Archive for the 'A Country Doctor Reads' Category

A Country Doctor Reads: April 20, 2019

Suppressing The Inward Eye Roll

The Canadian RuralMed listserv, which I was invited to join, had a comment today, inspired by my post “If You Are a Doctor, Act Like One“, Dr. Yogi Sehgal reflected on how seemingly trivial concerns can be very appropriate if you try to understand the context:

“[Dr. Duvefelt’s] post reminds of one of my little practice tips that I have learned over the years to reduce frustration in the ER.

When a patient presents to the ER or the office with a very minor complaint, and the nurse says to you, “OMG, I can’t believe they came to the ER/office with this,” followed by an eyeroll, it’s easy to get jaded or cynical. I find the simple question, “Was there something specific you were worried about?” or “What was it about this that worried you?” is the gist of the “FIFE” questions that we were taught in medical school and do so poorly except on exams. It opens up the discussion about what the real issue is and gives you a chance to educate (doctor, from the Latin “docere”, meaning “to teach”) and feel less cynical or jaded.

Real cases recently:

Patient with a tiny little scratch on their finger which probably doesn’t need a bandaid. “I have a cut I’d like to get checked out.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient: “My grandmother died of tetanus from a minor cut like this, my mother died of sepsis from blood infection from a wound like this, I’m worried I’m going to die of this too.”

You: (Aha, now I get it!) “Ok, it sounds like the issue is not your finger so much but your family history. When was your last Td? Screen for anxiety… etc.”

Teenage patient comes to ER (with Mom) with a sore foot that comes and goes for the past week, not an athlete, pain-free now: “I sometimes have a sore foot.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient and Mom: “We were worried it had something to do with her congenital hip dysplasia.”

You (Aha, now I get it!): “Ok, sounds like we need to know a bit more about the hip and mechanics of what’s going on.” (Turns out that indeed it likely was partly related to her hip in this case, and she needed to do some PT at home which she had not been doing.)”

(yogi sehgal)


Sore knee? Maybe You Have a Fabella

The BBC has an interesting little piece about a small extra (sesamoid) bone that seems to be more common now than even just a hundred years ago, even though other sesamoid bones elsewhere in the body are not becoming more common.

The fabella (“little bean” in Latin) can be the cause of knee pain and perineal nerve palsy.

“Between 1918 and 2018, reports of the fabella bone’s existence in the knee increased to the extent that it is now thought to be three times as common as 100 years ago.
The scientists’ analysis showed that in 1918, fabellae were present in 11% of the world population, and by 2018, they were present in 39%.”

The BBC originally picked this item up from a Wiley publication

“Hou (2016) recently investigated the effects of the fabella on posterolateral pain and palsy of common peroneal nerve following total knee arthroplasty. During trials, fabellae were excised from some patients but left in others. Post‐surgery, posterolateral pain and palsy of common peroneal nerve were only observed in patients who still had fabellae. Accordingly, Hou recommended removing the fabella when knee replacement surgery is performed.”


Vaccination is Not Really Just a Personal Decision: People Don’t Understand Herd Immunity -NEJM

I may survive an infectious disease just fine, but what about vulnerable people I come in contact with? The less of it there is going around, the less risk for morbidity and mortality for everyone.

The New England Journal of Medicine editorialized about this:

Exposure to measles in the community certainly represents a danger to high-risk persons during a local outbreak; however, nosocomial transmission may pose an even greater threat and has been reported throughout the world. For example, during a measles outbreak in Shanghai in 2015, a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%.5 When the umbrella of herd immunity is compromised, such populations are highly vulnerable.
— Read on

A Country Doctor Reads: April 13, 2019

Vitamin D as Cancer Therapy? Insights From 2 New Trials – JAMA Network

All right, I’ve been less than enthusiastic, even downright acerbic, about the widespread interest in Vitamin D. I’ve written many times about it. Then I started taking Functional Medicine courses….

This is from this week’s JAMA:

It may be tempting to interpret the preliminary findings regarding recurrence- and progression-free survival as specific antineoplastic effects of vitamin D3 supplementation. However, higher vitamin D levels have been associated with substantially decreased mortality and morbidity among hospitalized patients with a range of nonneoplastic diseases as well as with cancer.14-16 Thus, the findings of the 2 trials may reflect relatively broad biological effects of vitamin D.

In summary, the SUNSHINE and AMATERASU clinical trials reported in this issue of JAMA provide new information regarding the potential use of vitamin D among patients with colorectal cancer and other luminal gastrointestinal malignancies. Confirmatory trials are needed to evaluate these preliminary findings, ideally with longer follow-up to obtain better estimates of effects on survival as well as biological measurements to clarify underlying mechanisms.

— Read on


Billion dollar Medicare Fraud depends on doctors signing papers without reading – The New York Times

In this day of electronic medical records, we still get a lot of paper to sign, and we really never have time to read much of it. Home Health nursing orders require a signature on every single spaced page, for example.

This week, the New York Times wrote about the billion dollar market for fraudulent prescriptions for a back braces etc. I get these often, always return faxed with the comment “MEDICARE FRAUD!”, and I also get prescriptions “needing” my signature for compounded enormously expensive pain creams.


Leonardo da Vinci – The Lancet

We may laugh or shrug at the Brits, but when it comes to their medical journals, I am always impressed by their depth, from both a humanistic and historical perspective. Last week’s The Lancet has a nice article about Leonardo da Vinci:

“It is a sobering thought”, said the satirist Tom Lehrer, “that when Mozart was my age he had been dead for 2 years”. Leonardo di ser Piero da Vinci lived almost twice as long as Wolfgang Amadeus Mozart, but his life and work provoke an even deeper sense of hopeless awe. Leonardo made three of the most influential and most parodied artworks in history—the Mona Lisa, The Last Supper, and his sketch of Vitruvian Man. Throughout his life, he kept notebooks, works of art in themselves, crammed with crisp observations and lists of questions from every field of life. No-one, wrote Giorgio Vasari in his gossipy biography of the Renaissance masters, was ever his peer in “vivacity, excellence, beauty and grace”. What can we do but throw up our hands and call him a genius?

More snippets from this wonderful article:

“the four universal conditions of man”—joy, weeping, fighting, and labour..

… he began the Mona Lisa and the Salvator Mundi, and became the subject of intense jealousy from the young Michelangelo…

True to form, he left behind a mess: unfinished paintings, flaking murals, and a heap of manuscripts that took centuries to sort—a fitting memorial for what the art historian Kenneth Clark called “the most relentlessly curious man in history”. But the “disciple of experience”, as he once signed himself, also left a humanist paradise in paint and ink, revealing the world as it might have wished to depict itself.


Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study – The BMJ

This population based, sibling controlled analysis showed a clear association between clinically confirmed stress related disorders and a higher subsequent risk of cardiovascular disease, particularly during the months after diagnosis of a stress related disorder, in the Swedish population. This association applies equally to men and women and is independent of familial factors, history of somatic/psychiatric diseases, and psychiatric comorbidities. These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.
— Read on


Writing the body – The Lancet

The Lancet offers free access to some of its articles by just signing up. This week has an interesting book review:

Ned Beauman argues for the utility of the appendix, arguing in favour of the theory that in less hygienic times it served as a reservoir for helpful bacteria, ready to repopulate our insides after infection had purged us. Appendicitis, he says, is the mark of an immune system “deranged by tedium”.
— Read on

A Country Doctor Reads: March 16, 2019

The Right Way to Help Colleagues Excel – Harvard Business Review

Having just completed annual provider reviews, this sobering and thought-provoking article in the Harvard business review caught my attention, partly because of how you could give better feedback but also because in the business world they apparently don’t have to stick to a formula or protocol like we are supposed to do in medicine. I guess they want people who can think for themselves??

”How to give people feedback is one of the hottest topics in business today. The arguments for radical candor and unfurnished and pervasive transparency have a swagger to them …… But at it best, this fetish with feedback is good only for correcting mistakes-in the rare cases where the right steps are known and can be evaluated objectively and at worst it’s toxic because what we want from our people-and from ourselves-it is not, for the most part tidy adherence to a procedure agreed-upon in advance or, for that matter, the ability to expose one another’s flaws. It’s that people contribute their own unique and growing talents to a common good, when that good is ever evolving, when we are, for all the right reasons, making it up as we go along. Feedback has nothing to offer to that.”


Beyond the Borderline – The Lancet Psychiatry

I had another Saturday wrap-up with my Behavioral Health Director last week, and I asked if he thought a mutual patient had Borderline Personality Disorder. He didn’t think so, because he doesn’t believe in it. I still can’t quite wrap my head around it, so I guess I don’t believe in it either. Looking for an update, I found this in The Lancet Psychiatry:

Borderline personality disorder is not so much a diagnosis as it is a liminal state. Individuals to whom the label applies exist between mental illness and mental health, between experiencing an acute condition and a chronic condition, and between being highly visible to clinicians, yet invisible to major epidemiological projects such as the Global Burden of Disease. The diagnostic criteria for personality disorder fall between the objective descriptions expected of medical manuals, and value judgements based on received opinion. DSM-5, for example, includes diagnostic criteria of inappropriate, intense anger. It is hard to conceptualise anger that is not intense in nature; and as artist, writer, and mental health trainer Rachel Rowan Olive asks, “Who decides when anger is appropriate?” The past few years have seen events such as the revelations regarding child abuse in the Catholic Church and the global #MeToo movement, which have given survivors of exploitation and injustice platforms with which to share their stories and experiences. Their anger would perhaps have been considered inappropriate and intense only a decade or so ago, by societies in denial about the existence and the extent of their problems. Despite these advances, it is still possible that people with a history of abuse might suffer twice: first from the abuse itself, and second from having their resulting emotional response pathologised.

A Country Doctor Reads: March 9, 2019

Ketamine, first synthesized in 1962, is in the news this week both for its antidepressant and its analgesic effects, again demonstrating the blurry line between Pain and Suffering.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

“Moreover, based on the available preliminary evidence, the magnitude of the antidepressant effects of ketamine appears to be more than double that of conventional antidepressants.[10]On the basis of these findings, a 2017 review described ketamine as the single most important advance in the treatment of depression in over 50 years.”

FDA Approves Ketamine Nasal Spray for Depression

The U.S. Food and Drug Administration today approved Spravato (esketamine) nasal spray, in conjunction with an oral antidepressant, for the treatment of depression in adults who have tried other antidepressant medicines but have not benefited from them (treatment-resistant depression). Because of the risk of serious adverse outcomes resulting from sedation and dissociation caused by Spravato administration, and the potential for abuse and misuse of the drug, it is only available through a restricted distribution system, under a Risk Evaluation and Mitigation Strategy (REMS).

Ketamine Reduces Opioid Need in Severely Injured Patients – Pain Medicine News

San Diego—The first randomized, double-blind, placebo-controlled trial of ketamine in patients with rib fractures has shown that low-dose ketamine infusions are a safe adjunct in the setting of treatment of acute traumatic pain

Weight Loss Cures Diabetes. Is Anybody Surprised? – The Lancet Diabetes & Endocrinology

I keep writing about my small victories in sometimes motivating overweight Type 2 Diabetics to give up particularly processed carbohydrates and thereby reversing and curing diabetes.

But if you read the manual, it is actually a flex fuel body. It isn’t metabolizing carbs properly, but it can still run on fat and protein, and believe it or not, we now know that diets that are low in carbs and higher in protein and at least what we call good fats, are good for weight loss, diabetes control, lipid lowering and heart risk reduction.

I tell my diabetic patients that I agree with the notion that a balanced diet is generally best, but that their diet so far has probably been unbalanced enough to stress their carbohydrate burning system. It is as if they have already had their lifetime supply of carbohydrates and they now need to correct that imbalance.

Now The Lancet is saying he same thing…

The DiRECT programme sustained emissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss.

It’s Not Burnout, It’s Moral Injury

All medical bloggers write about BURNOUT and I am no exception:

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

The Counterintuitive Concept of Burnout Skills

Here’s a video I saw via a Canadian Rural Medicine Listserv, renaming “Burnout” as “Moral Injury” and calling it “Victim Shaming

A Country Doctor Reads: March 2, 2019

Risk of dying from delayed treatment of UTI – BMJ

In the nursing home, we worry about complications from antibiotic use, like Clostridium Difficile colitis. It is now common practice not to start antibiotics, even with typical symptoms, until a culture confirms the diagnosis.

This week’s BMJ has a sobering review of that practice:

“Finally, 2.0% (6193/312 896) of the participants older than 65 years who presented to their GP with a UTI died within 60 days; 5.4% (1217/22 534) for no antibiotics, 2.8% (545/19 292) for deferred antibiotics, and 1.6% (4431/271 070) for immediate antibiotics (table 1). The NNH estimate for death within 60 days was lower with no antibiotics (NNH=27) than with deferred antibiotics (NNH=83), with a calculated risk relative to immediate antibiotics. The Kaplan-Meier curves showed a significant reduction of the 60 day survival for older adults prescribed no antibiotics or deferred antibiotics compared with those prescribed immediate antibiotics.”


Adverse Effects of Fluoroquinolones: Where Do We Stand? – NEJM Journal Watch

A long time ago a patient of mine ended up hospitalized from an interaction between levofloxacin and warfarin. I have seen a handful of cases of tendon pain from quinolones, but never a tendon rupture. I have seen a grown man tremble as he described the demonic nightmare he had after his first dose of levofloxacin. So I worry a lot about this class of antibiotic.

In Britain, there is talk of restricting GPs from prescribing quinolones; not only do we have tendon ruptures and psychiatric side effects to consider, we also have the recent FDA warning about vascular complications such as aortic rupture.

NEJM Journal Watch has a nuanced review of the dilemma of whether or not to prescribe quinolones:

“The risk for aortic rupture or dissection from quinolones is approximately 1 to 2 cases per 10,000 treatment courses…

…The new FDA warning clashes indirectly with Infectious Diseases Society of America community-acquired pneumonia (CAP) treatment guidelines, which suggest use of fluoroquinolones in high-risk patients with comorbid conditions and patients at risk for drug-resistant Streptococcus pneumoniae (Clin Infect Dis 2007; 44 Suppl 2:S27). These patients — who frequently are elderly and have hypertension or vascular disease — are precisely those for whom “health care professionals should avoid prescribing fluoroquinolone antibiotics,” according to the FDA warning. The rates of resistance of S. pneumoniaeto doxycycline and macrolides may be as high as 15% to 30%, whereas rates of resistance to quinolones remain at or below 1%. Therefore, if quinolones were abandoned for such patients, the number of patients receiving inadequate antimicrobial coverage would likely exceed the number of patients who would be spared aortic rupture. For example, assuming that one third of CAP cases are caused by S. pneumoniaeand that one quarter of these cases are resistant to nonquinolone therapy, about 8% of patients with CAP would receive inadequate treatment.”

A Country Doctor Reads: February 16, 2019

Find Nutrients Depleted by Medication – Nutrient Depletion Calculator –

I came across a cute website that lists common deficiencies associated with medications, for example B12, iron and many others from Nexium, esomeprazole:

— Read on

How Long Do Hip Replacements Last? -The Lancet

There is concern about hip replacements performed in middle aged adults. Will they wear out? The Lancet has an open access impressive review, which outlines the odds of failure over the remaining lifetime of 50-something patients:

“Moreover, these results are particularly important because of the growing number of younger, more active patients receiving hip replacements, as well as increasing population ageing and life expectancy.7,  8 In fact, lifetime risk of revision of total hip replacements for patients aged 50–54 years is estimated to be 29%, but only 5% in patients aged 70 years.9 Much of the increased risk of revision is due to component wear. The findings from Evans and colleagues’ study can therefore be used to more appropriately counsel patients”

A Country Doctor Reads: February 9, 2019

Feed a Cold, Don’t Starve It – Cell via The Atlantic

“Feed a fever, starve a cold”, the saying goes. But, unlike many old adages, this one is turning out to be dead wrong, literally.

A 2016 article in The Atlantic, number 3 under “Popular” on their website, quotes an article from the same year in Cell with a longer and less catchy title: “Opposing Effects of Fasting Metabolism on Tissue Tolerance in Bacterial and Viral Inflammation”.

The Atlantic staff writer James Hamblin, MD, explains, “Sometimes sugar causes inflammation. Sometimes it does the opposite.”

Researcher Ruslan Medzhitov conducted a series of distasteful experiments on mice with various infections, and found that mice with listeria, a bacterial infection, survived when they were refusing to eat and perished if they were force fed, but only if their diet was essentiallly sugar; they survived if they were fed fat and protein.

Mice with influenza fared better if they were force fed glucose than if they were allowed to refuse food.

The Cell article concludes: [In influenza infection,] “inhibition of glucose utilization is lethal.” Whereas glucose was “required for survival in models of viral inflammation, it was lethal in models of bacterial inflammation… Glucose Utilization Promotes Tissue Damage in Endotoxemia”.

And the article implies that ketosis has a protective effect in bacteremia.

The conclusion: Drink juice and tea with sugar or honey when you have the flu. But don’t eat if you don’t feel like it when you have pneumonia.


Association of Thyrotropin Suppression With Survival Outcomes in Patients With Intermediate- and High-Risk Differentiated Thyroid Cancer – JAMA

A dear friend and an anxious woman with a history of thyroid cancer is simply not tolerating suppressive doses of thyroid hormone, so with the blessing of my go to endo, she is on suboptimal suppressive doses. This article helps me sleep better at night:


Eczema and Our Skin Biome – The Wall Street Journal and the AAAAI

The prevalence of eczema in children has doubled in the past 17 years. Now we are starting to think of our bacterial skin flora as another area where promoting good bacteria can improve health. The Wall Street Journal reports on two small studies that demonstrated that applying healthy bacteria to eczematous skin brought clinical improvement.

“15 pa­tients, in­clud­ing five chil­dren, sprayed their rashes with bac­te­ria that re­searchers sus­pected could im­prove eczema. Two-thirds re­ported less itch­ing, less need for top­i­cal steroids and bet­ter sleep af­ter us­ing the spray twice a week for four months. On av­er­age, these mea­sures im­proved by 84% in adults and 78% in chil­dren.”

This led me to look for more information, and it’s out there:

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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