Diary from a Week in Practice



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Am Fam Physician. 2000 Dec 15;62(12):2604-2606.

Monday

WLL has been pleased with the effectiveness of vitamin B6 (pyridoxine) in dosages of 12.5 to 25 mg every eight hours in treating nausea of pregnancy. When this is not effective, he will increase the dosage to 25 to 50 mg orally three to four times a day in combination with doxylamine, in dosages of 10 to 12.5 mg orally once or twice per day. Doxylamine and vitamin B6 are labeled pregnancy category A by the U.S. Food and Drug Administration. Doxylamine is available over-the-counter in 12.5-mg (Decapryn) and 25-mg tablets (Unisom Nighttime Sleep-Aid Tablets). The combination of vitamin B6 and doxylamine is contained in the prescription drug Diclectin, which is available in Canada. However, the combination of B6 and doxylamine is currently unavailable in the United States because of fears of birth defects. These were likely an erroneous association, however. Now comes a suggestion appearing in a letter to the editor of Family Practice News (July 1, 2000, p. 10) in which a family physician reported successfully using 1 cc of intravenous pyridoxine per day for two to three days for severe nausea and vomiting of pregnancy. He “found this treatment worked for vomiting during pregnancy many times over the years, for hundreds of patients.” He says that he “regrets not doing more scientific study” on his “trick of the trade.” WLL hopes someone will put it to the test.

Tuesday

JTL today followed up with a patient who is a manual laborer with recurring “trigger fingers.” This condition, known as stenosing tenosynovitis, can often be managed by the family physician. JTL, to refresh his memory, referred to a guide titled The Hand: Primary Care of Common Problems (available from the American Society for Surgery of the Hand, 3025 S. Parker Rd., Ste. 65, Aurora, CO 80014). The procedure, which JTL previously used on this patient's left hand, involved injecting a mixture of 0.5 cc of triamcinolone with 0.5 cc of lidocaine in a tuberculin syringe or a 1-cc syringe with a 27-gauge needle. The needle is advanced directly over the palmar aspect of the flexor tendon sheath, which is usually just distal to the metacarpal joint of the affected finger. After advancing to the floor of the tendon sheath, and then drawing back while applying gentle pressure to the syringe, the mixture is readily injected into the tendon sheath. JTL will then have the patient wear a splint with the finger in an anatomic “intrinsic plus” position overnight. This patient experienced dramatic relief after a similar injection to the left third digit a year ago, and was now requesting the same for his right hand. JTL is thankful for resources such as “The Hand”—a reference that has proved useful from time to time.

Wednesday

Prevention magazine covers the growing popularity of herbal medicine in a survey of herbal and dietary supplement usage in the United States. The survey found that 49 percent of adults used an herbal remedy in 1999 and 24 percent used herbal remedies regularly. The most commonly used herbs were garlic (13 percent of all U.S. adults), ginseng (8 percent), gingko (7 percent), St. John's wort (4 percent) and echinacea (2 percent). The survey also reported the reasons that people would use herbs instead of a prescription/over-the-counter product: prefer natural products (43 percent/47 percent), fewer side effects (21 percent/17 percent), more effective (14 percent/17 percent), allowed self-treatment (11 percent), less expensive (8 percent) and more gentle or mild (6 percent/8 percent). As can be seen from the results of this survey, many patients believe that because herbal remedies are natural, they are less harmful than pharmaceutical drugs. In general, herbal remedies are milder because they are less concentrated. However, herbs are not harmless. More than one third of the pharmaceutical drugs on the market today were originally isolated from plant material. Therefore, herbs have the potential to be harmful or to cause interactions with drugs, supplements or even foods. To keep up with his patients, WLL is having to become better educated on natural medicines—including herbs, vitamins and supplements.

Thursday

One of the pleasures of practicing family medicine in modern times is the opportunity to negotiate with HMOs to obtain needed services for patients. Today, JTL was able to convince an HMO to allow a 26-year-old woman to travel to Mississippi for medical evaluation and treatment. Following an uneventful vaginal delivery of a daughter over one year ago, this woman had an iliac deep vein thrombosis. Four vascular surgeons have evaluated her, performing three surgeries including a hysterectomy (in an attempt to alleviate the incredible pain brought on by pelvic vein dilatation). Now, all of the surgeons were recommending referral to a well-known surgeon in Mississippi, yet the HMO was balking. Finally, when the woman's pain reached the point that she was unable to function at home, JTL admitted her to a local hospital for pain relief. Interestingly, the referral process sped up once the HMO personnel learned that the patient was now an inpatient. Within the day, JTL was finally able to bring this woman some good news in the form of an actual appointment date in Mississippi. And, JTL was pleased to learn at least one way to speed up the managed care machine.

Friday

Often, WLL's patients who are addicted to cigarettes are reluctant to stop smoking because they fear gaining weight. In the past, WLL has attempted to convince patients that the weight gain is less harmful than smoking, but this does not always work. Now, he has a new option; smokers who use bupropion (Zyban or Wellbutrin-SR) as a smoking cessation aid may gain less weight than those who quit using a placebo. This information was first presented during the 11th World Congress on Tobacco or Health. The differences in weight gain were most marked in women. Researchers from Massachusetts General Hospital in Boston analyzed data from a multicenter study originally designed to evaluate maintenance use of bupropion. In that study, 784 smokers were placed on seven weeks of therapy with bupropion. Next, 432 patients who had not smoked in the past seven days continued for 45 weeks on either the drug or placebo. At the end of the study, 97 smokers who had abstained from smoking for 24 months were evaluated for weight gain. The ex-smokers who had continued taking bupropion gained an average of a little more than 9 lb less than those who took the placebo. Now WLL has a new tool in his anti-tobacco crusade.

Saturday/Sunday

One aspect of family practice that JTL has always enjoyed is having the opportunity to help his patients at times when they might otherwise have to wait several hours in the emergency department. This Sunday, while visiting with one of his patients at a nursing home, JTL was paged by the father of a 10-year-old girl whose hand had been injured and was feared broken. At first JTL was tempted to advise them to go the nearest hospital, but instead he asked where they lived. It turned out their home was not far off the route that JTL would take back to his home. JTL offered to meet them in the parking lot of a grocery store that would be convenient to both parties. Once there, JTL examined the girl's hand and found evidence suggestive of a nondisplaced fourth metacarpal fracture, with no neurovascular compromise. JTL advised that the girl use the RICE technique (rest, ice, compression, elevation) until Monday, at which time she could come to the office after school for a radiograph to determine the need, if any, for a splint. JTL was pleased to have helped this girl and her family, and so was JTL's wife, who asked him to pick up a few things at the grocery store on the way home.

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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