 3A, CYP 2D6, or CYP 2C9.  It should be used with caution with other drugs that can increase heart rate or blood pressure.

Contraindications

Hypersensitivity, concurrent use of MAO inhibitors, and narrow angle glaucoma.

Precautions

Should be used cautiously in patients with hypertension, tachycardia, or other cardiovascular conditions.  It may also increase the risk of urinary retention and should be used cautiously in patients at risk for this.

Use In Pregnancy

Pregnancy Category C.

Posted by Jacob Reider, MD at 06:44 PM | Permalink

"Lemon-flavored cod liver oil and a multivitamin-mineral supplement for the secondary prevention of otitis media in young children: pilot research."

I missed this one last summer .. but just stumbled on it.  Cod Liver Oil can prevent recurrent otitis meida! (more research required)

Posted by Jacob Reider, MD at 09:14 PM | Permalink

I promised yesterday to write more about the AAFP's Open EMR project.  Several e-mails this morning have reminded me that I still need to do so.  The AAFP board will, I gather, be voting on this today.  So we'll see what they decide. 

The NAPCI leadership is talking about how this project is problematic because AAFP would be forging ahead with their own project - rather than involving the other allies of NAPCI.  NAPCI includes leaders from Internal Medicine, and Pediatrics, as well as folks from AHRQ, STFM, AAFP, and NAPCRG.

A common goal is to enhance the availability of electronic resources to physicians.  It is now clear that electronic records in some form can enhance both efficiency and quality. 

But poorly implemented technology enhances neither.  The very high cost of most electronic medical records system precluded their adoption in most small practices.  The complexity of the installation and support is intimidating for both large and small practices, and the return on investment is simply unclear.

I know rather few of the details of the AAFP proposal, and most of what is circulating about the listservs is hearsay.  I do know that the proposal is to develop the product as open-source.  Open Source can mean many things.  So I'm not sure which license is contemplated.  Many are saying that there is no way that an open source electronic medical record can "make it."  I disagree.  An EMR that is open source could be quite successful, so long as the project is well coordinated.  Being managed by one organization is hard enough.  The trouble with many open source projects is that they are developed by many people with very strong technical skills and very poor user-interface skills.  It takes a well-managed project team to focus on functional requirements (what a program does) and the user interface (what the users see to make the program DO what it DOES).

There are many commercial examples of bad UI, so I won't kick a dead horse here.  My point is that the management of the project - not the "openness" of the code - is what is likely to determine the success.

The concept of the AAFP project is that the application is developed and provided to physicians at a low or minimal cost -- then support is provided for a reasonable fee by other companies.  Ideally, there will be many vendors who will compete with each other to provide support and additional functionality (interfaces, custom modules, etc) for a fee.

I do think that it's a model that could work -- whether it's the AAFP's project or another.  Though it would be a shame to see more than one such project undertaken at the same time.

With NAPCI involved with the AAFP project, I think it's possible that there could be federal support for a project like this -- even NLM or SBIR grant funding. 

Even if the AAFP board doesn't support this, we could all capture some of the enthusiasm for the effort, and push it forward together.  At the very least, David Kibbe deserves kudos for pulling together a clear proposal to the AAFP board.  While one may be critical of him for not involving the other specialties (yet), he's moving forward toward a goal that we all agree is a good one.

Posted by Jacob Reider, MD at 12:24 PM | Permalink

Big news day .... Today's Wall Street Journal has this report on the AAFP's efforts to create an open-source EMR. 

I've got to run .. but I'll comment on this later today.  Very interesting that this is making such big news.  It's good.  But I'm guarded about the AAFP plan. 

Posted by Jacob Reider, MD at 04:08 PM | Permalink

More doubts about the smallpox vaccine program advocated by George W:

Medical Panel Has Doubts About Plan for Smallpox. The government's plan for smallpox vaccinations is too rushed and lacks adequate safeguards, according to a panel of independent medical experts. By Denise Grady. [New York Times: Health]

Posted by Jacob Reider, MD at 01:41 PM | Permalink

This week's Informatics Review has some useful entries:

• A mention of the recent paper by David Bates and the leadership of NAPCI on electronic medical records in primary care.  NAPCI is the brainchild of John Zapp who served as Chair of the AMIA primary Care Informatics Working Group for the past two years. (David Little has now taken over for his two-year term).  NAPCI is a great idea.  The concept is that NAPCI will help unify efforts to standardize implementation of EMRs in primary care.  The EMR vendors have defined what EMRs are .. and what they do.  This is the opposite of what should be happening.  The user community needs to step up to the plate.  We need to define basic configuration and architecture parameters.  We need to define basic functionality and even basic specific for data models and interface requirements.  No small task.  But without a unified voice, there is no clear guidance from the user community.  Indeed, I would hope that the EMR vendors would embrace such a unified voice from all of primary care.   We need to work together.  I have the privilege of representing STFM in the leadership of NAPCI. 
  
• A discussion of guidelines for online communications in healthcare.  Some highlights:
  
  1. Security. Online communications between health care provider and patient should be conducted over a secure network, with provisions for authentication and encryption in accordance with eRisk, HIPAA and other appropriate guidelines. Standard email services do not meet these guidelines. Health care providers need to be aware of potential security risks, including unauthorized physical access and security of computer hardware, and guard against them with technologies such as automatic logout and password protection.

  2. Authentication. The health care provider has a responsibility to take reasonable steps to authenticate the identity of correspondent(s) in an electronic communication and to ensure that recipients of information are authorized to receive it.

  3. Confidentiality. The health care provider is responsible for taking reasonable steps to protect patient privacy and to guard against unauthorized use of patient information.

  4. Unauthorized Access. The use of online communications may increase the risk of unauthorized distribution of patient information and create a clear record of this distribution. Health care providers should establish and follow procedures that help to mitigate this risk.

  5. Informed Consent. Prior to the initiation of online communication between health care provider and patient, informed consent should be obtained from the patient regarding the appropriate use and limitations of this form of communication. Providers should consider developing and publishing specific guidelines for online communications with patients, such as avoiding emergency use, heightened consideration of use for highly sensitive medical topics, appropriate expectations for response times, etc. These guidelines should become part of the legal documentation and medical record when appropriate. Providers should consider developing patient selection criteria to identify those patients suitable for email correspondence, thus eliminating persons who would not be compliant.

  6. Highly Sensitive Subject Matter. The health care provider should advise patients of potential privacy risks associated with online communication related to highly sensitive medical subjects. This warning should be repeated if a provider solicits information of a highly sensitive nature, such as issues of mental health, substance abuse, etc. Providers should avoid active initial solicitation of highly sensitive topic matters.

  7. Emergency Subject matter. The health care provider should advise patients of the risks associated with online communication related to emergency medical subjects such as chest pain, shortness of breath, bleeding during pregnancy, etc. Providers should avoid active promotion of the use of online communication to address topics of medical emergencies.

  8. Doctor-Patient Relationship. The health care provider may increase liability exposure by initiating a doctor-patient relationship solely through online interaction. Payment for online services may further increase that exposure.

  9. Medical Records. Whenever possible and appropriate, a record of online communications, pertinent to the ongoing medical care of the patient, must be maintained as part of, and integrated into, the patient's medical record, whether that record is paper or electronic.

  10. Licensing Jurisdiction. Online interactions between a health care provider and a patient are subject to requirements of state licensure. Communications online with a patient outside of the state in which the provider holds a license may subject the provider to increased risk.

  11. Authoritative Information. Health care providers are responsible for the information that they provide or make available to their patients online. Information that is provided on a medical practice Web site should come either directly from the health care provider or from a recognized and credible source. Information provided to specific patients via secure email from a health care provider, should come either directly from the health care provider or from a recognized and credible source after review by the provider.

  12. Commercial Information. Web sites and online communications of an advertising, promotional or marketing nature may subject providers to increased liability, including implicit guarantees or implied warranty. Misleading or deceptive claims increase this liability.
      

Posted by Jacob Reider, MD at 01:36 PM | Permalink

Newsweek's cover story this week is on diets.  It's worth a read .. though there are fewer popups in the paper version.  (It's amazing to me that a mainstream magazine like Newsweek has popus on their website.  I apologize for the infected link ... I feel like I'm breaking an unwritten weblog rule ...)

I'm warming up to the low-carb diets.  I wrote about this last summer .. and it's in the news again.    Many of my patients are trying low carb diets in some form.  While Atkins is most popular, some folks are trying the Sugar Busters (reviewed at the Chase Freedom website -- an interesting website with reviews of many 'fad' diets). While I've haad a few who found the Schwarzbein principle.

Some anecdotes:

Total Cholesterols are not changing much
HDLs are going up
People report more energy and fewer mood swings
Weight loss does occur

I've been experimenting a bit too.  I do notice that when I avoid carbohydrates, I am less hungry.  This makes some sense to me.  The hypoglycemia that occurs as one comes "down" from a large glucose load (and the pancreatic response) causes craving for food (carbohydrates) and the roller-coaster continues.

Posted by Jacob Reider, MD at 08:53 AM | Permalink

Fibromyalgia is a reasonably common diagnosis.  A few interesting links.

A very good review in American Family Physician .. with a patient handout

POEM on fibromyalgia

Like many (?most?) physicians .. I struggle with this diagnosis.   Treatment is only occasionally successful, and it seems that once the dagnosis is made, depression and anxiety worsen.

So I'm not very enthusiastic about making the diagnosis.  There is no test for it .. no "wonder drug" that will treat it ...

There are also an alternative view of this condition:

Based on precedents in the literature, I could assert even 15 years ago that the "fibrositis/fibromyalgia" construct was a sophism that would serve no therapeutic purpose. Even then, my conviction was readily defensible. Today, as I've detailed most recently in the 2nd Edition of Occupational Musculoskeletal Disorders, the construct itself is not defensible on scientific grounds. It is a but one of a number of labels that grows out of an iatrogenic diagnostic process and that denotes escalating discordance between feeling miserable and possessing no demonstrable primary pathophysiology. Today I am joined by others who share my disdain for the labels and the labeling.

He's kinda got a point. 

Or does he? 

When humans are in pain ... especially when they don't know the reason ... depression, fear, despair and anxiety are paramount.  We YEARN for a diagnosis.  A REASON .. something to explain the symptoms. 

So does it really matter that we can't do a test for this disorder?  So long as there is a reasonably clear set of criteria .. and a better-than-nothing treatment strategy .. at least this diagnosis provides a sense of clarity. 

Posted by Jacob Reider, MD at 01:41 AM | Permalink

"Rep. Ralph Regula, R-Ohio, introduced a Labor/HHS/Education spending bill Jan. 8 that would restore most of the primary care training funds that had been zeroed out in earlier budget proposals."

Title VII funds are responsible for funding the majority of grants in primary care.  Title VII funding is good. .. and it's important.

On another ... but related note ... CMS revised guidelines for teaching physicians in November.   So What?  This document helps us to understand how medicare will reimburses us for services rendered to patients in the hospital as we teach residents and medical students.

Posted by Jacob Reider, MD at 01:09 AM | Permalink

TIME asks you: which country poses the greatest danger to world peace in 2003?

North Korea?  IraQ? US?

Posted by Jacob Reider, MD at 08:40 PM | Permalink

The pans can explode or separate when preheated, used on high heat, or used for frying, which can pose a serious burn hazard from hot oil or food contents spilling onto consumers ...HSN LP (Home Shopping Network) sold the pans nationwide from October 2001 through September 2002 for between $20 and $50 individually and between $150 and $300 as a set.

At first, I thought that this was a joke.  Frying pans exploding?  I suppose it's the "double-wall" thing.  Seems like a good idea at first ...  double-walls.  Here's the (not-so) funny part ... a description of Ultrex II pots and pans.  This is NOT the recalled line (which have been withdrawn from the market) ... but it's the same company:

From stock pots to omelet pans, fryers to casseroles, Ultrex II nonstick cookware delivers form, function and practicality. With 18/10 stainless steel construction, tempered glass lids, easy-grip handles and ergonomic design, it will endure the rigors of real-life, daily use. It may just outlast the cook!

But the recalled pans remain available from some sources.  For example, Graveyard Mall.com (no .. I'm not kidding!) .. still has them available. 

Along with making sure that our patients wear their seatbelts .. we should now make sure we take an accurate frying pan history.

Posted by Jacob Reider, MD at 08:15 PM | Permalink

Craig Shirky writes a compelling article on WiFi and VOIP.  These technologies are important to watch.  VOIP is close.  We'll all have it in 3 years.   It's not ready for prime time, yet.  I tried using Vonage.  (I won't flatter then with a link)  their customer service is terrible.  Don't bother (yet).  They have no competition whatsoever.  This will change.  Things will improve. 

WiFi is pervasive.  We've got it in our office.  If patients want to bring their laptops ... they are welcome to 'surf' in our waiting room.  Don't worry.  The EMR is locked down pretty well.

Posted by Jacob Reider, MD at 11:18 PM | Permalink

"Among men, consumption of alcohol at least three to four days per week was inversely associated with the risk of myocardial infarction"

Another chapter in this interesting saga.  Drinking is good.  No -- it's bad -- no it's good.

I don't advise my patients to drink .. but those who drink more than one dink per day are advised to cut back to one -- and that one may be good for them.

Posted by Jacob Reider, MD at 01:56 AM | Permalink

Posted by Jacob Reider, MD at 07:21 PM | Permalink