ADHD evaluation

Posted on June 8, 2018 by drlesliegreenberg

I recently went to a lecture on ADHD.   There are different ADHD subtypes: combined (hyperactivity with impulsivity), predominantly inattentive, predominantly hyperactive without impulsivity.  The ADHD with hyperactivity is most likely diagnosed because of the child’s attention-getting (conduct disorder) behavior.  Stimulants make everyone improve their ability to concentrate.  3-7% of school children affected in US. Males have ADHD more common than females.

Other things to think of… Does the child have a seizure disorder, chronic ear infections, sleep apnea, narcolepsy, metabolic abnormality (like hyperthyroidism), toxic exposures (like lead poisoning or fetal alcohol syndrome)?  These are issues that can look like ADHD, but are not.  Your physician also needs to rule out learning or language disorder, autism spectrum disorder or sleep disorder.  The child may also have anxiety, depression or other mood disorders, psychotic disorders or substance use disorders (huffing or chugging Benadryl).  Tics are very common and the treatment for ADHD may make the tics worse.

ADHD disease course.  1/3 resolve spontaneously.  As ADHD patients age, the symptoms may seem to decrease even if they continue to have ADHD.  Must treat the co-morbidity.  Treat the parents.  The parents will often bring the patient to the doctor when they are fed-up.

MTA (Multimodal treatment of ADHD) Study of 1999.  This NIH-sponsored study showed medication (stimulants) are effective.  Behavioral treatments are not as effective as medication for core ADHD symptoms.  Increased physician contact improves outcomes.  More frequent and higher dosing may lead to less ADHD symptoms.  2-year follow up showed benefit with medication over behavioral therapy.  Stimulants are not found to help at 3-year or 8-year follow up compared to behavioral therapy.  For kids at 4-5 years of age, have parents work on parenting and scheduling.  Then try methylphenidate.  If there’s no benefit, your physician may start dextroamphetamine.  The side effects from medicine: insomnia and decreased eating.  There is a concern for decreasing growth velocity (the child may have an adult height 2 inches shorter than without stimulants).   When adolescents take stimulants, think of the potential for abuse and diversion.  The patient will need to see the physician monthly to confirm that the medication has helped and that side effects are kept to a minimum.

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Great definition of a family physician

Posted on June 5, 2018 by drlesliegreenberg

img_0851Great definition of a family physician.

I am NOT a generalist. 

I am NOT a provider.

I am NOT a practitioner. 

I am a medical professional who cares for complex and healthy patients regardless of age.  I am best understood as an integrationist. 

I integrate the mental, spiritual, and physical wellbeing of my patients, in the context of their families and community, to help them become whole. 

I integrate the sometimes disparate recommendations of medical specialist to insure that treatments that benefit one organ system does not damage another. 

I integrate and apply complex medical research on populations to the unique biology, needs, and goals of my patient.

I am the “pluripotent stem cell” of the medical community.  I start with a broad education and then adapt to the needs of my community to fill the voids in healthcare.

I am the marine of medicine.  I get the job done, often under harsh conditions.  To my patients, Semper fidelis.

                By Bruce Bushwick, M.D., York, PA

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HPV

Posted on May 29, 2018 by drlesliegreenberg

I took notes at the Nevada Family Medicine meeting when expert Dr. Trudy Larson spoke about HPV.

Here are the take-home points…

Who gets HPV?

  • 80 % of adults have a strain of HPV.
  • “HPV happens.”
  • There are 40 subtypes of HPV.
  • HPV affects the base of the mucosal surface (cervix, mouth, anus) and causes abrasions.
  • Once the HPV is in place, the vaccine doesn’t work well. Prevention is the key! 80 million Americans infected.
  • Most common in teens and early 20s.
  • Most people don’t know they have HPV, because the body CAN clear it.
  • We cannot predict WHO will be chronically infected. Again, prevention is key.

HPV is our second cancer vaccine. The first one is the hepatitis B vaccine which decreases liver cancer. Hepatitis B vaccines are given to newborns.  The HPV vaccine cannot cause cancer. The vaccine helps the body make antibodies to HPV.

Is the HPV vaccine safe? Yes! They may get redness at the injection site just like with every other injection. The HPV vaccine should not be given to those with yeast allergy. The vaccine is made of proteins, no virus. So, it only generates antibodies to HPV, and cannot cause it.

What is the impact of HPV vaccine?

  • Decreased HPV found on cervical exam by 68%.
  • Decreased anogenital lesions by 51%.

There’s a herd effect which means that when some people are UNvaccinated, the ones who are vaccinated decrease the chance that the UNvaccinated will be infected.

HPV antibodies are at a significant level 10 years after vaccine given. So, the vaccine, although given at a young age, lasts through adolescence and early adulthood which (as a parent and physician) are most likely the “risky years.”

 

http://www.CDC.gov is the best source for vaccine information.

Posted in infections, Male issues, Pediatrics, Sexually Transmitted Infections, Uncategorized, Vaccines, Vaccines | Tagged , , , , , , , , , , , , , , | Comments Off on HPV

A taboo topic: heavy menstrual bleeding

Posted on May 22, 2018 by drlesliegreenberg
flickr.com/ photos/tingy /484468

flickr.com /photos/tingy /484468

A taboo topic: heavy menstrual bleeding…Do you have heavy menstrual bleeding? There are lots of ways to fix this.  The most effective method is to remove the uterus (a hysterectomy) but this method comes with surgical risks and (of course) infertility.

What is considered heavy menstrual bleeding?  By textbook, it is more than 80 milliliters of menstrual blood loss per cycle.  This affects nearly 20% of menstruating women.

What are all the options for decreasing menstrual blood loss?

  • Hysterectomy
  • endometrial ablation
  • levonorgestrel-releasing intrauterine system (IUD), or
  • daily birth control pills.

 

There was a study with over 1200 women who received various of the above treatment options and the results showed that patients who chose surgery (including both hysterectomy and endometrial ablation) had greater satisfaction at 6 months.  At 2 years, the higher level of satisfaction was with those with endometrial ablation. But, by five years the satisfaction with both surgical groups was the same to those who took oral birth control pills. This five-year finding is confounded as more than 50% of the oral medication group had changed their therapy within the five years and had a surgical intervention to decrease bleeding.

So, what do the guidelines tell us?

  • The National Institute for Health and Care Excellence states that “pharmaceutical treatment should be considered where no structural or histological (cell-type) abnormality is present, or for fibroids less than 3 cm in diameter which cause no distortion of the uterine cavity.”
  • Alternately the Americal College of Obstetricians and Gynecologists suggests that medical management be done first and then surgical options (ablation or hysterectomy) be done if medical management is not effective or contraindicated.
  • My job as a family physician is to inform the patient of all her options and to let her know that if conservative measures (oral birth control pills or levonorgestrel IUD) fail, then a gynecologist can help them further with a possible endometrial ablation or hysterectomy.

Want more information?  www.cochrane.org/CD003855.

Posted in Ear, General Medicine- Adults, menstrual issues, Uncategorized, Women's Health | Tagged , , , , , , , , , , , , , | Comments Off on A taboo topic: heavy menstrual bleeding

Why should YOU have a primary-care physician who knows you?

Posted on May 21, 2018 by drlesliegreenberg

Why should YOU have a primary-care physician who knows you? Here’s a beautifully-written NYTimes article about the emotionally-satisfying, save-you-money, have-your-concerns-be-heard, life-altering ways that you having a relationship with your Primary care physician can alter your life. Read on….

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I helped write an article on NerdWallet.com Travel medical advice…

Posted on May 18, 2018 by drlesliegreenberg

I helped write an article on NerdWallet.com… Travel medical advice… https://www.nerdwallet.com/blog/travel/how-to-avoid-germs-on-planes/

 

 

 

 

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Does calcium and vitamin D help with community-dwelling older adults?

Posted on May 16, 2018 by drlesliegreenberg

Does calcium and vitamin D help with community-dwelling older adults?  JAMA put out a great article recently about calcium and vitamin D and its help to decrease fractures.

The low down on this study is that in this meta-analysis (meaning a compilation of many randomized clinical trials with over 51,000 patients) the use of supplements including calcium and vitamin D was NOT associated with a lower risk of fractures among community-dwelling older adults.

These findings do NOT support the routine use of these supplements in community-dwelling older people.

Want more information?  1252802383_d8582894a7_ohttps://www.doximity.com/newsfeed

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How can physicians help patients keep prescription cost down?

Posted on May 15, 2018 by drlesliegreenberg

How can physicians help patients keep prescription costs down? This is a very important and constantly changing problem.  Pharmaceutical companies have figured out how to get more money for their prescriptions.  Some ways to keep inflated prices are that there are limited alternatives to the medication (ex: lead poisoning treatment), older medications with few manufacturers (ex: EpiPen and colchicine), single manufacturer with no generic available (example: humalog insulin), “evergreening” or making slight changes to existing drugs to continue patent exclusivity (ex: ortho tri-cyclen or oxycontin).

It is the rare patient who is not plagued with high prescription drug costs.

How can your physician help manage high prescription drug costs?

  • Choose low-cost generic drugs first.  There are many drugs available for $4/month (which may be a long-term medication or for a short course for a specific ailment).  I am a fan of the Walmart $4/month medication list. http://www.walmart.com/cp/4-Prescriptions/1078664.  This list can help to decide which medications could be obtained at Walmart for $4/month.  Consider asking your favorite pharmacy to match their price.
  • Learn the costs of your medications.  Your physician may have you on a medication with no generic, but if there is a generic within that same medication class you can consider a switch.  If the generic is just as effective and without side effects, ask your doctor to change prescriptions. For example, there is a cholesterol-lowering medication called pitavastatin (not available in a generic form) for $3000 per year or a generic lovastatin available for $40 per year.
  • Do not assume that your insurance will help lower the costs of medications more than paying cash for your medications (as if you had no insurance).  A name-brand medication may cost MORE with insurance than a generic without. Or at times a generic medication may cost MORE with insurance than paying without your insurance.  ALSO, there are some over-the-counter medications like acne cream that are less expensive bought off the shelf than from the pharmacist.
  • If your physician’s office offers samples for a drug, consider that even though the samples are free… the medication (when you buy it from the pharmacy) may cost more than if you were started on a less-expensive medication.  When a pharmaceutical representative drops off samples at a physician’s office, those are most-often-than-not EXPENSIVE medications. Beware.

 

Did you know there are patient assistance programs?  NeedyMeds at www.needymeds.org or  RxAssist at www.rxassist.org help patients find assistance with drug costs.

 

Want to try a new medication?  Be wary. New medications may have unknown side effects or long-term complications AND are more likely to be expensive.  I understand that pharmaceutical companies need to recoup their research and development costs, but you can be a smart consumer and decide what you are willing to pay for your medications.  The relative safety, effectiveness, tolerability, price, and simplicity of new drugs are presented in the STEPS department in the American Family Physician (our family medicine go-to-journal) at www.aafp.org/afp/steps.

 

I have no relevant financial affiliations.

pills

flickr.com/ photos/masterslate/ 3003880273

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Hyperthroidism, an overactive gas pedal to our body…

Posted on May 8, 2018 by drlesliegreenberg

Hyperthyroidism.  This is when the thyroid gland (the gas pedal to our body) is working too hard.    The actual definition is an excessive concentration of thyroid hormones. This can be caused by the body making too many thyroid hormones or taking more thyroid hormone than is needed.  The most common causes of excessive production of thyroid hormones is toxic adenoma, toxic multinodular goiter and Graves disease. Excessive passive release of thyroid hormone can be painless thyroiditis.

 

Symptoms of hyperthyroidism are

  • heart palpitations or fast heart rate,
  • jitteriness,
  • weight loss despite increased appetite,
  • anxiety,
  • rapid or pressured speech,
  • insomnia or
  • even psychosis.
  • A late finding is exophthamos (where the eyes seem to “bug out”).

 

How to test for hyperthyroidism?  Your doctor will do a blood test. You do not need to fast for this test.  The test with the highest sensitivity and specificity for hyperthyroidism is the TSH (Thyroid stimulating hormone). If this value is LOW, then a free thyroxine (T4) and a total triiodothyronine (T3) level may also be checked.

There are other reasons the thyroid labs could look like hyperthyroidism without being hyperthyroidism.  Pregnancy. Estrogen therapy. Acute illnesses. Steroid or dopamine treatment.

Aren’t there imaging tests?  Yes. A radioactive iodine uptake test and thyroid scan can help determine the cause of hyperthyroidism.  The uptake is the percentage of an iodine I-123 tracer dose that is taken up by the thyroid gland. It should be 15-25% at 24 hours.  If the uptake is very low, like 0-2%, this could signal thyroiditis (where the thyroid is inflamed) and high in patients with Graves disease, a toxic adenoma, or toxic multinodular goiter.  If the tracer is homogeneously distributed, this can signal Graves disease and if it accumulates in certain spots this could signal a toxic adenoma or if in multiple areas, a toxic multinodular goiter.  Ultrasound is sometimes used as a cost-effective and safe alternative to radioactive iodine.

How to treat hyperthyroidism?

  • To control the symptoms. Propranolol is a beta blocker often used to slow the heart rate down to normal and decrease symptoms.
  • Otherwise, there are three treatment options to control hyperthyroidism long-term.
    • 1. Antithyroid medications (like methimazole or propylthiouracil)
    • 2. Radioactive iodine I-131 to ablate (burn out) the thyroid
    • 3. Or surgical removal of the thyroid gland.

I hope this helps.

rainbow

flickr.com/photos/ devilskebab/7355494132

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Summer travel is upon us: International travel and medication advice!

Posted on May 1, 2018 by drlesliegreenberg

International travel and medication advice.  As the summer travel season heats up, what should you know about medications and travel?

There are two great websites, the Centers for Disease Control and Prevention (CDC) and the Transportation Security Administration (TSA) to help delineate the rules on medications and international travel.

Travel tips:

  • Carry a legible updated medication list while traveling with brand (and generic name of the drug), dosage and dosage schedule and indication for the medication.
  • Carry copies of recent laboratory tests, electrocardiogram results, a list of chronic medical problems a recent medical history and physical examination results, and any pertinent recent hospital records (if applicable).
  • Keep essential medications with you in a carry-on bag.
  • It may save you distress to keep your medication in the original containers (even though in the US you are allowed to transfer medications to a pillbox) as this will also have the name of the prescribing physician and their phone number.
  • There are specific rules (current as of 4/2018) with TSA regarding liquids and syringes and needles.
    • You can travel with an excess of 3.4 ounces on airplanes, provided the traveler follows TSA’s rules.  “You may bring medically necessary liquids, medications and creams in excess of 3.4 ounces or 100 milliliters in your carry-on bag.”
    • Remove them from your carry-on bag to be screened separately from the rest of your belongings. You are not required to place your liquid medication in a plastic zip-top bag.”
    • “Also declare accessories associated with your liquid medication such as freezer packs, IV bags, pumps and syringes. Labeling these items can help facilitate the screening process.”  These supplies may need to undergo additional screening procedures. Consult with TSA before traveling!

 

Bringing breastmilk or formula?  TSA will allow more than 3.4 ounces of either liquid to be brought onto airplanes.  You are instructed to “inform the TSA officer at the beginning of the screening process that you carry formula, breastmilk, and juice in excess of 3.4 ounces in your carry-on bag.”  The liquids will undergo x-ray. You can request visual inspection instead.

Illegal medications in other countries:

  • Pseudoephedrine is illegal (even with a prescription) to be brought into Mexico.
  • Amphetamines (like Adderall) are illegal (do not bring into) in Japan.  Check the US Department of State to review if your medication can be brought in to your destination.

Differing brand names:

  • Be aware that your US medication may be named something else in another country.
  • Or the same sounding medication name in another country can be another kind of medication altogether elsewhere.

 

Buying medications overseas:

  • Quality control of overseas medications may not be as rigorous as the US.
  • The CDC estimates that medication sold in developing countries is counterfeit up to 30%.
  • If you do buy medication overseas, check that the medication is in its original packaging and that the printing on the package looks original.
  • Buy medications are reputable pharmacies and ask the pharmacist if the new medication has the same active ingredient as the medication it is replacing.

How to get help overseas.  Consider asking the US embassy for suggestions for medical services like reputable physicians, health care facilities and pharmacies.  To find an embassy www.usembassy.gov

I hope this helps.

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flickr.com/photos/n8kowald/1981964609/

 

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