What are “red flag” symptoms for those with low back pain?

img_2327What are “red flag” symptoms for those with low back pain?  When a patient presents to the office or hospital with low back pain, we are looking for the “red flag” (or VERY concerning symptoms) because it reveals that there is a more ominous cause.

  • new inability to urinate,
  • progressive loss of strength in the lower legs,
  • urinary incontinence,
  • a recent invasive spinal procedure,
  • progressive sensory loss (of the anus or near genitals),
  • history of cancer,
  • fever.

If red flags are ABSENT, the guidelines are to NOT perform an MRI, CT or x rays within the first 6 weeks of onset of back pain.  Often back pain resolves spontaneously within 6 weeks, so this is the reason for waiting… unless a “red flag” is present.

I hope this helps.

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Social determinants of health. As a physician am I asking the right questions?

img_2255Social determinants of health.  As a physician, am I asking the right questions?  I recently went to a conference given by Aaron Dieringer MD who is also a Masters in Public Health candidate.  He showcased the ways that I can be aware of environmental differences in patient’s lives.  These issues need to be addressed differently than I have been doing before.

Examples of issues that are biased// juxtaposed to more appropriate questions…

  • “Do not take this medication on an empty stomach.”  //What if the patient does not have access to food regularly (or even daily)?
  • “Go outside to walk every day for exercise.”  //Do you have a safe nearby area to walk?
  • “Come back in the office in 4 weeks.”  //Is there a time or date that works best for your next appointment to help with transportation issues?
  • “See the specialist that I am sending you to.” //If you are unable to get to the specialist’s office due to transportation issues (not on a bus route) let the social worker in my office know and we will work with you to get this fixed.

How to help?

  • Consider immediate postpartum placement of long-acting reversible contraception.  50% of pregnancies are unintended.  The risks unintended pregnancies are that the patient may not be taking a prenatal vitamin or may be using alcohol or drugs.
  • Centering pregnancy.  This is a group prenatal visit.  The first few minutes are one-on-one with a physician and then the rest of the hour is a group learning session about a pregnancy issue.  This form of prenatal visits has decreased the disparity in pregnancy outcomes. https://www.centeringhealthcare.org/what-we-do/centering-pregnancy
  • Student Outreach Clinic.  The University of Nevada Reno has a free medical clinic available to the local underserved population.  One patient example given was a woman seen for asthma exacerbation who needs steroids to avoid worsening in her condition, necessitating an ER visit or a hospitalization.  One question to ask of all patients is  “If I prescribe you medication on the $4 Wal-Mart list, can you afford this?”  Some patients cannot afford this and there are social work workarounds…  Up to 60% of preventable mortality is attributable to social and economic circumstances. Want to know more about our UNR SOC?   med.unr.edu/soc/clinics
  • Project Upstream is a program which accompanies the UNR Student Outreach Clinic.  These Project Upstream volunteers help address the social determinants of health that may affect their treatment (transportation, $4 medications) so that the physician’s advice has a better chance to be adhered to with more optimal care outcomes.

I hope this helps.

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Inflammatory bowel update

Inflammatory bowel update.  Of note, inflammatory bowel includes Crohn’s disease and ulcerative colitis.  Inflammatory bowel disease is not irritable bowel.  I recently attended a lecture by a local gastroenterologist  Here are some of the “pearls” from that talk…

  • Patients with ulcerative colitis flares are at increased risk of blood clots, especially when ill and are sedentary (like when in bed in the hospital).  DVT prophylaxis needed.
  • IBD patients may be more at risk for skin, lymphoma, cervical and anal cancer.  Additionally, colon cancer risk is 2 times higher than the general population.
  • A routine patient (without inflammatory bowel)  is at lifetime-risk of colon cancer is 5-6%.
  • If a patient has pancolitis, colonoscopy should be done after 7 years. Then a colonoscopy every 2 years.
  • Primary sclerosing cholangitis patients get a colonoscopy every one year because their risk of colon cancer can be as high as 20 times the routine population’s risk.

Biologic medicines (that are often used to control inflammatory bowel disease) decrease immune strength and therefore increases the risk of many different kinds of cancers:

  • Melanomas.  These patients should be more sun-aware (sunscreen and spf clothing) and have skin cancer screenings yearly.
  • Lymphoma risk increases with patients on azathioprine.
  • Cervical cancer screening: Consider HPV vaccine, decrease tobacco exposure, get routine pap screenings.
  • Anal cancers are usually squamous cell carcinoma and are more at risk with patients with long standing anorectal colitis or men who have sex with men or HIV patients.  Anal strictures should be biopsied by colorectal surgeon to rule out anal cancer.

What vaccines do inflammatory bowel disease patients need?  Varicella (live vaccine) , Zoster, MMR (live), Tetanus, flu, HPV, hepatitis B, hepatitis A, meningococcal, and pneumococcal (pneumovax).  It is important that patients receive live vaccines before biologic medicines (which can cause immune suppression) are started.  If immunosuppressed, it is suggested that pneumonia vaccines be given before the rest of the population is due (at age 65).  The American College of Gastroenterology (statement offered in 2018) suggests Prevnar followed by Pneumovax 8 weeks later.  Then Pneumovax booster is suggested 5 years later.

Your GI doctor will recheck labs depending on what therapy you are on.  You may need renal function labs, DEXA (bone density) scans, vitamin D or calcium level, comprehensive metabolic panel, tuberculosis test

When to start colon cancer screening in routine-risk patients?  New data shows that first screening should be at age 45, but insurers are not following this yet.  African Americans should get their first screening colonoscopy at age 45.

http://www.cornerstonehealth.org is a great website.

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Intravenous magnesium sulfate helps with asthma exacerbations!

Intravenous magnesium sulfate helps with asthma exacerbations!  I was the attending physician on the hospital service recently and had many children with respiratory distress present to the emergency room.  Many of them had RSV or influenza infections resulting in respiratory distress, but two of them had asthma exacerbations.  A literature review ensued for the most up to date treatment of asthma exacerbations and magnesium sulfate is a new addition to our pharmacotherapy.

It has been found that in an acute asthma exacerbation that has not responded to our first-line therapy (consisting of bronchodilators and steroids) often benefit from a dose of magnesium sulfate intravenous.  I fact hospital admission decreased by 68% patients 18 months to 18 years of age who were given magnesium sulfate.  Of note, the magnesium sulfate was only given if the bronchodilators and steroids were ineffective.  The studies showed no harm caused by magnesium sulfate.  It was a weight-based dose that was given once in the patient’s vein.

I love having one more medication in our arsenal to help asthmatics.

I hope this helps.img_2234-1

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Do you want to pay less for your medicine co-pays?

 

img_2339-1Do you want to pay less for your medicine co-pays?  Who doesn’t?!  A recent JAMA article (see link below) looked at 9.5 million medication claims and found that nearly 23% of patients paid more through their insurance co-pays than the cost of those medications to insurers or to the pharmacy.

I urge you to do some research on the cost of your prescription with AND without “running it through” your insurance plan.  My family member recently had knee surgery and I picked up the prescriptions and saved $15 on one prescription by using the GoodRx app and not using my insurance co-pay for that medication.

Want more information? https://jamanetwork.com/journals/jama/fullarticle/2674655

 

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What should we do about male-pattern hair growth on females?

What should we do about male-pattern hair growth on females?  The medical term for this condition is hirsutism.  Hirsutism affects 5-10% of premenopausal women and is usually an indication of an underlying endocrine disorder like polycystic ovarian syndrome.  Women with hirsutism have coarse dark hairs in androgen-sensitive areas like the upper lip, chin, back, and buttocks.  Please see your physician to investigate the root cause of the hirsutism.

There was a recent meta-analysis, where many studies are combined to get a more robust result.  The best treatment for hirsutism is birth control pills with combined estrogen-progestin pills.  Other medications that help curb this hair growth are antiandrogens like finasteride or metformin a medication used mostly for diabetics.

Want more information?  J Clin Endocrinol Metab 2018: 103 (4): 1258-1264.

I hope this helps.

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Are you older than 50? Get your Shingrix!

Are you older than 50?  Get your Shingrix!

What is Shingrix?  It is the “new” shingles vaccine.  Shingrix, also called recombinant zoster vaccine, is a rockstar of vaccines.

It decreases shingles infections

  • For those 50-59 years, Shingrix decreases shingles by 96%
  • For those 60 to 69 years, Shingrix decreases shingles by 97%
  • For those 70 and older, Shingrix decreases shingles by 91%.

It also decreases postherpetic neuralgia, the medical term for long-term nerve pain where the shingles rash was.  This can continue after the rash has cleared.

  • For those 50 to 69 years,  Shingrix decreases postherpetic neuralgia by 89%
  • For those 70 and older, Shingrix decreases postherpetic neuralgia by 89%

The FDA suggests that if you received Zostavax in the past, you should get the Shingrix vaccine.  In comparison, Zostavax is only 51% effective in preventing shingles and 67% effective in preventing long-term nerve pain.

Want more information? https://www.aafp.org/afp/2018/1015/p539.html

the vaccines

flickr.com/photos /lavid/ 01793987

 

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