May 29th, 2009 by DrWes in Better Health Network
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There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.
Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.
But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?
Please.
Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.
But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.
No, better to torment instead.
May 28th, 2009 by Paul Auerbach, M.D. in Better Health Network
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Outdoor enthusiasts are often stricken with infections for which they might be prescribed antibiotics in the class known as fluoroquinolones, one common member of which is ciprofloxacin (Cipro). They should be aware that a fairly well accepted complication of taking a fluoroquinolone for more than a few days is development of tendinitis leading to tendon rupture, notably of the Achilles tendon. The risk is such that the Food and Drug Administration (FDA) requires the makers of such drugs as ciprofloxacin and levofloxacin (Levaquin) to publish a black box warning on the packages alerting users to potentially serious side effects. The full list of drugs affected by the warning include ciprofloxacin (marketed as Cipro and generic ciprofloxacin); ciprofloxacin extended release (marketed as Cipro XR and Proquin XR); gemifloxacin (marketed as Factive); levofloxacin (marketed as Levaquin); moxifloxacin (marketed as Avelox); norfloxacin (marketed as Noroxin); and ofloxacin (marketed as Floxin and generic ofloxacin). As new fluoroquinolones appear on the market, they will undoubtedly be included in the warning program. The warning does not apply to eye and ear drops – only to medications taken orally or by injection.
Many patients and health care professionals are not aware of this risk, which is very real, having been officially reported in literally hundreds of patients. Although the drugs are phenomenal in terms of their ability to fight certain bacterial infections, users should be aware of this possible side effect, so that they can discontinue taking the culprit medication and switch to an alternative antibiotic(s) if need be. If tendon pain develops (typically about a week after initiation of therapy) when a person is taking a fluoroquinolone antibiotic, that is the time to make the switch. Simultaneously, anyone affected should diminish or avoid exercise and cease stressing the affected area until such time as the situation is resolved, as would be determined by decreased pain and other signs of inflammation. Most patients can be expected to recover within 10 weeks after discontinuing the antibiotic, but it may take longer.
Fluoroquinolones are widely used to treat infections in adults. They are not commonly prescribed for children because of a risk for eroding cartilage; however, if the medical necessity is important, they can be used in young individuals. The tendon rupture problem is therefore largely a problem of adults, and typically affects the Achilles tendon, with onset of symptoms within the first few weeks after the initiation of antibiotic therapy. Other tendons, including those of the upper extremity, may be involved. It is perhaps the large forces placed upon the Achilles tendon that makes it so prominent in this particular medical situation. Furthermore, the risk of fluoroquinolone-associated tendinitis and tendon rupture appears to be greater in persons older than 60 years of age, in those taking corticosteroid drugs (“steroids”), and in kidney, heart, and lung transplant recipients.
This post, Fluroquinolone Antibiotics and Tendon Rupture, was originally published on
Healthine.com by Paul Auerbach, M.D..
May 27th, 2009 by DrRob in Better Health Network
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“That doesn’t make any sense.”
The patient sits across the exam room and looks at me with a combination of surprise and hurt. He had answered all of my questions to the best of his abilities, hoping that I would figure out what was causing the symptoms and fix his problem. A bit of doubt shows on his brow as he goes over what he feels and what happened in the past. Did he say things wrong? Did he mistake the way it felt? Is he just bad at explaining things?
“I am not accusing you of being untruthful. Your symptoms are your symptoms, and you felt what you felt. Unfortunately they don’t always read the medical textbooks and so make me earn my keep. I believe your symptoms are real; I just don’t understand how they fit together. It’s confusing.” I say this as reassuringly as possible. He relaxes visibly as I speak.
But that doesn’t change the fact that the symptoms defy logic. It’s my job to figure things out and fix things, right? Isn’t this an admission of defeat? Isn’t it a confession of my inadequacy? Won’t this undermine the thing that I have said is the cornerstone of a doctor/patient relationship: trust?
Some people seem impatient for an answer, but most are OK with me not knowing for a while. The thing that makes it acceptable for me to be confused is the longstanding nature of the relationship of a patient with their PCP. This is one page in the book, not the whole story. This concept – of the patient’s “story” – is one I actually use in this situation. I say:
You know when you see a movie that is really confusing in the start? You don’t know who is who, or why one person was mad at the other, etc. It is just hard to figure out what is going on. But later on in the movie things become clear. You say “Oh, so that’s who that guy was! That’s why she was so mad at him.” It all clears up over time. With your illness, we may just be at that confusion part of the movie. It may just take time for us to be able to make sense of what is going on.
I have to say that I actually am glad for those cases where things are confusing at the start. No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones. If I can sort through things and come up with an answer when one wasn’t apparent, I am showing the merit of all of my hard work. I justify my salary. I go home feeling like I am more than just a bunch of algorythms.
I don’t want everyone to be confusing, but just because things seem to not add up it doesn’t mean we won’t come to a good answer eventually.
*This blog post was originally published at Musings of a Distractible Mind*
May 24th, 2009 by eDocAmerica in Better Health Network, Health Tips, Humor
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One of our most revered faculty members, Lee Archer, MD, a neurologist, provided a copy of the handout he gives to his headache patients. With his permission, I adapted it for use with my own patients. I thought it was so good that I asked him if I could publish it on my blog so that others could benefit from his advice.
Headaches are incredibly common and usually frustrating for providers. It has become increasingly evident that chronic or frequently occurring headaches are often virtually impossible to identify as either “migraine” or “tension” headaches and often simply are called “chronic headaches”. Treatment often becomes a revolving door of trying new medications that sometimes work, but more commonly don’t. And, even worse, many headache patients gradually simply become dependent on addictive pain medications just to try to cope with their often daily discomfort.
But, there are some really basic things about dealing with chronic headaches that we should never forget to try. So, without further ado, here is his advice:
Ten Steps to Overcoming Your Headaches
There are some things that everyone can do to help their headaches. There are a number of things you can besides just take medication to help their headaches. If someone follows all of these directions, the need for prescription medication is often dramatically reduced if not eliminated.
1. First and foremost, taking pain medication everyday is definitely not a good idea. Daily pain medication tends to perpetuate headaches. This is true for over-the-counter medications like Excedrin and BC powders, as well as prescription medications like Fiorinal, Midrin, and “triptans” like Imitrex, Zomig, Relpax, Frova, etc. Exactly why this occurs is unclear, but it is a well established clinical finding. Anyone who takes pain medications more than twice a week is in danger of perpetuating their headaches. Occasional usage of pain medications several times in one week is permissible, as long as it is not a regular pattern. For instance, using pain medication several days in a row during the perimenstrual period is certainly permissible.
2. Regular exercise helps reduce headaches. Exercise stimulates the release of endorphins in the brain. These are chemicals that actually suppress pain. I encourage people to aim for at least 20 minutes of aerobic exercise (like walking or swimming) five days a week if not daily. In addition to helping reduce headaches, this also will prolong your life because of the beneficial effects on your heart.
3. Stress reduction is a definite benefit in reducing headache frequency and severity. Headaches are not caused by stress alone, but can make most headaches worse. There are no easy answers for how to reduce stress. If it is severe, we can consider referral to a therapist for help.
4. Too much or too little sleep can trigger headaches. Pay attention to this, and note whether or not you are tending to trigger headaches from sleeping too little or too much. People differ as to how much sleep is “right” for them.
5. Caffeine can precipitate headaches. I encourage patients to try stopping caffeine altogether for a few weeks, and we can decide together whether or not caffeine might be contributing. Abruptly stopping all caffeine can trigger headaches, too, so try to taper off over a week.
6. NutraSweet (aspartame) can cause headaches in some people. If you are drinking multiple servings/day of beverages containing NutraSweet you might consider trying to stop that, and see if your headaches respond.
7. There are some other foods they may trigger headaches in some people. Usually people learn this very quickly. For instance, red wine will precipitate migraines in many people, and chocolate, nuts, hot dogs and Chinese food triggers headaches in certain cases. I generally don’t advise omitting all of these foods, unless you notice a pattern where these foods are causing headaches.
8. If I give you a prophylactic medication for headaches, you should take it daily, as prescribed. If you have trouble tolerating it, please let me know and we can consider using something else. No prophylactic medication works in every patient with headaches. Generally, each of the medications works in only about 60% of people. Therefore, it is not uncommon to need to try more than one medication in any given patient. We must give any of these medications at least four to six weeks to work before giving up on them. It generally takes that long to be sure whether or not a medication is going to work.
9. Keep a calendar of your headaches. Use a standard calendar and mark the days
that you have a headache, how severe it is on a scale of one to ten, what you took
for it and how long it lasted. Also note anything that you think could have
precipitated it. By keeping this over time we can tell if our efforts
are helping.
10. Riboflavin (vitamin B2) 400mg daily helps prevent migraines in many people. It
comes in 100mg size tablets, so you will need to take four of them each day. You
can add it to anything else we try. You do not need a prescription for it.
Do you have chronic headaches? If so, I challenge you to apply these ten principles, then come back and provide a comment on this blog post!
Thanks and good luck!
*This blog post was originally published at eDocAmerica*
May 23rd, 2009 by Jon LaPook, M.D. in Better Health Network
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The answer is “yes.” An estimated 5.3 million Americans suffer from Alzheimer’s Disease, the majority – 5.1 million – over the age of sixty five. Research suggests that less than 35 percent of people with Alzheimer’s or other dementias are properly diagnosed. Early diagnosis is crucial for many reasons, including:
1) There are medications available today that can reduce symptoms in many people – at least temporarily – and improve the daily lives of patients. There are also trials of new drugs that researchers hope will slow or stop the underlying processes that cause Alzheimer’s in the first place.
2) Knowing what’s going on can lessen anxiety and allow for planning – not only for patients but for their families, friends, and caregivers.
3) Although Alzheimer’s causes 60-80 percent of dementia in patients over 65, there are other causes that need to be considered, especially potentially reversible ones due to medications, alcohol, low thyroid, low B12, depression, and infections. Dementia can also be caused by tumors, increased pressure, blood clots and other abnormalities within the head itself that can be detected by a CT or MRI of the brain. And patients with “vascular dementia” due to problems such as multiple small strokes (that may not have caused any other symptoms) can be treated with measures that include medications and lifestyle adjustments to lower their cardiovascular risk.
The Alzheimer’s Association is a terrific resource for information about Alzheimer’s and other forms of dementia. Its website includes ten warning signs for Alzheimer’s Disease.
