Family Practice International

CLINICAL INFORMATION FROM THE INTERNATIONAL FAMILY MEDICINE LITERATURE

Am Fam Physician. 1999 Dec 1;60(9):2690.

Absent Male Patients

(Australia—Australian Family Physician, August 1999, p. 773.) Men consult physicians only about one half as frequently as women. Cultural and personal reasons for this discrepancy include difficulty in admitting stress or symptoms, low priority for health compared with work and other activities, fear of confidentiality and embarrassment, and dislike of being touched or examined. The medical office is often oriented to women and children, making it an uncomfortable environment for men. Physicians should avoid being judgmental toward male patients, and stress confidentiality and commitment to the patient's welfare, regardless of the circumstances. Much can be done to develop a trusting patient-physician relationship during visits for minor or routine problems, thus establishing a basis for managing more serious or complex issues when they occur. Male physicians in particular should address their own attitudes toward health care and lifestyle habits as they relate to treating and counseling men.

Complications of Parkinson's Therapy

(Australia—Australia Family Physician, September 1999, p. 897.) Although most patients with Parkinson's disease initially respond well to levodopa therapy, adverse effects remain a concern. Nausea and postural hypotension are common initial problems. These complications usually respond to manipulation of the medication dose. One approach is to change the brand of levodopa and slowly titrate the dosage to effective levels. Domperidone, a peripheral dopamine blocking agent, may be added to alleviate nausea. More serious initial problems—confusion, paranoia and hallucinations—require the addition of a major tranquilizer as well as adjustment of the levodopa dosage. Unfortunately, the efficacy of levodopa wanes over several years and after a decade, drug response can be unpredictable and difficult to manage. “End-dose slowing,” a shortening of the duration of motor response, may respond to increased frequency of doses, use of long-acting formulations or addition of catechol O-methyltransferase inhibitors. Another common problem is “peak-dose dyskinesia,” which involves unwanted abnormal movements during the peak-dose phase of medication. This requires careful reduction in dosage to maintain therapeutic effect without precipitating dyskinesia. Small doses of liquid levodopa are useful to titrate efficacy and abate unwanted effects. This strategy may also alleviate discrepancies in medication response between different parts of the body.

Removing Ear Wax

(Australia—Australian Family Physician, August 1999, p. 817.) Hard ear wax is a common problem for which patients seek the advice of a family physician. Many remedies have been suggested to soften ear wax and facilitate its removal. A study by an Australian general practitioner concluded that a 15 percent solution of sodium bicarbonate was more effective than use of commercial preparations in dispersing ear wax. One traditional home remedy, olive oil, had no effect on softening ear wax in this in vitro experiment.

Recommendations on Dementia

(Canada—Canadian Family Physician, September 1999, p. 2136.) Even though current evidence does not support screening asymptomatic patients, new guidelines from Canada recommend that a high index of suspicion be maintained for dementia in the elderly. The diagnosis of dementia is based on history, physical examination and psychometric testing (such as the Mini Mental State Examination). Serial assessments may also be required. To exclude other potential causes of symptoms, only limited laboratory studies are indicated—complete blood count, thyroid function tests, and assessment of serum calcium, glucose and electrolyte levels. Cranial computed tomographic imaging is only recommended if one or more of the following factors are present: the patient is younger than 60 years; there is rapid decline in cognition and function; neurologic symptoms are present; duration of dementia less than two years; or history, signs or symptoms suggest a treatable cause for the dementia. Most patients and families prefer to know of the diagnosis early in order to start making long-term plans, but marked cultural differences may be encountered in the coping strategies of patients and families. Once the diagnosis is confirmed, the risk of depression is high and over 90 percent of patients eventually develop behavior problems. Patients and families require support and information, particularly concerning treatment options and the widespread use of nonapproved substances such as vitamin E and Ginkgo biloba.


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