Sunday, February 27, 2011

Flu Activity, 2011 Week 7

As I predicted, the numbers are starting to go up. For the week ending February 19, 2011 Connecticut has climbed the ladder to 'moderate' activity. The bad weather may have kept people indoors; slightly warmer temperatures have gotten people out of their houses and allowed them to share their germs. Remember: meticulous handwashing!

The End to the Indignity?

Last month, a commentary in the Journal of Women’s Health, the official journal of the American Medical Women’s Association, argued that ‘routine’ pelvic examinations serve little purpose and may be the reason that many women avoid preventive care. Additionally, the authors postulate that overuse of the pelvic examination contributes to high health care costs without any compensatory health benefit.

Annual testing of women for cervical cancer has been routine in the United States for decades: an estimated 65 million women had a Pap test in 2005. To best assess the risk for cervical cancer, the Pap test should be performed in tandem with a screening test for human papillomavirus (HPV). The HPV test is less useful in women aged 21-29 and young women have the most to lose from aggressive evaluation and treatment - there is a substantial risk to their obstetrical future while the risk of cervical cancer is exceedingly small.

The pelvic examination is not helpful in detecting early ovarian cancer and screening for sexually transmitted diseases can be accomplished via a urine test or a self-administered vaginal swab test. Home tests for STD screening are available via the internet in the United Kingdom. As a result of ‘routine’ pelvic examinations, older women face unnecessary hysterectomies for ovarian cysts and fibroids that are without symptoms.

Women still need to have screening for cervical cancer, but the frequency of these examinations can be less than many patients expect. Of course, women with risk factors and abnormal test results may need more frequent follow-up. There is some data that women older than age 30 should be screened every five years until the 60’s; after that, only when symptoms suggest a problem.

The authors conclude, “eliminating unneeded annual pelvic examinations will please many women and simultaneously free their physicians to provide other more needed care.”

Journal of Women's Health. January 2011, 20(1): 5-10.

Sunday, February 20, 2011

Flu Activity, 2011 Week 6

I have seen two cases of flu this week, but the levels of influenza-like illness (ILI) are still low for Connecticut.
During week 6, the following ILI activity levels were experienced:
                Twenty states (Alabama, Arkansas, Colorado, Georgia, Idaho, Indiana, Louisiana, Maryland, Missouri, New Jersey, New Mexico, New York, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, and West Virginia) experienced high ILI activity.
                Nine states (California, Florida, Hawaii, Illinois, Kansas, Kentucky, Mississippi, Pennsylvania, and Wyoming) experienced moderate ILI activity.
                New York City and five states (Arizona, Massachusetts, Nebraska, Nevada, and Wisconsin) experienced low ILI activity.
Minimal ILI activity was experienced by the District of Columbia and 16 states (Alaska, Connecticut, Delaware, Iowa, Maine, Michigan, Minnesota, Montana, New Hampshire, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Vermont, and Washington).

Less Can Be More

My patients will be interested in two studies published this week, both of which support the adage that less is more. The first, from the American Journal of Surgery, indicates that a needle biopsy should be the first diagnostic step to evaluate an abnormal mammogram instead of a more invasive surgical procedure. The other, in a position paper from The American College of Physicians, indicates that imaging studies are too frequently used to evaluate lower back pain.

An abnormal mammogram causes great concern. The good news is that in 80% of cases, there is no cancer found. When there is a malignancy, surgery is an essential part of the treatment but should not be the first line of diagnosis. A surgical biopsy means a trip to the operating room – an expensive, stressful experience. There is an increased risk of infection and bleeding. The resultant scar may be unattractive and the distortion of the underlying breast architecture makes subsequent mammograms more difficult to read.

Routinely ordering X-rays, CT scans or MRI scans for low back pain drives up health care costs and does not resolve the problem. Imaging studies are indicated if the pain worsens despite initial care or if there are signs of nerve damage or a serious medical condition (weight loss, fever or loss of sensation or muscle power in the legs). X-rays and CT scans expose patients to radiation, which over time may increase the risk of cancer.

In general, I will only order a blood test or a diagnostic procedure if we are prepared to act on the information. Curiosity is not reason enough. I particularly disdain  “shotgun medicine:” ordering every possible test to see what comes back positive. It is intellectually sloppy, a waste of someone’s money and causes unneeded stress to the patient.

More care does not mean better care. Unfortunately, it can be easier to overtreat a patient than to explain why any test or procedure has no benefit. We must always remember: primum non nocere, first do no harm. 

Sunday, February 13, 2011

Flu Activity, 2011 Week 5

Just as the bad weather patterns marched across the country, we are seeing influenza approaching the northeast. This week there is high activity in New York State, New Jersey and Pennsylvania. Influenza-like illness remains minimal in Connecticut. The rate for New York City is low this week, as it is for Massachusetts. 

Stress Fractures

Everyone is anxiously anticipating the milder weather this week – maybe some of the snow will melt! As people think about resuming their exercise regimens, they should be mindful of an under-recognized risk: stress fractures. Stress fractures are the result of excessive stress on the bone, resulting in microfractures with insufficient time for repair, leading to bone stress reaction and eventually fracture. Persons who participate in repetitive, high-intensity training are at risk for stress fractures, such as runners who average more than 25 miles per week. Women are at higher risk (especially if there is an eating disorder or osteoporosis). Other risk factors include consuming more than ten alcoholic beverages per week, smoking, sudden increase in physical activity and low levels of vitamin D.

It can be difficult to make a diagnosis of stress fracture. Most patients (81%) will have pain with walking, many will have swelling at the site of injury (18-44%) and almost all will have tenderness at the site of the fracture. It may take more than one imaging study to clinch the diagnosis.

Initial treatment is reducing activity to pain-free functioning. Healing time varies from four to twelve weeks (or longer) from the time that activity is restricted. Acetaminophen (Tylenol) may be used for pain relief; there is some animal data that indicates NSAID’s such as ibuprofen (Motrin) and naproxen (Aleve) may inhibit healing. Physical therapy and cross-training will help maintain flexibility, strength and cardiovascular fitness.

Prevention of stress fractures has been studied in military personnel. Shock-absorbing shoes inserts have been shown to be effective and calcium and vitamin D supplementation may play a role in prevention of stress fractures. Adequate rest is important, but there are currently no definitive recommendations as how much rest is needed. Once again, it appears that moderation is the key: a healthy diet with a gradual increase in exercise while cutting back on alcohol and smoking.

Am Fam Physician. 2011;83(1):39-46.

Sunday, February 6, 2011

Flu Activity, 2011 Week 4

Not much to report - influenza-like illness activity is still minimal in Connecticut. Activity is low in New York City and New York State. However, activity is high in Pennsylvania and New Jersey. We in Connecticut have been lucky so far this season. It's not too late to get a flu shot.

Saturday, February 5, 2011

No Free Lunch?

The new calendar year brought new and revised insurance plans to many people. Now that we are several weeks in, I have noted some unsettling trends.

For the first time in several years, many co-pays have gone down. Additionally, federal law has eliminated cost-sharing for preventive health services. Patients are delighted with these changes.  But as we know, there is no free lunch. In return for what seems to a lower out- of-pocket expenditure, the insurance companies have increased premiums. It’s a rare company that doesn’t pass on some of the burden of these increases to the employee – a increased $100 monthly deduction from a paycheck doesn’t make a $10 ‘discount’ for a medical visit co-pay look that great.

This year I am finding more constraints on prescription medications: not only are certain medications being denied, but also I am finding limits on how many pills are allowed. There is not always a substitute medication. Patients have the choice of paying out of pocket and hoping to win an insurance denial appeal, or doing without.

As insurance companies restrict payment for true medical services, the glossy promotional brochures tout the added value in their policies. Upon close inspection, the discount offered for eyeglasses is no better than what is printed in the newspaper supplement. Offering a promotion to sign up with a weight loss franchise that requires purchase of private brand meals but not covering visits to a registered dietician is troublesome.

Patients are stuck. The reality is that the true purchasers of medical services are the large employers. Sometimes they just don’t know what they have bought – it sounded good at the time. 

Tuesday, February 1, 2011

Snow: More Bad News

It’s an unfortunate but predictable event: a father of school-age children dies from a heart attack while shoveling snow. These are typically not terribly out of shape men in their mid-forties to mid-fifties, who venture out to clear the walkway or tidy up the mounds left by the plow, not realizing the terrible danger.

There are a number of reasons that shoveling snow leads to sudden cardiac events. The most obvious is that snow is heavy and there is a lot of it. It doesn’t take long for the heart rate to double and the demand by the large muscles for more oxygen-rich blood increases the force of each heartbeat. This places a huge burden on the coronary arteries to deliver more blood to the laboring heart muscle. Even a small narrowing caused by plaque can leave a section of the heart muscle under-perfused. If one is lucky, this will lead to chest pain (angina) and the shoveler will stop and seek medical attention. Breathing in the cold air through the mouth (which is usual when working hard) can lead to spasm of coronary arteries (the heart is right behind the windpipe). If the spasm occurs in an already narrow part of the artery, the heart muscle might be completely without blood. A few minutes without nourishment will lead to death of heart muscle (myocardial infarction). Oxygen-starved heart muscle is irritable and may provoke an irregular beat. Cardiac arrhythmia can lead to death faster than an infarction, since the heart is unable to pump blood (ventricular fibrillation or ventricular tachycardia).

Hire a kid to shovel the snow! It’s good for the economy and may save a life.

Flu Activity, 2011 Week 3

Influenza-like illness remains merely background noise in our area. Activity level is minimal for Connecticut and low for New York City. Eastern Pennsylvania is reporting widespread activity with outbreaks in more than half the reporting districts; early indicators are that activity is about to spike higher in Connecticut and New York City.