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Monday, September 30, 2013
Q&A Session at HealthTap.com
I currently have the contraception NXT inserted in my arm. Am I able to take the pill Levlen ED aswell?
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Q&A Session at HealthTap.com
How big is the chance to get pregnant if my husband has low testosterone?
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Caught Between A Rock And A Hard Place - Part 7
It's deja vu all over again
- Yogi Berra
So here I am, safely ensconced back home again, having returned from a week inside the San Diego Convention Center where the American Academy of Family Physicians held its annual Congress of Delegates followed by its annual Scientific Assembly. I'm trying again to desperately catch up on my reading & paperwork before the patient care starts up again later today. Then I stumbled upon a retrospective cohort study published earlier this month in the British Medical Journal in which the authors concluded that using proton pump inhibitors to attempt to prevent stress ulcers in coronary artery bypass graft patients was associated with an unintended consequence of post-operative pneumonia.
Which begs the question: what do I/you do? Well, when it comes down to conflicting studies, we believe more strongly in the double-blind, placebo-controlled trial which demonstrates cause & effect, whereas as retrospective cohort & other observational studies only demonstrate an association but can't tell what caused what, if indeed one thing caused another. In this particular case, both studies are retrospective cohort studies, so that doesn't help us.
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- Yogi Berra
But didn't I just write about PPIs recently? Turns out I did discuss some harms associated w/PPIs just 11 days ago in response to a study to be published in next month's issue of the Mayo Clinic Proceedings. But to show you that medicine is not always so clear cut, a population-wide retrospective cohort study was published over 3 years ago in this very same BMJ in which the authors came to a diametrically opposed conclusion: there was no link between PPI use and post-operative pneumonia.
So let's take a look at the bigger issue. Use of PPIs is linked to multiple other unintended consequences as I pointed out in Part 6. Based upon that, I see no reason to take a PPI w/o good reason based upon one study that found no harm given the many others that did. Remember, first, do no harm. Primum non nocere.
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Sunday, September 29, 2013
Saturday, September 28, 2013
Q&A Session at HealthTap.com
Shot hurts in thigh where testosterone given, is this normal?
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Q&A Session at HealthTap.com
Does just one testicle produce enough testosterone?
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Friday, September 27, 2013
Choosing Wisely Part 2
Oops! . . . I did it again
Britney Spears
If you hadn't already heard, one of the worst kept secrets in Las Vegas entertainment history was revealed 10 days ago when Britney Spears confirmed/announced that she would hold her own residency at Planet Hollywood for the next 2 years and join the likes of Celine Dion, Elton John, Garth Brooks & Shania Twain. I'm not a big fan of hers but the above phrase in one of her hits came to mind when the American Academy of Family Physicians announced earlier this week its 3rd list of tests & procedures that patients & physicians alike should question. This brings a total of 15 items to (re)consider as promulgated by the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign, first announced in April 2012. I won't attempt to paraphrase the most recent 5, nor rehash the first 10, as you can review them in context here. Just be sure to read them now before going to see your family physician.
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Britney Spears
If you hadn't already heard, one of the worst kept secrets in Las Vegas entertainment history was revealed 10 days ago when Britney Spears confirmed/announced that she would hold her own residency at Planet Hollywood for the next 2 years and join the likes of Celine Dion, Elton John, Garth Brooks & Shania Twain. I'm not a big fan of hers but the above phrase in one of her hits came to mind when the American Academy of Family Physicians announced earlier this week its 3rd list of tests & procedures that patients & physicians alike should question. This brings a total of 15 items to (re)consider as promulgated by the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign, first announced in April 2012. I won't attempt to paraphrase the most recent 5, nor rehash the first 10, as you can review them in context here. Just be sure to read them now before going to see your family physician.
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Thursday, September 26, 2013
Can Cinnamon Spice Up Your (Diabetic) Life?
I know cinnamon as a basic spice, although truthfully, I couldn't name off-hand any particular dish in which it is a definitive ingredient, aside from say, hot cocoa. However, I have heard rumblings of late (besides from my stomach) that it might have a salutary effect on diabetes. But as with all thing natural & organic, there is more than meets the eye. For instance, just as with vitamins D & E, there are various types/forms/species of cinnamon as denoted by Wikipedia. That might explain why a review published a year ago in the Cochrane Library found no benefit for the use of cinnamon in diabetes, whether Type 1 or 2. Of course, one could counter-argue that the Cochrane review consisted of only 10 studies involving 577 participants.
So it's rather timely that I stumbled upon another review, this time published in this month's issue of Annals of Family Medicine, in which the authors concluded that use of cinnamon in Type 2 diabetes could potentially lower fasting glucose & improve a typical lipid panel by raising HDL while lowering total & LDL cholesterol along w/triglycerides. However, while use of cinnamon did lower fasting glucose, it did not appear to lower Hemoglobin A1c, a 3 month measure of average sugar control. In all fairness, this review & meta-analysis also included 10 studies (perhaps the same 10?) but this time including just 543 participants.
As the authors noted, the range of doses (from 120mg/d to 6g/d) along with the short duration of individual studies (from 4-18 weeks) made the data too heterogenous to conclude anything more than a need to study the use of cinnamon more rigorously in diabetes. And as I've learned while perusing several websites in preparing to post this blog, we also have to become more specific as to which cinnamon plant we are referring as well as develop a potentially more objective measure than just dose/weight, since the potential benefit may be derived from the 0.5-1% that consists of aromatic oils.
Bottom line, for now, there may be some truth in those miraculous TV ads. However, to be safe, don't buy your cinnamon without knowing its source (unlike Reumofan for which we have no idea of its manufacturer).
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So it's rather timely that I stumbled upon another review, this time published in this month's issue of Annals of Family Medicine, in which the authors concluded that use of cinnamon in Type 2 diabetes could potentially lower fasting glucose & improve a typical lipid panel by raising HDL while lowering total & LDL cholesterol along w/triglycerides. However, while use of cinnamon did lower fasting glucose, it did not appear to lower Hemoglobin A1c, a 3 month measure of average sugar control. In all fairness, this review & meta-analysis also included 10 studies (perhaps the same 10?) but this time including just 543 participants.
As the authors noted, the range of doses (from 120mg/d to 6g/d) along with the short duration of individual studies (from 4-18 weeks) made the data too heterogenous to conclude anything more than a need to study the use of cinnamon more rigorously in diabetes. And as I've learned while perusing several websites in preparing to post this blog, we also have to become more specific as to which cinnamon plant we are referring as well as develop a potentially more objective measure than just dose/weight, since the potential benefit may be derived from the 0.5-1% that consists of aromatic oils.
Bottom line, for now, there may be some truth in those miraculous TV ads. However, to be safe, don't buy your cinnamon without knowing its source (unlike Reumofan for which we have no idea of its manufacturer).
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Wednesday, September 25, 2013
Breast Cancer Genetics: The Role of Your Family Physician Part 3
Tuesday was another amazing day of learning & renewal. The Congress of Delegates heard from several passionate candidates for the Board of Directors as well as Directors vying for President-Elect of this amazing group of people. The energy & enthusiasm was quite palpable and aptly summed up by one speaker thusly: Being a family physician is the best job EVER! So after a long day, I crawled back to my room to attempt to catch up on my journals (especially after Nevada State Senator Joe Hardy asked me point blank why I hadn't been actively blogging as I had previously).
Earlier this spring, a day after our taxes were due to be filed, the United States Preventive Services Task Force (USPSTF) published a systematic review of breast cancer chemoprophylaxis in the Annals of Internal Medicine. Not even a month later, actress & mother Angelina Jolie surprised the world with her announcement of having underwent prophylactic double mastectomy due to her increased genetic risk for breast & ovarian cancer.
So what are the women in our lives to do? Surgery vs pills? Follow in the footsteps of a famous actress? Luckily, the USPSTF followed up their systematic review with a Grade B recommendation statement published online yesterday in the same Annals of Internal Medicine which concluded that women at increased risk for breast cancer, as determined by the Gail Model, and who are also at lower risk for side effects, be given the option to consider chemoprophylaxis in the form of tamoxifen or raloxifene. On the other hand, the USPSTF also gave a Grade D recommendation statement against the routine use of said chemophylaxis in those women who are not at increase risk for breast cancer.
Most importantly, the USPSTF recognized the importance of shared informed decision making in which our patients are given enough information at an appropriate level of understanding to make a decision consistent with their stated goals & desires. Of note, these recommendation statements apply only to those women >35yo who are w/o diagnosis of either breast cancer or carcinoma in situ.
Aside from propitious timing, why discuss this article? Because as family physicians, we care for the whole patient, the whole family, the whole community. Because as family physicians, we prevent disease, rather than just treat it. Because as family physicians, we help our patients understand all the options available to them. And we help each one decide what's best for her (or him) at that stage in life. And finally, because as family physicians, we are not gatekeepers; we practice comprehensive care w/o discrimination, regardless of gender, age, setting (be it rural or urban, outpatient or inpatient) or any other laundry list item. We are vital to the foundation to a healthy America. We have the best job EVER!
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Earlier this spring, a day after our taxes were due to be filed, the United States Preventive Services Task Force (USPSTF) published a systematic review of breast cancer chemoprophylaxis in the Annals of Internal Medicine. Not even a month later, actress & mother Angelina Jolie surprised the world with her announcement of having underwent prophylactic double mastectomy due to her increased genetic risk for breast & ovarian cancer.
So what are the women in our lives to do? Surgery vs pills? Follow in the footsteps of a famous actress? Luckily, the USPSTF followed up their systematic review with a Grade B recommendation statement published online yesterday in the same Annals of Internal Medicine which concluded that women at increased risk for breast cancer, as determined by the Gail Model, and who are also at lower risk for side effects, be given the option to consider chemoprophylaxis in the form of tamoxifen or raloxifene. On the other hand, the USPSTF also gave a Grade D recommendation statement against the routine use of said chemophylaxis in those women who are not at increase risk for breast cancer.
Most importantly, the USPSTF recognized the importance of shared informed decision making in which our patients are given enough information at an appropriate level of understanding to make a decision consistent with their stated goals & desires. Of note, these recommendation statements apply only to those women >35yo who are w/o diagnosis of either breast cancer or carcinoma in situ.
Aside from propitious timing, why discuss this article? Because as family physicians, we care for the whole patient, the whole family, the whole community. Because as family physicians, we prevent disease, rather than just treat it. Because as family physicians, we help our patients understand all the options available to them. And we help each one decide what's best for her (or him) at that stage in life. And finally, because as family physicians, we are not gatekeepers; we practice comprehensive care w/o discrimination, regardless of gender, age, setting (be it rural or urban, outpatient or inpatient) or any other laundry list item. We are vital to the foundation to a healthy America. We have the best job EVER!
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Tuesday, September 24, 2013
Caught Between A Rock And A Hard Place - Part 6
As President of the Nevada Academy of Family Physicians, I'm spending the week here in San Diego, first to attend the Congress of Delegates and then the Annual Scientific Assembly. It's been an amazing day & half so far, learning about how policy is made, listening to heated yet respectful debates between professionals from different backgrounds w/diverse perspectives, all striving towards the same goal of caring for the whole person & family. It's been an amazing time of growth & renewal, rekindling friendships & making new ones.
So after tonight's meetings, I thought I'd try to catch up on my reading, seeing as how I got distracted by HealthTap's Summer 2013 Top Doctors Competition. It turns out that one of the major issues w/post-hospital care is sorting through all the medications our patients are discharged on, some of which may not really be necessary. Case in point are proton pump inhibitors (PPIs) which are often used during hospitalization to prevent stress ulcers and then just left on the discharge medication list even if the patient never had any complaints prior to hospitalization.
You can argue that PPIs must be safe because after all, they're available over-the-counter w/o prescription. Surely, we wouldn't allow them to be made freely available to the public if there were some concern, right? Yet, of late, they've been linked to osteoporotic fractures, possibly due to their adverse effect on calcium absorption. If that weren't bad enough, PPI use has also been linked to community acquired pneumonia & cardiac dysrhythmia, as well as C difficile diarrhea. So it shouldn't be any surprise to find a retrospective case-control study published earlier this month in the Mayo Clinic Proceedings in which the authors again linked PPI use to C difficile infection, this time during hospitalization.
This doesn't mean that you shouldn't take your PPI if you need it. But like any other medication, procedure or surgery, don't take it if you don't need it! In other words, make sure benefit exceeds risk.
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So after tonight's meetings, I thought I'd try to catch up on my reading, seeing as how I got distracted by HealthTap's Summer 2013 Top Doctors Competition. It turns out that one of the major issues w/post-hospital care is sorting through all the medications our patients are discharged on, some of which may not really be necessary. Case in point are proton pump inhibitors (PPIs) which are often used during hospitalization to prevent stress ulcers and then just left on the discharge medication list even if the patient never had any complaints prior to hospitalization.
You can argue that PPIs must be safe because after all, they're available over-the-counter w/o prescription. Surely, we wouldn't allow them to be made freely available to the public if there were some concern, right? Yet, of late, they've been linked to osteoporotic fractures, possibly due to their adverse effect on calcium absorption. If that weren't bad enough, PPI use has also been linked to community acquired pneumonia & cardiac dysrhythmia, as well as C difficile diarrhea. So it shouldn't be any surprise to find a retrospective case-control study published earlier this month in the Mayo Clinic Proceedings in which the authors again linked PPI use to C difficile infection, this time during hospitalization.
This doesn't mean that you shouldn't take your PPI if you need it. But like any other medication, procedure or surgery, don't take it if you don't need it! In other words, make sure benefit exceeds risk.
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Thursday, September 12, 2013
Testosterone, Estrogen & Body Composition
In any case, I stumbled once more upon a very exciting randomized, double-blind, placebo-controlled study published today in the New England Journal of Medicine in which the authors concluded that testosterone level is related to muscle mass, estrogen is related to fat mass, and both are linked to sexual drive. Imagine that! More importantly, take time to read the editorial. Perhaps we'll start taking this hypogonadism situation a bit more seriously. And hopefully weed out those who just want to abuse testosterone, too.
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