Diary from a Week in Practice

Am Fam Physician. 2001 Feb 15;63(4):657-659.

Monday

WLL has found that two of his asthmatic patients have pH monitor-proven gastroesophageal reflux disease (GERD) and with treatment have been able to reduce their asthma attacks and medications. Now the data reveal that despite an absence of symptoms, GERD may be common in asthmatic patients. Researchers from the University of Alabama at Birmingham (Am J Respir Crit Care Med 2000;162:34–9) studied 26 patients with stable asthma and no reflux symptoms with esophageal manometry and 24-hour esophageal pH testing. Sixteen (62 percent) of these patients showed abnormal amounts of esophageal acid and were determined to have GERD. They were then compared with 30 asthmatic patients with symptomatic GERD. The team found that reflux severity in asymptomatic patients was “not less than” in those with symptomatic reflux. In addition, demographic asthma variables, including nocturnal asthma symptoms, did not differ between groups. According to the research team,“identifying ‘clinically silent’ gastroesophageal reflux in asthma patients requires 24-hour esophageal pH testing.” However, it should be noted that (1) the finding of GERD in asthma patients does not necessarily imply that the GERD causes or aggravates their asthma, (2) subclinical GERD might be equally common in nonasthmatic patients and (3) testing asthma patients for GERD is unlikely to be cost-effective.

Tuesday

WLL is almost fanatical about obtaining bone density screening in patients older than 50 years who suffer a fracture. He has been surprised at the number of cases of osteopenia and osteoporosis he has found this way, allowing him the opportunity to treat the bone thinning and prevent future disability. A recent study (J Bone Joint Surg 2000;82:1063–70) suggests that current physician practice may be inadequate. Researchers reported that patients who had sustained a wrist fracture had almost twice the relative risk of sustaining a hip fracture in the future, as about 90 percent of women with a distal radial fracture meet the World Health Organization diagnostic criteria for osteoporosis or osteopenia. In this study, 1,162 women 55 years or older who had sustained a distal radial fracture were evaluated. Only 2.8 percent of the women had undergone a bone-density scan within six months of sustaining the fracture and only 22.9 percent had been treated with medication recommended for established osteoporosis. Obviously, a fracture in a woman older than 55 years indicates that osteoporosis is likely to be present—no matter the mechanism of injury. By being vigilant, family physicians have an excellent opportunity to decrease the 350,000 hip fractures that occur each year in the United States.

Wednesday

The latest research supporting the potential cardiovascular health benefits of chocolate were presented at the 22nd Congress of the European Society of Cardiology. The research shows significant increases in plasma prostacyclin levels and a decrease in leukotriene levels in persons who consumed 37 g per day of chocolate. Prostacyclin promotes vasodilatation and inhibits platelet clumping. Conversely, leukotrienes are vasoconstrictive, causing a slow and persistent contraction in the smooth muscle of the blood vessels and can be platelet aggregatory. There are concerns that other chocolate ingredients, such as fat, might increase cardiovascular risk. However, researchers believe that this is unlikely because of the profile of fatty acids present in chocolate—which contains about 60 percent saturated fatty acids (35 percent stearic acid and 25 percent palmitic acids) and about 40 percent unsaturated fatty acids—mainly oleic acid. But, say the researchers, palmitic acid increases and oleic acid decreases plasma LDL cholesterol levels and stearic acid has a negligible effect. Based on these considerations, it can be expected that the contribution of chocolate consumption to cardiovascular risk, if any, is low. Now, just because the researcher presenting this view is employed by a company that makes chocolate treats is no reason to dispute these findings—especially around Valentine's Day.

Thursday

“Doc, do you mind if I tell you something personal?” JRH had just stepped into the minor procedure room to excise a skin cancer. He was wary of the question, but as he was pondering his answer, the patient's wife spoke up again. “Or maybe I shouldn't?” Well, that did it—now JRH had to know. Nodding to the spouse, he heard the most unexpected thing. “You've got a hole in your pants!” Not wanting to believe it, but knowing he'd better check anyway, JRH found a gaping hole in his slacks. It was true! The spotlight was certainly off the skin cancer and on the doctor. JRH decided to recoup from this with as much dignity as possible. So, asking the patient and his spouse to play along with him, JRH called for his nurse to bring him his long white coat and to bring up the stool so he could sit during the surgery and to turn off the air conditioning because it felt somewhat breezy in the office that day! Only after the surgery was over did JRH reveal to his nurse his predicament. And a good laugh was had by all.

Friday

Family physicians argue about whether pacifiers are good or bad for infants. Now comes a study implying that pacifier use is a preventable risk factor for ear infections in infants (Pediatrics 2000;106:483–8). These authors state that limiting pacifier use to the moments when an infant falls asleep decreases the risk of acute otitis media (AOM). Parents attending the intervention clinics received information explaining the harmful effects of pacifier use and instructions to restrict its use, whereas parents seen at the control clinics received no information on the topic. Parents in both groups were instructed to record the occurrence of AOM symptoms and changes in pacifier use. The mean duration of monitoring was 4.6 months. After the intervention, the researchers reported a 21 percent decrease “in continuous pacifier use at the age of seven to 18 months, and the occurrence of AOM per person-month at risk was 29 percent lower among children at the intervention clinics.” The authors state, “it would be ideal if children could use a pacifier freely until the age of six months, only when falling asleep or on special occasions between the ages of six and 10 months, and then decrease or stop the use after 10 months.” WLL is pleased that limiting use of the pacifier, rather than complete stoppage, appears to be enough to prevent disease.

Saturday/Sunday

During a recent visit to a local mall, ASW was stopped by a husband and wife who were visibly glad to see her. They reminded her that she had recently excised a melanoma in situ from the wife's arm, and they wanted to thank her once again for “catching it in time.” As she walked away, ASW reflected on the story behind this biopsy. This young woman had come in requesting excision of a benign-appearing facial mole, but a complete skin examination revealed an abnormal dark lesion on her right arm. The patient was slightly annoyed when ASW explained that the lesion on her arm should be excised, because she had come prepared to have the lesion on her face biopsied. After a discussion that included a review of some photographs of melanomas, the patient agreed to the arm biopsy and to leave the facial mole alone. Although the diagnosis of melanoma was a shock, the patient and her husband were thrilled to know that it was taken out before it had a chance to spread and thankful to have a doctor who looked beyond their concerns to find and address the real need. ASW was grateful for their appreciation (after all, it is one of the sweetest rewards family physicians enjoy), but even more, for the reminder that a visit for a skin lesion becomes an opportunity to evaluate all of the skin. It takes a minute or two, but as in this case, it can be potentially life-saving.

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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