How To Drive Your Doctor Crazy

Medpage Today carried an amusing piece about “Six Patient Behaviors That Drive Doctors Nuts”. I thought it worth summarizing them, just in case any of my readers think they might “fit the cap”.

1. Bringing meddling family members into the consulting room.
2. Failing to mention the herbs, supplements, and over-the-counter meds taken. This can be frustrating for doctors and dangerous for patients.
3. Quitting medications without notice. Again, can be dangerous.
4. Demanding a pill instead of a change in lifestyle. Many, many problems can be attributed to eating too much and moving too little.
5. “Hi, Doc, I need a prescription for . . .” Patients’ insistence on an unnecessary drug is physicians’ most common complaint.
6. Demanding extra tests and procedures that are medically unnecessary.

 The article contains many examples, explanations, and comments that are useful, but can’t be summarized here. It’s well worth reading, even if you think you have an excellent relationship with your family physician.

Do You Have a Purpose in Life? If So, You May Live Longer

The journal Brain, Behavior and Immunity carries an interesting report from Dr Chapman and his colleagues at Rochester It examines the role that the presence of different extraversion vs. introversion personality traits are associated with circulating blood levels of interleukin (IL)-6. This substance is a pro-inflammatory cytokine, meaning that it’s an indicator of the degree of inflammation present in the body. Higher levels of IL-6 have been described in a number of conditions in the elderly, ranging from coronary artery disease to cognitive decline, muscle weakness and disability. And for elderly people at risk of cardiovascular disease, raised inflammatory markers like IL-6 indicate a higher risk of a fatal rather than a non-fatal heart attack or stroke.

Extraversion is a personality trait with three components: a tendency to happy thoughts, a desire for companionship, and “dispositional energy” (this is a sense of vigor, purpose, and active engagement with life). The study reported above found that happiness and companionship didn’t correlate in any way with IL-6 levels, but dispositional energy did. Increases in this trait were associated with significant decreases in IL-6 levels. In general, women and minorities have higher levels of IL-6 than white males. In this study, both white and minority women had significant differences I IL-6 level, depending on whether they had high or low dispositional energy. The magnitude of the differences were similar to those reported for a doubling in 5-year mortality in another study.

About 9% of the differences in IL-6 were due to gender, 6% to dispositional energy, and4% to race or ethnicity. The authors of the study considered it “a great surprise” that a personality trait could contribute more to IL-6 levels than race/ethnicity.

If you’re elderly, an introvert, and lacking in “life force”, maybe you should try to consider incorporating an exercise regime into your lifestyle, preferably in a gym where you’ll meet and interact with others. (Physical activity lowers IL-6 levels, amongst many other benefits.)

Does Your Veterinarian Give Better Service Than Your Physician?

Many people may think so. When they’ve been to the doctor and had a lab test or X-ray, they don’t always get a report of the results in a timely fashion. And this can sometimes be a cause of worry. My veterinarian, on the other hand, always calls us on the day of the test and gives us the dog’s results – positive or negative. That’s what I call great service.

Too many doctors fail to provide this important information. A study reported in the Archives of Internal Medicine revealed some disturbing findings. US researchers examined primary medical care records of some 5400 patients aged 50 to 69, looking at 11 specific blood tests and 3 screening tests. They also surveyed physicians at the practices with uninformed patients about their methods for handling test results.

There were 1900 clinically significant abnormal results; 6% of these were not communicated to the patient, while 1% were communicated but this was not documented. Practices with partial electronic medical records had the highest failure rates, whereas those with either full electronic records or only paper records both had fewer rates. In fact, most practices didn’t have a standardized system for managing test results.

The researchers suggest that 5 simple procedures could be combined to provide to eliminate most errors: test results go to the responsible doctor; the doctor signs off on them; the office informs the patients of all results; the office documents that patients have been informed; finally, patients are told to call after a given time if they haven’t received test results.

This study shows that patients shouldn’t assume that “no news is good news”. If necessary, ask your doctor whether they have a routine for telling patients their test results; this may just stimulate them to emulate my veterinarian’s practice.

Try Milk Instead of Fruit Juice at Breakfast . . .

I know fruit juice counts as one of your “five-a-day” fruit or veggies and is an important health food, but the Dairy Council would like you to consider milk instead. They quote an Australian study reported in the American Journal of Clinical Nutrition, in which the effects of skim milk satiety and energy intake at lunch are estimated in comparison to fruit juice.

Overweight women and men attended at two sessions, one week apart. At each session, the participants ate a standardized breakfast (fixed calories) together with either 600 mL skim milk or a 600 mL fruit drink. At the first session they were randomly assigned milk or fruit juice, and were then given the alternative drink at the second session – in other words, this was a randomized cross-over trial.

There were 21 female and 13 male participants. When they had skim milk at breakfast, they consumed, on average, significantly fewer calories at lunch than those who had taken fruit juice: 635 calories vs. 581 calories. Self-reports of satiety – a feeling of fullness – were higher throughout the morning after a breakfast with skim milk than one with fruit juice; the difference became greater over the 4-hour period leading up to lunch.

It looks as if this would be a useful strategy for those wanting to lose some weight. However, they should make up their missing fruit-or-veggie, and they must rigidly avoid any milk other than skimmed!

Pets Can Cause Serious Infections in Humans

Veterinarians from Florida have written an article in the Lancet Infectious Diseases that points the finger at household pets, indicting them of being responsible from some serious human infections, such as MRSA (methicillin-resistant Staphylococcus aureus).

Infections produced by bites are the main culprits. They can be mixtures of bugs from the patient’s skin and the pet’s oral cavity, such as Pasteurella multocida, Streptococcus, Fusobacterium, and Capnocytophaga canimorsus. In addition, cats and dogs can be colonized by MRSA – probably acquired from their owners (cats and dogs usually carry Staph. intermedius). The MRSA is often the USA300 clone, the strain responsible for skin soft-tissue infections in community-acquired MRSA in the USA.

Animal bites make up about 1% of all emergency room visits – about 60% by dogs. 20% by cats, and the rest by other animals. Severe infections occur in about 20% of such bites, with possible serious consequences: bacteremia, meningitis, endocarditis, and peritonitis. Between 30% and 40% of hand bites become infected, so an ER visit is mandatory. No matter how much you love your pet, remember his mouth is very, very dirty (just like a human’s).

Too Many Glaucoma Patients Don’t Stick to Their Treatment

There are many sorts of glaucoma, but they all lead to damage of the optic nerve, which carries visual information from the eye to the brain. That’s why it’s essential that glaucoma patients take their medications as prescribed, and see their ophthalmologist regularly. Unfortunately, adherence to eye drop use is poor in glaucoma patients, as revealed in a study done by Johns Hopkins physicians and reported in the journal Ophthalmology.

There were 196 men and women in the study with open-angle glaucoma, angle-closure glaucoma, or ocular hypertension. They were supplied with free eye drops (travoprost, Travatan®) to be given to one or both eyes once daily; they were to use the Travatan Dosing Aid, a levered dispensing device that recorded date and time of use. The devices were collected after 3 months, and the data on drop use analyzed.

The results showed that 87 of the study participants – 44% - did not take their eye drops more than 75% of the time. When these non-adherent patients were compared with those who took more than 75% of their doses, it was found that poor adherers were more likely to be younger (below 50) or older (over 80), African-American, in poor general health, more depressed, and have lower income.

There are many sorts of glaucoma, but they all lead to damage of the optic nerve, which carries visual information from the eye to the brain. That’s why it’s essential that glaucoma patients take their medications as prescribed, and see their ophthalmologist regularly. Unfortunately, adherence to eye drop use is poor in glaucoma patients, as revealed in a study done by Johns Hopkins physicians and reported in the journal Ophthalmology. There were 196 men and women in the study with open-angle glaucoma, angle-closure glaucoma, or ocular hypertension. They were supplied with free eye drops (travoprost, Travatan®) to be given to one or both eyes once daily; they were to use the Travatan Dosing Aid, a levered dispensing device that recorded date and time of use. The devices were collected after 3 months, and the data on drop use analyzed. The results showed that 87 of the study participants – 44% - did not take their eye drops more than 75% of the time. When these non-adherent patients were compared with those who took more than 75% of their doses, it was found that poor adherers were more likely to be younger (below 50) or older (over 80), African-American, in poor general health, more depressed, and have lower income. As the researchers say: “physicians need to ask about adherence with therapy and offer patients assistance figuring out how to be successful in taking medications as prescribed.” Pharmacists, too, can help in emphasizing the importance of not missing doses, if eyesight is to be maintained as long as possible. As the researchers say: “physicians need to ask about adherence with therapy and offer patients assistance figuring out how to be successful in taking medications as prescribed.” Pharmacists, too, can help in emphasizing the importance of not missing doses, if eyesight is to be maintained as long as possible.

Saturday Quack – $2½ Billion Finds No Effective Alternative Meds.

The media (for example, Yahoo and MSNBC) have recently taken a few shots at the US government investment into the study of Complementary and Alternative Medicines (CAM). The AP headline tell it all: “$2.5B spent, no alternative med cures” and the article continues: “Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.”

The National Institutes of Health center in question - the National Center for Complementary and Alternative Medicine – has sponsored large clinical studies that found the following CAM products are not effective in their advertised conditions: echinacea for colds, gingko biloba for poor memory, glucosamine and chondroitin for arthritis, black cohosh for menopausal hot flashes, saw palmetto for prostate problems, and shark cartilage for cancer. The only CAM products shown to be effective are St John’s Wort for depression and ginger for the nausea associated with chemotherapy.

Around 40% of the US population has tried CAM during the last year, according to the NCCAM. One member of the Center suggests that this high number is because the public “not getting relief from conventional medicine”. Comments on blog sites reveal a split on the value of CAM – science on one side, belief on the other.

To my mind, the studies done by the NCCAM are useful, as they may convince people to avoid spending money on worthless medications. However, I’m not sure that $2½ billion should be budgeted again without a critical review of the Center’s role.

If Viagra Doesn’t Work, One Can Try Adding Metformin

An Argentinean study reported at the recent Endocrine Society meeting may give new hope to men with erectile dysfunction (ED) when Viagra® has failed to help. Seventeen men with Viagra-resistant ED were instructed to take metformin 1,700 mg daily, and Viagra (sildenafil) ‘on demand’. Thirteen men with the same problem were given a placebo daily, and took Viagra on demand.

Evaluations made at baseline and after 2 and 4 months included weight, waistline, basal metabolic index (BMI), blood glucose and insulin, and a recognized ED questionnaire score.

At baseline, the average ED scores were 14.3 in the metformin group and 15.2 with the placebo. After 2 months, they were 17 with metformin and 14.8 with placebo. And after 4 months, they were 19.8 with metformin and 15.8 with placebo. In addition, there was significant improvement in insulin resistance with metformin, compared with placebo. BMI and waist circumference declined significantly with metformin.

How does metformin help in this situation? Erectile function depends on the release of nitric oxide in the small blood vessels of the penis; Viagra works by blocking the breakdown of nitric oxide. Insulin resistance (a condition encountered in type 2 diabetes and pre-diabetes) can interfere with Viagra’s ability to block nitric oxide breakdown. And metformin, a useful anti-diabetic medication, in addition to other effects, increases insulin sensitivity.

The results of this study show that metformin has a role to play in helping Viagra, and other PDE5 inhibitors like Cialis® and Levitra®, to improve ED in selected men. A trial of metformin may be a useful approach in such cases, and can also lead the way to an early jump in the prevention of diabetes in a susceptible person.