Thursday, December 31, 2009

Ginko biloba, Not as good as once thought!

Ran across a new article in JAMA about "Ginko biloba for the preventing cognitive decline in older adults."
This study is the best kind of study we can perform in medicine. It was randomized, double-blinded, placebo-controlled trial of 3069 patients aged 72-96 years old from 2000-2008.
Patients were either given Ginko 120mg twice daily or identical placebo. Multiple rating scales employed to objectively rate cognitive decline and or improvement.

The authors concluded that Ginko 120mg twice daily did not result in less cognitive decline in older adults with normal cognition or with mild cognitive impairment.

The bottom line is, if you are taking Ginko for memory you are likely wasting your money.

Here's the article:
Ginkgo biloba for Preventing Cognitive Decline in Older Adults
A Randomized Trial
Beth E. Snitz, PhD; Ellen S. O’Meara, PhD; Michelle C. Carlson, PhD; Alice M. Arnold, PhD; Diane G. Ives, MPH; Stephen R. Rapp, PhD; Judith Saxton, PhD; Oscar L. Lopez, MD; Leslie O. Dunn, MPH; Kaycee M. Sink, MD; Steven T. DeKosky, MD; for the Ginkgo Evaluation of Memory (GEM) Study Investigators
JAMA. 2009;302(24):2663-2670.

Bryan Glick, DO

Wednesday, December 30, 2009

Hangover Remidies

There have been multiple remedies suggested for New Years Day hangover. Personally, I have had great results with taking ibuprofen 4 tablets by mouth with a snack, right before bed and 16-20 oz of water. I also, wake up and do the same. Alcohol dehydrates you so make sure you are urinating and your urine is clear, not yellow.

This article I found from 2007 reports that:
Drinking a glass of milk and eating a slice of toast with honey or syrup may combat that hangover.

check out the article yourself:

Have fun and be safe.
Bryan Glick, DO

Wednesday, December 23, 2009

Red yeast rice and your cholesterol

Saw an interesting article in American Family Physician. It was actually a summary of an article published in the Annals of Internal Medicine June, 2009.

Questions posed: Is Red Yeast Rice effective in Statin-Intolerant Patients?

Typically when patients have high cholesterol, as physicians, we initially recommend therapeutic lifestyle change (TLC) for a couple months. This is when the patient gets the message that they have to change the way they eat and start exercising. Some patients respond but the vast majority don't. "I'm too busy, I don't have time." My response is, "You have to make time to exercise or take time to take a pill." That pill is usually a STATIN class of cholesterol lowering medications. These are the ones you see on TV named Lipitor, Crestor and Zocor for example. These medicines can be prescribed by your doctor and usually your liver function tests need to be monitored periodically.

Now some patients do actually have an allergic reaction to STATIN medications and cannot take them. So they need alternatives. This article addressed one of these alternatives, Red Yeast Rice.

The Study:
Patients were enrolled in 12 weeks of a lifestyle change program and received Red Yeast Rice 1800mg twice daily for 24 weeks. Baseline LDL cholesterol was measured. At the conclusion of the study, the Read Yeast Rice group showed significantly lower LDL cholesterol levels.

The Answer:
The authors concluded that Red Yeast Rice in conjunction with therapeutic lifestyle change may be useful for treating hyperlipidemia in patients who cannot tolerate STATIN therapy.

So this information is good right? Go out and buy your read yeast rice, immediately? I don't think it's a bad thing but you do have to watch the fine print. These patients were in a 12 week lifestyle change program. Likely, provided nutritional and exercise education. I can provide that, but not for 12 weeks. Yes, the medicine helped but it's not clear how much what the lifestyle changes program entailed and to what extent the effect was.

The question always arises, "Doc, what can I do to lower my cholesterol."
The answer is Diet and Exercise and Weight loss. Other options include: Fish Oils, Red wine, 2 servings of oatmeal a day and avoiding saturated fats.

You can read the article yourself at:

Bryan Glick, DO

Tuesday, December 22, 2009

Do you have sinus congestion?

Arizona is known for many things besides the beautiful scenery. Medically speaking, Arizona is known for seasonal, strike that, year round allergies. Many people have post-nasal drip, runny nose, sinus congestion, sore throat and cough. None of these symptoms is associated with a fever usually and patients typically complain that this has been going on for weeks. I personally grew up in Northern California and never had allergies until I settled in Arizona. The relative lack of humidity, year round, is a huge factor.

I have a lot of patients who present with 2-3 days of sinus headache, nasal congestion and post-nasal drip. They always want antibiotics. Do they need them? Officially, no, but do I prescribe them anyway, yes. These reason, I prescribe them when I think this is allergic or viral is because, the patient was concerned enough to come in and be seen. They have to go back to work or take care of the kids and it's not for me to say "No, you can't have that medicine, you'll be fine." Some of you might be think, isn't that the job of a physician, to tell you what medicines you can have and which are unnecessary? Yes, that is the job of a physician but it's also my job to provide care in the best interest of patients. That's why if you want narcotics and don't need them you won't get them here, for example.

There have been many studies on the placebo effect (taking a sugar pill that you think will heal you because you have been told so by your doctor) and how well it works and the ethical questions surrounding it. If I have an antibiotic that you have taken before, and you have attached a value to that therapy ("Doc, every time I get this I take a Z-pak and it goes right away") such that it works and it's all you need, If I deny you that medication, am I doing more harm than good? Don't know. Don't even know how that could be studied. I do know that patients all the time think their illnesses are cause and effect when very little but death and taxes are cause and effect. As a physician, I see them as coincidences or completely unrelated but to challenge a patient to an academic argument when they are ill is the antithesis of care. So, If a patient says "Doc, every time I get a running nose, I take chemotherapy and it goes right away," well that patient needs to be educated and they won't get chemotherapy. Azithro (z-pak) is relatively safe medicine, yes antibiotics resistance is possible but I just wonder if the placebo effect may be the real medicine in this situation.

In an effort to be avoid antibiotic Resistance and possible side effects from unnecessary medications, let me give you a head start on what you can do if you start having either allergic or viral sinusitis.

Initially, you should start with pseudophed OTC 30-60mg every 4-6 hours which will help shrink the sinuses. Don't take it in the evening as it could keep you awake.

Next, you can take ibuprofen at the same time for pain relief but sometimes this isn't necessary because the shrinking of the sinuses allows for drainage which relieves the pressure and takes the pain away. If you are going to take it, make sure it's with some food.

If you feel that your eyes, ears and nose are itchy, this may be a allergic issue and you might want to take plain benadryl 25mg at bedtime as an antihistamine. This will make you drowsy and will help prevent all that mucous production.

A cool mist humidifier will increase the humidity in your bedroom and prevent your nasal passages from drying out while you sleep.

If you feel achy and run down, this may be an viral process and you may want to take one of the many OTC viral remedies. The one I like is Umcka Cold Care.

When do you need antibiotics, you ask?
We reserve antibiotic therapy for patients given pseudophed and ibuprofen for 7 days who have the following:
Facial pain, green nasal discharge, tooth pain, or antibiotics in that last month for another illness.

Using the above treatment regime will not only provide you relief sooner and cheaper but will also aid the doctor in understanding how bad your sinuses are and help you get antibiotics when you need them rather than when you want them.

Bryan Glick, DO

Ibuprofen vs Tylenol with Codeine for Kids

Following an arm fracture, is ibuprofen as effective as acetaminophen (paracetamol) with codeine to relieve short-term pain?

Bottom Line:In the first 3 days following a fracture, ibuprofen is as effective as acetaminophen with codeine in the treatment of children's pain due to an arm fracture. It also causes fewer side effects. One caveat: The total daily dose of ibuprofen used in this study is higher than typically used because it was given every 4 to 6 hours rather than every 6 to 8 hours (as labeled). (LOE = 2b-)

Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med 2009;54(4):553-560.

Taken from Evidence Essential Plus, Daily POEM.

Wednesday, December 16, 2009

H1N1 Vaccine Recall

Today you may hear on the news that the CDC has found some of the prefilled H1N1 vaccines are being recalled. The recalled vaccines have demonstrated less immunogenicity (protection) than previously thought. Those children that need a booster should still get it. If you child received one of the recalled vaccines you DO NOT NEED to repeat the recalled vaccine. Just continue to get the booster in the 4 week interval.

CDC website has information about it. See link below for details as well as lot numbers.

If you received you vaccination from our clinic, your safe. We have only multi dose vials which were not named in the recall.
Feel free to call if you have any questions.

Tuesday, December 8, 2009

Experience teaching at the Caepe School

Just returned from TRYING to teach nutrition at the Caepe School in Anthem in Mr. Miller's class of 7th and 8th graders.

Myself and Ben, my medical student, anticipated talking about food labeling and how to read the nutrition facts on the box.

Needless to say, we all had a good time. The kids were very enthusiastic and asked, no joke, 50 + questions. I have taught in high school, college level and medical school before, but never for middle school. I will have to work on keeping the topic focused. One of the topics that one of the students asked about was "tree man." Many of the kids have seen him on the internet. Ben and I had no idea what they were talking about. When we got back to the office we looked it up and apparently this gentleman has a immune system defect that allows viral warts to go out of control. Rather interesting but I need to work on what educational info can be gained by talking about it.

Another good topic that the kids brought up was genetics and I will work with Mr. Miller to do a whole topic on Mendelian genetics. I hope I can present that in 1 hour or less.

I think the kids had to get all of their questions out and next time we can be a little more focused.

In the future, we are trying to coordinate CPR training for the kids along with First Aid.

Overall, an amazing experience, and I think I will be able to teach science in a fun and gross way. The kids did have a bunch of questions about vomit and other gross topics.

Next week, 12/17, we will revisit the food label topic. Finish it and prepare for another topic first of the year.

Really fun to get out of the office.

Bryan Glick, DO

Thursday, December 3, 2009

Do you take a med for cholesterol? Are you taking CoQ10?

We have known for years that CoQ10 is a metabolic nutrient that has been shown to be helpful in patients with heart failure. The Japanese government has advocated daily use of CoQ10 since the 1970's. A significant proportion of our population if not the world are on Lipid lowering medications known as "statins." We know that these statin medications lower CoQ10 levels which may lead to sore muscles and fatigue. There is proven benefit from the addition of CoQ10 in patients with heart failure but conjecture still exists regarding CoQ10 effectiveness in patients taking statins.

The American Family Physician wrote an article re CoQ10 which is a general overview. Make sure to read the "update" section at the bottom for the summary.

Bryan Glick, DO

Monday, November 30, 2009

Tylenol and Iburpofen to treat fever in children???

First, it must be made clear that any child with a fever should be evaluated by a physician to determine if antibiotics or a higher level of care is required, especially during H1N1 season.

That being said, you have a child who doesn't have any other source of infection other than a viral illness and now what do you do. There are a lot of theories as to whether you should treat it or not with medications like tylenol and ibuprofen. I will leave that up to parents to decide. My opinion is that when you treat a fever, the child feels better, sleeps better and is able to return to normal activities. Typically children greater than 1 year can have either tylenol or ibuprofen. Some viral illnesses will have a high fever and many parents will call when they can't give another dose based on the bottle instruction and child's fever, breaks through. When that happens, I recommend alternating doses of tylenol and iburpofen every 4 hours so their is at least 8 hours between doses of the same medications. I will even recommend mom set an alarm and wake the child up in the middle of the night to give them some medicine and some fluids and have them go back to bed. Attached is an article about using both medications is better. Read for yourself.

Bryan Glick, DO

Journal of Family Practice
December 2008 (Vol. 57, No. 12)
Patient Oriented Evidence that Matters

Do combination antipyretics work faster than ibuprofen alone in children?

Hay AD, Costelloe C, Redmond NM, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008;337:a1302.

No. Adding acetaminophen (paracetamol) to ibuprofen does not reduce fever faster than ibuprofen alone in children. Over 24 hours, however, children receiving the combination spent 2.5 to 4.4 more hours without fever than children who took either drug alone.
Individual randomized controlled trials (with narrow confidence interval)
These investigators enrolled 156 children ages 6 months to 6 years at 35 primary care sites. The children were un-well and had a fever of at least 37.8°C, but no more than 41.0°C, and could be cared for at home. Children with dehydration were excluded.
The children were randomly assigned (concealed allocation) to receive ibuprofen 10 mg/kg per dose every 8 hours, acetaminophen 15 mg/kg per dose every 6 hours, or the combination, for the first 24 hours and then in response to symptoms for another 24 hours. The first doses were given in the office upon enrollment. Matching placebo of the alternate drug was given to the children in the single-drug groups. Analysis was by intent-to-treat, ie, the children were analyzed in the group to which they were assigned regardless of whether they followed the advice for therapy. Over the first 24 hours, full dosing of acetaminophen occurred in 42% to 65% of children and full dosing of ibuprofen occurred in 71% to 73% of children.

Combination antipyretics don’t work faster than ibuprofen, but they are longer acting
Ibuprofen lengthens time without fever during first 4 hours
Ibuprofen, either alone or with acetaminophen, produced more time without fever in the first 4 hours—an additional 55 minutes with the combination and an extra 39 minutes with ibuprofen alone—as compared with acetaminophen alone. This difference resulted from a 23- to 26-minute faster onset of fever reduction when ibuprofen was used either in combination with acetaminophen or alone.
Combination therapy has benefits during the 24-hour window
Over the first 24 hours, children spent more time afebrile with the combination of drugs as compared with either drug alone: 20.3 hours as compared with 15.7 hours with acetaminophen alone and 17.6 hours with ibuprofen alone.

Wednesday, November 25, 2009

What do these Breast Cancer guidlines mean?

Breast Cancer Screening Information for Patients

EBSCO Publishing's Consumer Health editors have created a 3-page handout to explain current breast cancer screening evidence and guidelines to patients.

See Breast Cancer Screening: Research and Guidelines.

DynaMed's Systematic Literature Surveillance is used to update Nursing Reference Center (NRC), Rehabilitation Reference Center (RRC), and Patient Education Reference Center (PERC), supporting EBSCO Publishing in providing current evidence-based references across the continuum of clinical care.

New Breast Cancer Screening Guidelines

Mammography Screening May Reduce Breast Cancer Mortality

The United States Preventive Services Task Force (USPSTF) recently updated their recommendations for breast cancer screening. These recommendations were based in part on a systematic review that included 8 randomized trials evaluating mammography screening for women ≥ 39 years old. Follow-up ranged from 11-20 years. Most trials were designed to compare the effects of inviting women for screening vs. no invitation rather than to directly compare screening vs. no screening. Invitation to mammography screening was associated with decreased risk of breast cancer mortality in all age strata for women aged 39-69 years (level 2 [mid-level] evidence).

For women aged 39-49 years, the pooled risk ratio (RR) for breast cancer mortality in screening groups was 0.85 (95% CI 0.75-0.96) in 8 trials with 348,219 women. The authors estimate that 1 breast cancer death would be prevented for every 1,904 women in this age group in a screening program for 10 years. Mammography was also associated with reduced breast cancer mortality in women aged 50-59 years (RR 0.86, 95% CI 0.75-0.99 in 6 trials), with 1 breast cancer death prevented for every 1,339 women recommended for screening, and in women aged 60-69 years (RR 0.65, 95% CI 0.54-0.87 in 2 trials), with 1 breast cancer death prevented for every 377 women. There was no significant difference in breast cancer mortality in women aged 70-74 years in the only trial that included this age group.

The review also examined outcomes per screening round in a cohort of 600,830 women ≥ 40 years old who had mammograms between 2000-2005. Rates of false positive mammograms per 1,000 women screened were 97.8 for ages 40-49 years, 86.6 for 50-59 years and 79 for 60-69 years. In addition, for women aged 40-49 years, 5 biopsies were performed for each cancer detected compared with 3 biopsies per cancer detected for women aged 50-59 years and 2 biopsies per cancer detected in women aged 60-69 years.

The most serious potential harm from screening is "overdiagnosis," meaning detection of cancers that would never have been symptomatic during the life of the woman. This can lead to unnecessary treatment with surgery, chemotherapy, or radiation. The overdiagnosis rate was estimated to be 1%-10% based on increased rates of cancer detected in screening groups compared to control groups (Ann Intern Med 2009 Nov 17;151(10):727). However, there are many factors in addition to overdiagnosis that may increase the rate of cancers detected through screening (Breast Cancer Res 2005;7(6):266).

The USPSTF now recommends against routine screening for women aged 40-49 years, suggesting the decision to begin screening should be individualized based on each patient's context and values (grade C recommendation). They recommend screening for women aged 50-74 years (grade B recommendation) and find insufficient data to make recommendations for women aged 75 years or older (grade I recommendation). USPSTF also recommends against clinicians teaching breast self-examination (grade D recommendation) and makes no recommendation about clinical breast exams (grade I recommendation). When mammography screening is done, USPSTF suggests every 2 years instead of annually (Ann Intern Med 2009 Nov 17;151(10):716). It should also be noted that the USPSTF recommendations do not apply to women who may be at increased risk for breast cancer due to factors such as genetics.

The benefits of breast cancer screening were also examined in a recent Cochrane review of 11 randomized trials (including the 8 above) with 616,327 women. There was no reduction in overall mortality associated with mammography (RR 0.99, 95% CI 0.97-1.01 in analysis of 8 trials), but there was a reduction in breast cancer mortality (RR 0.81, 95% CI 0.74-0.87 in analysis of 9 trials) (level 2 [mid-level] evidence). This reduction, however, was not statistically significant in an analysis restricted to 4 higher quality trials (RR 0.9, 95% CI 0.79-1.02). Attendance rates for scheduled mammography ranged from 60%-100% for the first mammogram and 40%-89% on subsequent screenings (Cochrane Database Syst Rev 2009 Oct 7;(4):CD001877).

For more information, see the Mammography for breast cancer screening topic in DynaMed.

Wednesday, November 4, 2009

Elderberry Extract May Reduce Influenza Symptoms

One of my evidence-based medicine resources just sent out a weekly update discussing Elderberry extract as a natural remedy for influenza symptoms. You can google Elderberry extract but the two commonly marketed forms are Sambucol and ViraBloc are avialable locally. You can find ViraBloc at GNC, online. I searched at Wal-mart and Walgreens and neither sell it online. The Sambucol can be found online at Walgreens and CVS. CVS online reports that it's in stock at CVS on Daisey Mountain.
Again, during influenza season, it's most important to be seen in a timely manner, especially with H1N1 or if you have any chronic medical problems. Elderberry extract is something that may help improve symptoms after having influenza. I wouldn't use this as an exclusive therapy for influenza.
Pilot Clinical Study on a Proprietary Elderberry Extract: Efficacy in Addressing Influenza Symptoms. Fan-kun Kong, PhD.

Free Influenza information

Bryan Glick, DO

Sunday, November 1, 2009

What's the purpose of those package inserts that come attached to your medications?

Medication package inserts, or as I like to call them, 1001 reasons to not take this medicine, are informational documents included with all medications, prescription and OTC (over-the-counter) medications.

The package insert follows a standard outline of information provided: pharmacology, indications, off-label uses, contraindications, warnings, precautions, adverse reactions, abuse and dependence, over dosage, dose and administration, manufactured forms and recommended storage.

Typically a patient will present to the office with a myriad of complaints, for example, a patient with anxiety and panic attack. These patients will have a plethora of complaints and serious concern that "something bad is going to happen." Complaints commonly made by anxious patients include but are not limited to the following: impending doom, chest pain, shortness of breath, numbness in the fingers, dizziness, fatigue, poor sleep, thoughts racing, rapid heart rate, irregular heart rate, upset stomach, memory problems, etc. Many anxious patients will present with this many complaints and additional ones that they fixate on and really want to know what is causing of all of this. That being said, the patient and I have a meaningful conversation about what is most concerning to the patient and what treatment strategy they interested in pursuing.

I feel that stuffing an evidenced-based treatment regime down the throat of a patient who is not ready for that therapy is only delaying treatment and ultimately destroying credibility between myself and the patient. Some patients are very motivated and want some reassurance and then would like to make an effort to fix the problem with little or no medications. Other patients are wholly in the grip of anxieties hand. For these patients, very good medications with rather minimal side effects and very good evidence-based efficacy exist. With either patient, the question is, do the benefits of the therapy out weight the risks?

The office visit is concluded and those patients who chose a medication, take their prescription to their local pharmacy to be filled. Upon pick-up and purchase of the medicine, attached is the package insert to which I refer.

Many patients, especially those with anxiety, are by far the biggest population of people who read these documents. To be honest, I don't think I have every read one.

Now here's where the problem exists for me as a physician. The patient and I have discussed the symptoms, the diagnosis, the medications and the risks and benefits and in one fell swoop many of these anxious patients will actually pay for the medicine but will decide to not take the medicine.

I see the patient at a follow-up visit with many of the same complaints and I ask, "How is the medication we started last time working?" and the patient says, "I didn't take it."
From a physician perspective, this is very frustrating. I have learned to anticipate this scenario and play devils advocate in an attempt to prepare the patient for the package insert.

I have patients call me days later and ask, "Is this new medication going to interact with the other medications that I'm taking?" To ease the mind of my patients and the population as a whole, I have an electronic medical record (EMR) which will not let me prescribe two medications that interact, in some way, without a warning and having to manually override the system. Do all doctors have EMRs? The answer is no, but the federal government is mandating that all medical records be paperless by 2012.

These package inserts have generated a lot of calls to my office regarding certain risks of taking this medication. I have to remind the patient of the original symptom complex they presented with and asking for a solution. Medications are relatively safe and do a good job at improving quality of life for the most part. While some people may have an opinion about the FDA, the bottom line is, they do a reasonable job and provide over site for an industry that is constantly inventing new products. The vitamin industry, by comparison, doesn't have any oversight, nor do they provide package inserts. Vitamins can be just as risky if not more risky than traditional medicines because of their lack of regulation.

As it relates to anxiety, I recently was directed to a website by a patient for a new anxiety medication. Touts itself as relieving your stress, no prescription required, asserts you can be stress free if you take these pills. The website was very well done, soothing colors, beautiful imagery and then at the bottom of the site was the price, $24.99 for 1 month. That's where I about lost it. $24.99, are you kidding me? This company is probably making money hand over fist with absolutely zero regulations on the claims that it makes. By the way, the bottle was filled with a mix of B vitamins. My medication, on the other hand, has many double-blinded randomized controlled trials showing almost proven efficacy and costs only $4 for 1 month at Wal-mart.

The bottom line is that these package inserts are medical-legal documents that absolve any and all persons associated with this medication, except the prescriber, from legal responsibility.

I wish the package inserts would have at the top of the sheet in bold letters "NOT TAKING THIS MEDICINE WILL ALMOST GUARANTEE YOUR SYMPTOMS TO CONTINUE TO WORSEN." Maybe that's too harsh, but the sentiment is real. A patient had a complaint bad enough or persisted long enough that they presented to a doctors office for a solution. A solution was given and at just that critical point before the patient administered the medication, the package insert reared its ugly head in an effort to terminate or delay therapy.

My advice is, take the package insert with a grain of salt, along with your pill as prescribed by your doctor. Remember, this perspective isn't about getting patients to take pills but rather trying to improve treatment outcomes in those patients who asked for a pill to fix their problem.

Info about package inserts.

Bryan Glick, DO

Friday, October 23, 2009

H1N1, seasonal FLU and YOU!

Every day I see and get calls from patients that have questions about influenza, H1N1 as well as the vaccine.

Do you have both vaccines?
I want the flu but is the H1N1 safe?
Do you do testing for the flu?
A family member has cancer on chemo, can we get the nasal vaccination?
Are people really dying from the flu?

In terms of supply, this has been rather confusing. We pre-booked with our distributor for 100 doses. A couple of weeks ago the distributor told us that we will only be getting 10 total doses. They couldn't tell us whether or not we would get the rest of our doses anytime during the season. Early in the season we did enroll through the CDC to get H1N1 vaccine and ordered 200 doses. At this point we still don't know when they will be shipped. They said we will get an email stating it has shipped and doses should arrive shortly there-after. Obviously, the larger providers who purchase in the hundreds of thousands of doses will get priority over someone like me who orders only 100 or 200. At this time, the CDC is not reporting a shortage of vaccines. I believe, the seasonal flu vaccine production has been slowed or halted and now they are working on H1N1 production. Either way we have distributed our 10 doses to patients on a list and I myself went to Wal-mart to get my vaccination.

H1N1 vaccine safety. H1N1 is no more dangerous than the seasonal flu vaccine. Yes, in the past there have been problems with a rare neurological disease like Guillane-Barre and those patients allergic to eggs associated with vaccination. If you have ever had the seasonal flu vaccine, H1N1 is no different except for the viral particle used to provide the immunity. It's like playing music on a CD player. Every CD you listen to works the same way in your CD player, but if you change the CD you hear a different song. Every year the CDC is guessing at what strain of the viruses will be most prevalent in the upcoming season and they change the CD and make a different vaccine. The most common side effects are muscle soreness and redness at the injection site. Remember, there are risks to everything in life and you must weigh the risks against the benefits and for certain populations it's a "no brainer" being vaccinated. Key people who should get vaccinated are the following: Pregnant women, those who live with a child <6months old.

Dynamed free influenza information.

Bryan Glick, DO

Thursday, October 22, 2009

A Doctors Insight on Stress and Anxiety

I see more and more patients with stress and anxiety, especially in this economic environment. Many patients present with a myriad of symptoms that usually do not correlate to one specific illness other than "stress induced anxiety" or in doctor speak, "acute stress reaction NOS." The most difficult part for myself is that I see all patients with anxiety individually and while the patient is rightly concerned, their complaints are so strikingly similar to other patients with anxiety, that at times I think, "Is it Groundhog Day?" The fear, concern and pain that they feel is real but they don't realize that it's manifested by months if not years of stress. In my practice, I have the luxury to spend at least 30 minutes with each patient to really understand their concerns, the type of treatment that they would like and the barriers that will prohibit them from initiating treatment. That being said, I still think this disease is under diagnosed and under treated. That does not mean that every patient with anxiety needs medication. I try my best to treat the patient on terms that are acceptable to them. I have found that imposing a treatment regime on any patient for any illness leads to less successful treatment courses and greater follow-up.

What can you do to treat your anxiety?
First and foremost, how is your sleep? If you can't get to sleep, thoughts racing, noises bother you, room isn't dark and cool, watching TV, waking many times through the night, or waking up early without an alarm, these are all signs that your sleep is poor. We build our day on a foundation of sleep. A good nights sleep is the only way you will have the best chance of having a good day and dealing with stress and anxiety in a more purposeful way.

Next, you have to exercise and I don't mean to lose weight. I'm talking like 15-20 minutes everyday with your heart rate over 100. This will naturally increase your serotonin levels (same as anti-depressants) which will improve your mood and your ability to handle the stress of the day. In turn, this will help you sleep better which will in turn help you handle your stress the next day. Do you get my drift?

Lastly, work on prioritization, time management and perception in your world. What do I mean by that? I mean, we all have things that must get done, need to get done and we want to get done, but you can't do that everyday. We as Americans spread ourselves so thin that we never let our bodies rest and recharge. Do you know that Americans take less vacation annually than any other country in the world and have a higher rate of heart attacks and obesity. Why do you think that is? 100 years ago if you got sick, yes you could have died from infection or trauma, but the vast majority of illnesses resolved on their own. This is the bodies ability to heal itself. There was no such things as minute clinics or urgent care. The reason why more and more patients are presenting to doctors, urgent cares, hospitals etc it multi factorial but you have to admit that when the doctor recommends rest and time off work, nobody listens. So, with this in mind, prioritize you day within reason and manage your time better, not to be more efficient or to make more money but FOR YOUR HEALTH! Think about this, when you watch your favorite sports team playing a game and they win, you're happy, and win they lose, you're sad. How is that possible? Those feelings are self imposed. You have placed that perception on yourself that since your team lost, your in a bad mood. Is it possible that you imposed undue stress on yourself at home or at work or in relationships? I think we all do it, myself included. It's not very hard to see that stress begets stress and fatigue begets fatigue. What can't optimism beget optimism and energy beget energy?

In conclusion, we all have stress and anxiety. The question is how do you deal with it and how does it end up dealing with you? If you have had longstanding anxiety, you may appropriately need medications for several months to reverse the chemical nature your brain. There are things you can do for yourself without medication like getting better sleep, exercise and adjusting the way to react to your world.

In this economic climate, when you need to be your best to keep your job and your house, you can't afford to run yourself down. Make time for yourself and HEAL THY SELF.

Just some thoughts from the other side of the exam table.

Bryan Glick, DO

Thursday, October 15, 2009

Prediction Rule Identifies Low Risk Children after Minor Head Trauma

This email came to me from Dynamed which is an evidence-based medicine resource which gives good information about avoiding unnecessary radiation in a child with a bump on the head.
At Health Quest Family Medicine we try to take the conservative approach when treating children and adults.

Computed tomography (CT) is often performed on children with head trauma to diagnose clinically important traumatic brain injuries. Attempts have been made to develop criteria that might safely avoid unnecessary procedures. The Pediatric Emergency Care Applied Research Network study (PECARN) has now developed a prediction rule that identifies children at very low risk of clinically important injury for whom CT imaging may be avoided (level 1 [likely reliable] evidence). The derivation and validation cohorts included 42,412 children 2 years old meeting all of the following criteria: normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache. CT can be withheld in children hematoma except frontal, loss of consciousness 0-5 seconds, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents. The rule had sensitivity of 97%-100%, specificity of 54%-60%, and negative predictive value of 99%-100% (Lancet 2009 Oct 3;374(9696):1160).

For more information, see the Decision rules for computed tomography in head injury in children topic in DynaMed.

Health Savings Accounts in Arizona

Health Savings Account (HSA) allows patients to put aside part of their income in an account to be spent on medical expenses. It is not taxed like regular income and can be spent on drug store purchases, prescription medications, eye care, dental visits and doctor’s care, including at Health Quest.