Diary from a Week in Practice
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Am Fam Physician. 1999 Apr 15;59(8):2153-2154.
WLL has a patient with hepatitis C that was contracted during a blood transfusion over 10 years ago. The infection was associated with a slowly increasing alanine aminotransferase (ALT) level over the past two years. Liver biopsy showed mild to moderate inflammation with no cirrhosis. WLL's patient had read about using vitamin E, 400 IU per day, to reduce levels of ALT, hepatitis B e antigen and hepatitis B e antibody in patients with hepatitis B virus (Ann Intern Med 1998;128:156-7). In addition, he had heard of using the hepatoprotective botanical milk thistle (Silybum marianum) for reducing transaminase levels in patients with chronic active hepatitis (Int J Clin Pharmacol Ther Toxicol 1993;31:456–60) and alcoholic cirrhosis (J Hepatol 1989;9:105-13). The patient wanted to try them. So, he and WLL discussed the risks (which appeared to be few according to the literature) and benefits (which were only anecdotal for treatment of hepatitis C) and decided on a “trial-of-one.” WLL performed a polymerase chain reaction to check the patient's viral load, and the patient then began taking vitamin E, 400 IU per day, and silymarin, 150 mg three times daily. At today's follow-up, four months after starting this regimen, the patient reports that he has more energy, feels better and has no side effects. Of interest, his viral load is dramatically lower, and his ALT level is normal.
A 19-year-old woman presented today for follow-up of an ultrasound of the arm—which is an odd test to order—but true, nonetheless. About a year ago, the patient had visited a local health department for placement of a Norplant contraceptive. Because of various side effects, including irregular menstrual bleeding, weight gain and mood swings, she wanted the capsules removed. SEF examined the patient and thought that she felt all six of the implants, although one capsule seemed to be deeper than the others. During the removal procedure, she was only able to retrieve five implants. She could not find the sixth one despite making a second incision. The patient believed that only five capsules had been placed to begin with, but SEF was convinced that since the kit came with six implants, the last one must have become lodged under the muscle, so she referred the patient for the ultrasound. The test was negative and despite several attempts to obtain the other clinic's records of the insertion procedure, both patient and physician remained perplexed. The mystery may never be solved.
During our medical school days, it was stressed how important the family history was, but what they didn't tell us was how interesting it could sometimes be. Today JRH was dutifully asking a patient about family members with diabetes, heart disease, etc., when the man offered the information that his father had suffered from polycythemia. He expanded the history by noting that his father went for monthly phlebotomies and, in those days, was encouraged by his hematologist to take the surplus blood home with him. “Why?” JRH inquired. “Because it's good for growing roses—the best you've ever seen.” JRH was incredulous. “Yep,” the patient replied, “and my mother wouldn't hear of it, so my dad would give his unit of blood to our neighbor, who was very appreciative.” Later JRH repeated the exchange to WLL, an accomplished orchid grower, who verified the excellent nutritive value of blood, especially for roses. We confirmed this information with an area horticulturist, who told us that the active component in blood is the iron.
Being a family physician is like owning a storehouse filled with tidbits of knowledge and being able to draw from the stock placed there through the years. Today proved that point, as JRH saw a young woman who wished to have a lump (probably a sebaceous cyst) removed from her cheek. The lump had been there for many years, and she had always felt self-conscious about it. Not wishing to distort the tissues, JRH seized an idea from his knowledge storehouse: an infraorbital nerve block. This would be just the case in which to use regional anesthesia. After consulting SEF (who served a rotation in the dental clinic during her residency), JRH used the direct approach and deposited 3 mL of 2 percent lidocaine near the infraorbital foramen. The result was marvelous anesthesia, successful surgery and a very satisfied patient. Did I mention that the owner of the knowledge storehouse was satisfied, too?
We are all familiar with patients who bring a list of concerns with them to each appointment, and JTL appreciates the effort some of his patients make to prepare for appointments. During one recent introductory appointment with an elderly couple, married over 50 years, JTL noted that both husband and wife had such lists. As he progressed through the wife's list of problems, he inquired about the name of her previous physician so that he could obtain some of her medical records. Obviously having difficulty recalling the name, she turned to her husband and asked, “What was that doctor's name?” The husband, glancing at his list for a moment, replied, “Why are you asking me? I'm the one with the memory problems.” Sure enough, at the top of the list were the words, “Can't remember worth a darn.”
Do your patients take garlic? Do they ask you if it does any good? Are you confused because of the conflicting studies, with some saying that garlic works to reduce cholesterol, and others saying that it does not? A recent review in a newsletter, “Alternative Medicine Alert,” helped WLL understand this paradox. The review notes that at least 18 of the sulfur-rich derivatives of the amino acid cysteine occur in large amounts in fresh garlic. One of these compounds, allicin, is thought to provide medicinal benefits. However, the raw garlic has to be cut or crushed to allow the enzyme allinase (contained in the husk of the clove) to interact with the cysteine compound alliin (contained in the core of the clove) to produce allicin. Allicin gives garlic its taste and odor but is fairly volatile and breaks down at room temperature or after 20 minutes of cooking. It is this instability that makes the effects of garlic difficult to study, and the varying quality and type of garlic preparations seem to account for the differing study results. Garlic appears to be safe, and the most useful forms may prove to be fresh garlic, dried garlic powder or lightly cooked garlic. However, at best, the cholesterol-lowering benefit is modest.
This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., Stephanie E. Frisbie, M.D., John T. Littell, M.D., and Chad A. Griffin, M.D., six family physicians in private practice in Kissimmee, Fla.
Copyright © 1999 by the American Academy of Family Physicians.
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