Diary from a Week in Practice



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Am Fam Physician. 2001 Jan 15;63(2):249-250.

Monday

A pediatrician in our area recommends that his asthmatic patients use an antihistamine from overseas (ketotifen) to keep asthma attacks down in the winter. Last winter, several patients who transferred into WLL's practice had used this anecdotal suggestion. The moms involved felt it helped. Ketotifen is a mast cell stabilizer and is widely used abroad as an oral agent for the management of bronchial asthma. However, ketotifen is only available in the United States as an ophthalmic preparation. Researchers have now evaluated the prolonged pro-phylactic effect of oral ketotifen in asthmatic children (Ann Allergy Asthma Immunol 2000;85:46–52). Children in the six-month, double-blind trial were randomized to receive 1 mg of ketotifen twice per day or placebo in addition to their usual asthma medication. Those in the ketotifen group had significantly fewer days during which anti-asthma drugs were required and made 50 percent fewer emergency department visits than did the patients who received placebo. To our knowledge, the efficacy of ketotifen has not been compared with that of other mast cell stabilizers such as cromolyn sodium. The medication is available in some countries without a prescription and is obtained by WLL's patients via Internet sources. WLL is happy to read the newer studies but is fairly uncomfortable with the concept of patients obtaining medications from overseas via the Internet.

Tuesday

Today, JTL interviewed a patient suffering from obesity, despite a previous military career in which he was a “lean, mean fighting machine.” Addressing this 41-year-old man's dietary habits while conducting a physical examination, JTL first discovered that the patient's major caloric intake is through his evening meals. After emphasizing the need to reduce the number of carbohydrates in his diet, JTL recommended that the patient try to shift his biggest meal of the day from evening to the morning hours. JTL enjoys sharing with his patients one of the basic nutritional tenets espoused by the popular author of the 1960s and 1970s, Adelle Davis: “Eat breakfast like a king, lunch like a prince and dinner like a pauper.” The rationale? Calories taken in each meal need to be “worked off” during the day, while calories consumed late in the evening are generally stored up as fat while the consumer sleeps. JTL often shares with his patients his experience in Venezuela, where most workers, after several hours of productive morning work, return home to a large meal at noon. After a period of rest (siesta), workers return to the job, and then go back home for a small evening “snack” before retiring for the night. Europeans and other cultures often follow a similar routine. JTL wonders, why not Americans?

Wednesday

Finally, WLL has accepted the tide of evidence and has begun to avoid prescribing antibiotics to children older than two years with otitis media. After all, more than 80 percent of children with acute otitis media improve without antibiotic therapy within one week, according to a study released by the Agency for Healthcare Research and Quality. The study also found that children treated with amoxicillin had similar outcomes to those treated with more expensive antibiotics such as cefaclor (Ceclor), azithromycin (Zithromax) and clarithromycin (Biaxin). The analysis was conducted by the RAND Evidence-based Practice Center and looked at all of the clinical research on acute otitis media published from 1964 to 1999. Overall, the studies showed that most children older than two years with acute otitis media can be treated with “watchful waiting” for several days before an antibiotic is tried. The analysis showed that eight children with acute otitis media would need to be treated with ampicillin or amoxicillin rather than no antibiotic treatment to avoid a single case of clinical failure. This practice is common in the Nether-lands, where antibiotic resistance runs as low as 1 percent, compared with as high as 25 percent in the United States. The study estimated that 5 million episodes of otitis media occur each year in the United States at a cost of $3 billion. A summary of the study is published online at http://www.ahrq.gov/clinic/epcix.htm.

Thursday

After a busy day at the office, several of us were discussing some of the day's cases when suddenly one of our laboratory technicians came in complaining that she had abruptly developed trouble breathing. ASW quickly took her to an examination room, listened to her lungs with a stethoscope, but heard only normal breath sounds. Listening more carefully a second time, the normal sounds were almost instantly replaced by generalized wheezing that seemed to worsen with every second. Fortunately, the patient responded to diphenhydramine (Benadryl) and epinephrine. She was also given some parenteral methylprednisolone (Solu-Medrol). While the patient was recovering, ASW asked for additional information. The patient revealed that she had eaten seafood for lunch—and she and ASW realized that this was the likely culprit for the severe allergic reaction. With some reassurance and a prescription for diphenhydramine, a methylprednisolone dose pack, an albuterol inhaler and an anaphylaxis kit, the patient went home feeling much better. This experience gave ASW newfound respect for the speed with which allergic reactions develop and worsen.

Friday

WLL never stops encouraging his tobacco-addicted patients to “pick a day to stop.” He has always believed that even well into middle age, smoking cessation will greatly reduce the incidence of lung cancer. Now, researchers report that persons who stop smoking before middle age will see their risk of lung cancer that is attributable to tobacco drop by more than 90 percent (BMJ 2000;321:323–9). The researchers found that former smokers “had only a fraction of the lung cancer rate of continuing smokers, and this fraction fell steeply with time since stopping.” This meant that there were only one half the number of lung cancers that could have been expected if the former smokers had not quit. The risk of death from lung cancer by age 75 was 16 percent at 1990 rates in male cigarette smokers and 10 percent in female smokers. The report went on to say, “For men who stopped at ages 60, 50, 40 and 30, the cumulative risks of lung cancer by age 75 were 10 percent, 6 percent, 3 percent and 2 percent.” Given their findings, the group concluded that “mortality in the first half of the 21st century … will be affected much less by the numbers of new smokers who start than by the numbers of current smokers who stop.” It's time for family physicians to step up to the plate and join the Tar Wars team. We can make a difference. note: Tar Wars is a smoking cessation program of the American Academy of Family Physicians.

Saturday/Sunday

While JTL enjoys discovering new and alternative approaches to the practice of family medicine, there are times when the old, conventional wisdom prevails. One example might be in the emerging field of “anti-aging medicine,” which has led to patient interest in and demand for such agents as dehydroepiandrosterone, human growth hormone, antioxidants, etc. JTL recently read an excerpt from a talk given by Kenneth L. Minaker, M.D., of Massachusetts General Hospital, at the annual meeting of the American College of Physicians in Philadelphia. Making no mention of human growth hormone or noni juice, Minaker described in Physician and Sportsmedicine (2000;28[6]:19) “10 factors for successful aging”: (1) sleep seven to eight hours a night; (2) control weight; (3) exercise; (4) limit alcohol intake; (5) don't smoke; (6) eat breakfast; (7) seldom snack; (8) become more educated; (9) stay socially connected; and (10) maintain optimism and happiness. JTL feels that many of his highly content octogenarian (and older) patients heartily agree with this recipe for healthy aging. Incidentally, JTL rebels against the term “anti-aging,” which seems to perpetuate the belief that aging is a “disease” to be overcome, rather than a natural process to be embraced and, truthfully, enjoyed.

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.


Copyright © 2001 by the American Academy of Family Physicians.
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