Diary from a Week in Practice



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Am Fam Physician. 2000 Nov 1;62(9):2006-2011.

Monday

WLL believes the Internet is providing the general public with invaluable and incredible access to medical information. Unfortunately, it has also become the vehicle of choice for the unethical purveyors of unending medical legends, quackery and unscrupulous medical advice. As family physicians become masters of information management, they also need to become skilled at helping patients find the information that can be beneficial. There are a number of superior Web sites that will help you and your patients evaluate Internet “urban legends,” such as Alzheimer's disease and multiple sclerosis being caused by aspartame. One of the best sites for researching medical fraud, operated by Stephen Barrett, M.D., is titled “Your Guide to Health Fraud, Quackery and Intelligent Decisions” (http://www.quackwatch.com). A great site for finding medical information is the U.S. government's Healthfinder home page, “Your Free Guide to Reliable Health Information” (http://www.healthfinder.gov). WLL's favorite is the Web site of the National Health Information Center (NHIC is a health information referral service) that allows the search for diseases by keyword (http://nhicnt.health.org/alphakeyword.htm).

Tuesday

Long-time readers of “Diary” know of our love of maternity care. Now, there's a new position statement issued by the American College of Obstetricians and Gynecologists and the American College of Allergy, Asthma and Immunology on treating asthma during pregnancy. (Annals of Allergy, Asthma and Immunology 2000;84:475–80.) WLL found a number of useful, practice-changing tips. The bottom line for asthma is that virtually all standard inhaled medications used to treat asthma before pregnancy (including budesonide, salmeterol, nedocromil sodium and inhaled corticosteroids) can be continued during pregnancy. Even for oral steroids, the benefits usually outweigh any potential risks. As for the leukotriene modifiers, the guidelines recommend zafirlukast or montelukast but caution against using zileuton (as harmful effects have been seen in animal studies). Concerning allergies, WLL was surprised to learn the recommendation is to not use pseudoephedrine during pregnancy and to use no oral decongestant during the first trimester. Pseudoephedrine has been associated with the rare birth defect gastroschisis. For antihistamines, the report recommends chlorpheniramine and tripelennamine. If these older antihistamines are not well-tolerated, then loratadine or cetirizine are recommended. The report cautions against the use of fexofenadine because there is not yet enough documentation of its safety during pregnancy.

Wednesday

Here in Florida, we are partial to our palmettos. One of the most common is saw palmetto. WLL sees an increasing number of men taking saw palmetto (Serenoa repens or Sabal serrulatum) to prevent or treat benign prostatic hypertrophy (BPH). The results have been poor, at best. A Consumer Union's survey of more that 46,000 adults (Consumer Reports, May 2000:17–25.) looked at self-reported responses to prescription drugs and natural medicines. For “prostate problems,” of those who took a prescription, 26 percent reported it helped “little or none.” However, for saw palmetto, 46 percent said it helped “little or none.” The editors theorized that low levels of satisfaction may be related to poor product quality in this country. Recent data from an independent laboratory confirmed this theory. Researchers tested 27 U.S. brands of saw palmetto to determine whether they possessed the components found in the saw palmetto products used in published clinical trials. Only 17 products passed, most containing additional oils that may or may not have additional benefit. Only two products appeared to contain exclusively the saw palmetto extract similar to that used in most clinical trials (http://www.consumerlab.com/results/sawpalmetto.html). WLL now believes that in the case of natural medicines, the time for testing and regulation by the U.S. Food and Drug Administration is past due.

Thursday

In his previous experience as a “Fresh Start” smoking cessation facilitator, JTL had shared with his tobacco-addicted patients the many factors involved in nicotine addiction. Perhaps foremost among the reasons smokers do not relish the thought of quitting smoking is the fear of “losing a loved one” or parting with a “best friend.” Given that sustained-release bupropion (Wellbutrin SR) is labeled for depression, use of the same drug labeled for smoking cessation (Zyban, cessation rate of 10 to 24 percent) might make psychologic sense. JTL thinks that if bupropion can help someone in depression because of a personal loss, then by analogy this could be a meaningful way of describing its effect to patients who are about to undergo the loss of one of their best friends, tobacco.

Friday

Many of WLL's patients receive chronic benzodiazepine therapy for insomnia, but long-term use is not recommended. So, about three years ago, WLL began recommending low-dose melatonin (0.5 to 1 mg at bedtime) and valerian root (Valeriana officinalis, 160 to 320 mg at bedtime) for his patients willing to slowly taper their insomnia medications (i.e., reducing the total daily dose of the benzodiazepine by 25 percent weekly).This regimen seemed to work, perhaps because chronic use of benzodiazepines is believed to suppress the endogenous release of melatonin during the normal burst hours. It seemed to work. Now, WLL has found a study confirming his observation (Arch Intern Med 1999;159:2456–60). The study enrolled 34 subjects receiving long-term benzodiazepine therapy. Patients received 2 mg of controlled-release melatonin or placebo for six weeks. Subjects reduced their benzodiazepine dosages by 50 percent during week 2, 75 percent during weeks 3 and 4, and discontinued the benzodiazepine during weeks 5 and 6. Sleep-quality scores were significantly higher in the group receiving melatonin therapy and good sleep quality was maintained in 19 of 24 patients. With a relatively small number of patients, the results should be considered as preliminary evidence only. However, melatonin may be a potential tool in helping patients adhere to benzodiazepine discontinuation.

Saturday/Sunday

There are days in the life of a family physician when one has the opportunity to reflect on the many blessings that accompany the practice of family medicine. Today was one such day for JTL, who was awakened at 2:00 a.m. by an emergency page to labor and delivery. After a six-minute drive from home to the hospital, JTL was privileged to attend the birth of a baby boy. After returning home for a few hours of sleep, he saw his morning patients at the office and then went to the hospital to visit a patient with cancer, near death, requiring heavy doses of morphine. JTL stayed with the patient's wife and children as all awaited the patient's imminent death later that day. Next, JTL drove to a nearby nursing home, where he was able to admit one of his patients recovering from extensive surgery and undergoing rehabilitation. Many who are not in family medicine might look on the diversity of this Saturday experience and consider it overwhelming. However, family physicians are not only trained to provide high-quality care to the entire family but many seem to be driven to perform, and indeed excel, at the realization that, at any time, they will have the opportunity to minister to the health care needs of the patients they encounter, from conception to death.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Amaryllis Sanchez Wohlever, M.D., and John T. Littell, M.D., four family physicians in private practice in Kissimmee, Fla.


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