Monday, August 22, 2011

The past matters when it comes to heart disease

Many people think that exercising is important when it comes to protecting your heart. They are right. However, exercise is not a magical cure for heart disease. People who exercise can still have heart disease. Unfortunately, this is a fact that many patients like to cite whenever they try to justify their unwillingness to comply to prescribed exercise.

Marathon runners can suffer from a heart attack, but that does not mean that exercise is useless. In fact, those unfortunate marathon runners would most likely have had their heart attacks much sooner if they were not exercising regularly. Regular exercise also results in improving your cardiac reserve, meaning if you survive a heart attack your heart will continue to function more effectively than it would if had you not been exercising regularly.

One reason active people still suffer from heart disease is that family and personal history still have a major role in heart health. If you come from a family where your parents and grand parents have all had heart attacks by the time they were 50, you are automatically at an increased risk for heart disease...even if you exercise every day. Again, exercise is still beneficial to your cardiovascular system, but it will not necessarily stop you from ever getting the heart attack that your genetics has preordained for you. Personal history is important too because if you have been significantly overweight from the time you were 5 until you were 35, you are still at risk for heart disease even if you suddenly train your way up to running marathons. Those 30 years of unhealthy living may have resulted in atherosclerotic plaques forming in your blood vessels that can rupture to cause a heart attack in your future and, unfortunately, they do not just suddenly disappear if you decide to become more active.

Heart disease is complex and there are many different factors that can put you at risk for a cardiovascular event. The point I am trying to make here is that exercising within reasonable limits will almost always decrease your risk for a cardiac event; however, exercising cannot guarantee that your heart will not fail you. So please, do not decide to ignore your doctor's request for you to be more active because you read about a man who had a heart attack while going for a jog. Instead, just mention your concerns and keep asking questions until your physician gives you an explanation that satisfies you.

Sunday, August 21, 2011

Treatments for balding

The medical term for "male pattern baldness" is androgenetic allopecia. It is the most common type of hair loss and, colloquial name aside, it can affect both men and women. In men, androgenetic allopecia starts with balding on the crown of the head and makes an "M" pattern along the frontal hair line. In women, the hair loss is more generalized and diffuse, but the frontal hair line is usually spared.

Why does hair loss happen? The current theory describing the pathogenesis of androgenetic allopecia attributes hair loss to dihydrotestosterone receptors on hair follicles. When activated by dihydrotestosterone, these receptors cause the hair follicle to shrink and eventually the hair becomes too thin to pierce through the scalp, resulting in apparent hair loss. One enzyme involved in this pathogenesis is alpha-5-reductase, which converts testosterone and other androgens to dihydrotestosterone.

How do we treat androgenetic allopecia? Two of the most popular treatments, that are supported by research and do not involve surgery, are using rogaine (topical minoxidil) and propecia (oral finasteride).

Minoxidil is nice because it is a topical solution, meaning you spread it over your scalp and very little of it gets absorbed by the rest of your body. Unfortunately, we aren't exactly sure how minoxidil actually works; however, studies do support that it does actually restore hair growth in both men and women. Minoxidil's most common side effect is causing a contact dermatitis.

Finasteride is taken in pill form and works by inhibiting alpha-5-reductase, which reduces the amount of testosterone that is converted to dihydrotestosterone. Studies have shown that finasteride works at restoring hair growth in men and that it is significantly better than 2% concentrations of minoxidil; however, finasteride does not appear to help women with androgenetic allopecia. Rare, but concerning, side effects of finasteride include decreased libido and ejaculatory or erectile dysfunction. Health Canada recently released a statment about finasteride being associated with rare cases of male breast cancer. However, evidence suggests that all of these side effects are much more common in the 5mg formulation of finasteride, which is used to treat prostate disease. Androgenetic allopecia is usually treated with 1mg doses.

As with every treatment in medicine, there are obvious risks and side effects with any treatment, even for more cosmetic issues like androgenetic allopecia. We also do not have a lot of data regarding the long term affects for using the two therapies I discussed in this post. So make sure you take the time to assess how much risk you are willing to take to treat your hair loss before you begin taking either finasteride or minoxidil.

UpToDate has a great article on androgenetic allopecia, which was my major resource for this post.

Tuesday, July 19, 2011

How do you stop the elderly from falling? Diet and exercise

If you are over 65 years old, one of the most dangerous things that can happen in your world is a fall. Thousands of people die every year in North America from the repercussions of falling. Worse than death sometimes, falls can lead to significant reduction in quality of life. Elderly people who were independent and living on their own can be bed bound and completely dependent on assistance to do everything from shopping and cooking to eating and toileting.

The actual act of falling is rarely fatal for seniors. Obviously, if a person falls from the roof of their house, they could break their neck and die, but very few seniors are running around on roof tops. Death from a fall is usually secondary to the comorbidities caused by the fall. For example, an all too common way for an elderly person to die is to fall and break their hip. Their hip may be surgically repaired, but post-operatively their mobility has been decreased and they lie in bed all day. Lying in bed causes parts of their lung to collapse on themselves and become an incubator for bacteria. Then they develop a pneumonia that they cannot fight off and their weakened body succumbs to this series of insults hurled against it.

There are a number of ways to protect elderly people who fall, including hip protectors which cushion the hip from the force of the fall. Unfortunately, these are not the most stylish, comfortable, or even effective methods to protect seniors. The best protection is prevention. An article in the globe and mail discusses how a good diet and adequate exercise are fall prevention and protection methods.

I know that doctors and health media always push improved diet and exercise as the solution to every problems, but it really makes sense here. Seniors who exercise will have an increased range of motion, stronger stabilizing muscles, thicker bones, and better balance (I think the better balance is primarily due to the strong stabilizing muscles). This means that they will be less likely to fall. If they do fall, they will be more flexible and have stronger bones, which means they will be able to escape the fall with fewer torn muscles and broken bones.

Diet is also important because seniors are no longer as effective at getting or keeping nutrients from their food. Calcium and vitamin D are particularly important because they are essential nutrients in the building, strengthening, and repair of bones. Again, a healthy diet leads to a healthy body and that can better prevent falls and injury.

The Globe and Mail will be discussing fall prevention and protection in further detail. I suggest having a read through this series because stopping the falls and the injuries they can cause will significantly increase both the quantity and quality of the lives of any elderly family you have.

Sunday, July 17, 2011

Technology: Information technology and the informed patient

As technology continues to advance many facets of our lives, patients will become more knowledgable about and have better access to their health information. This is already very evident in multiple patient interactions I have every day.

Often when I meet with a patient, particularly a computer literate patient, they have already googled their symptoms and they have their own provisional diagnosis. I have even been told which lab tests I should order. There are obviously both benefits and drawbacks to improved patient access to health information.

First and foremost, I love having informed patients. Caring enough to look up symptoms on the internet is correlated with patients being motivated to actually get better. The apathetic, deflated patients who aren't interested in taking an active role in improving their own health are notoriously difficult to treat because even if I develop an amazing therapeutic plan for them, they often do not care to follow it. These patients need two treatment plans. The therapeutic plan for the disease and the motivational plan to get them interested in following through with the therapeutic plan.

Second, patients who have researched their illness have often learned about the physiology surrounding their disease and treatment. Obviously, it is easier to teach someone about their disease if they have done their homework.

Third, these patients have often studied the different available treatment options and reflected on their illness giving them a better idea about what kind of treatment they want and what they are willing to sacrifice to get better.

However, patient access to health information over the internet is not always positive. For instance, patients can come to their own diagnoses for their symptoms because they read something from "Dr. Google". I had a patient who knew she had endometrial cancer because she had uterine bleeding after menopause. Now, endometrial cancer is certainly something that needs to be ruled out when a patient has postmenopausal uterine bleeding; however, there are many more common, benign diseases that cause postmenopausal uterine bleeding that should be considered too. These patients are often fixed in their belief that they have a serious disease and it can be very difficult to prove to them that they have a more benign illness.

Patients may also decide they know which test needs to be ordered because they read an internet post about a person who claims that their disease was misdiagnosed until some doctor ran the correct (but rarely indicated) test. For example, I had a patient who was suffering from jaundice, abnormal liver enzymes, and abdominal pain who admitted to heavy drinking. Unfortunately, he would not accept a diagnosis of alcoholic liver disease. Instead, he insisted that he first get tested for alpha-1 antitrypsin deficiency with a liver biopsy because he read about a patient online who had similar symptoms and was misdiagnosed with other diseases, including alcoholic liver disease, until one doctor ordered a liver biopsy. This patient would not accept that we can look at alpha-1 antitrypsin levels in his blood to screen for the disease, he wanted the gold standard test, which is the biopsy. Any surgical procedure has associated risks that only make them worthwhile when they are the best option and for a patient who has new onset hepatitis and a known history of alcoholism... a liver biopsy is notthe best or safest first option.

Of course, overall I think it is better to have informed patients than ignorant patients. The benefits of the internet educating people about their health far outweigh the problems. However, I would prefer if patient used their internet research to question and challenge doctors and not assume physician incompetence when your doctor presents a differing view than John Doe does in his blog.

Monday, May 9, 2011

Treating a patella dislocation

Patellar dislocation is a relatively uncommon injury that is normally seen in athletes and adolescent girls, likely due to different mechanisms of injury. It usually occurs in high impact collisions that involve twisting, but it can happen in any scenario involving contraction of the quadriceps muscle.

Once a dislocation has occurred, the patient's patella is usually displaced towards the outside of the leg and the patient's leg is usually moderately flexed at the knee. The patients are usually in a reasonable amount of pain at this point. The dislocation is reduced, or made normal again, by getting the patient to relax their leg muscles (easier said than done), straightening their leg, and gently slipping the patella back into the right place.

Patellar dislocation can be associated with popliteal artery damage, MCL and ACL tears, and fracture of the patella. A physician must perform a neurovascular exam and x-ray the knee to assess for popliteal artery damage and patellar fracture. With the exception of a very obvious MCL injury, it is unlikely that a physician will be able to assess MCL/ACL damage because the swelling from the dislocation makes it difficult to examine the ligaments. The MCL and ACL can be reassessed when the swelling has reduced, which can take 3-4 weeks.

Patellar dislocation is rarely treated surgically. However, there are multiple conservative options available. This article mentions three different conservative treatments. A plaster cast, a posterior splint, and patellar bandage/brace.

Plaster cast
A plaster cast ensures that the patient's leg does not bend. It will definitely keep the leg straight.

Posterior splint
A posterior splint is a foam or cloth object that patients can wrap around their leg. It has a metal bar running through the material that should be oriented so it runs up and down along the back of the patient's knee. This keeps the leg straight, like the plaster cast. However, it has more give allowing the patient to flex his knee slightly. Also, the patient can take the posterior splint off if he wants to try bending their knee.

Patellar bandage/brace
A patellar bandage is a cloth that wraps around the knee. A patellar brace is similar to a bandage, but may have additional support.

The study found that patients had the best results if they used a posterior splint for 2-3 weeks after their dislocation was reduced. If they used the patellar bandage/brace, they were more likely to have a subsequent knee dislocation later. If they used the plaster cast, they were more likely to have limitations to the range of motion of their knee.

However, there were some serious limitations to this study. First and foremost, this was not a randomized control trial. Physicians would decide which patient received which treatment. This selection process is incredibly prone to bias. For instance, one physician may think that all of the older patients need additional support and decide that they all receive plaster casts. A good study compares oranges to oranges and if you have a significant selection bias, this can't be done. Also, the sample size is too small. A study with only 100 patients is not large enough to draw any large scale conclusions. Especially when there is a disporportionate number of patients in each therapeutic group. For instance, plaster casting alone had 60 patients, while 17 were put in posterior splints and 23 in patellar braces/bandages. Making conclusions about posterior splints based on the results of 17 patients would be a mistake. The reality is that a larger, better designed study needs to be made, conducted, and analyzed before we can conclude how to best treat patellar dislocation.

An orthopedic surgeon told me that, in the end, they try to balance protection of the knee with loss in range of motion (I will explain why the loss in range of motion happens in an other post). So he makes treatment decisions based on the personality and activity level of his patients.

Sunday, April 24, 2011

Psychiatry as a Med Student

My psychiatry experience was well rounded and very different from any of my other clinical rotations. I experienced inpatient, outpatient, early child, and geriatric psychiatry.

In psychiatry, there is no physical exam. I did not need my stethescope. I found this weird.

Since there is no physical exam, history becomes even more important than it usually is. Thus, the history in an average psychiatry note was at least 2 or 3 times longer than an average internal note and 4.6 million times longer than the longest surgery note.

Outpatient psychiatry is the worst. Outpatient psychiatry is basically psychiatric clinics for patients who are sick enough to still need help, but healthy enough to be in their homes doing their day to day activities. Our government does not currently provide funding for patients to see psychologists or counsellors. This means that if a patient cannot afford to see a psychologist/counsellor, but needs someone to talk to and work through problems with, they will go to a psychiatrist, which is covered under our province's health plan. This is a problem because we already have a psychiatrist shortage in this province and their time could be better used managing more acutely ill psychiatric patients rather than providing counselling which can be provided by other mental health providers.

Inpatient psychiatric patients blow my mind. I found patients in acute psychosis to be fascinating. For those of us who are lucky enough to be free of psychosis, our minds are who we are. If we develop cancer, lose an arm, or have a heart attack, we understand that our bodies are failing us, but our mind is still ours. I think that the sense of self which stems from our mind is the basis upon which philosophers created the concept of a soul. When you meet a schizophrenic patient, who was previous healthy like anyone else...and their mind has failed them, it is terrifying. I still do not understand how a once rational person can honestly believe that a microchip has been implanted into his tongue so UFO's can eavesdrop on his conversations. If our minds can become this sick too...then what are we? What is our consciousness? A random set of electrochemical reactions? That doesn't make sense...does it? WTF.


So my thoughts on psychiatry as a med student:

1. Great lifestyle
2. Interesting potential for research
3. Deal with a unique set of illnesses

1. Very little medicine
2. Looked down upon by many other doctors
3. Long, long patient interviews

Psychiatry was interesting and I think I will be better able to deal with psychiatric comorbidities in the future, but I definitely will not become a psychiatrist.

Friday, April 22, 2011

Surgical education: A problem with resources

Most specialties are either surgical or medical specialties. Surgical specialties include general surgery, neurosurgery, thoracic surgery, etc. Medical specialties are everything else, like internal medicine, psychiatry, dermatology, etc. Some specialties like family medicine and emerg have a mix of both surgery and medicine. Surgical residencies are known as brutal 5-6 year experiences because of the long hours as well as the busy and frequent nights on call. These residencies are intense, in part, because surgery is a challenging skill for residents to develop.

Learning surgery from a book is much more difficult than learning medicine from a book. Both are best learned and remembered in the context of real patients (i.e. I am more likely to remember how to treat sepsis if I learn about it while managing a septic patient rather than only reading about it in a text book), which is the argument for why we need a residency after we complete medical school. However, if context isn't available, it is much easier to learn medicine form a text book. In fact, I think it is almost impossible to truly learn surgery without practicing it on an actual patient under the watchful eye of an attending.

Learning a hands on technical skill is a new challenge for most residents. Excelling in academics from grade school through undergrad and into medical school has made most residents very proficient at learning theory from a book. However, on average, we are much, much slower at picking up practical hands-on work.

Thus, a surgical education is significantly more resource intensive than a medical education. The limiting factor in the training of a future surgeon is most definitely operating room time. There is a surplus of patients that need surgery. There is a surplus of medical students who want to become surgeons. The resource that is scarce is operating time. With limited operating rooms, you can only hire a limited number of surgeons. A surgeon can only really teach one resident how to perform one type of surgery at any given time.

If a hospital has eight surgical residents, but only four operating rooms where surgeries are occurring on a given day. Then only half of the residents will be in the operating room learning how to perform surgery. Since surgery is already difficult to learn, the fact that they are not in the operating room every single day slows their education even more. Thus, they need to work long hours and have frequent overnight call shifts to maximize their opportunities to learn their trade.

Surgical residents would have a much better and more balanced experience if they were able to always be the first assist learning directly from a fully trained surgeon every day. Unfortunately, this is not an economically feasible possibility. This is particularly unfortunate because I think the lifestyle of a surgical resident scares away many talented medical students who may have the potential to become great surgeons.

Of course, in Canada, we currently have a surplus of surgeons graduating every year, so I doubt there is sufficient motivation to address this problem in the near future... Plus, most surgeons wear the challenging lifestyle of their residency as a badge of honour.