These are quick notes I take when I attend conferences or find some info that I want to jot down for later. I often do not proof read and I write fast. So please any information you take from here should be carefully cross-checked for accuracy. If you are interested in adding to this leave a note in the comments section!
MINIMALIST MEDICINE:
Diabetes Mellitus
Minimalist approach:
- Start Metformin 500 bid monitor fasting
- increase to 1000 bid
- add amaryl (cheap) or add Januvia
- Add Actos (cheaper)
- see where blood glucose is over 6 months if a1c greater than 9.0 consider starting basal insulin
- start at .2U/kg/day of Glargine
- titrate up to .5U/kg/day monitoring fasting glucose increase .1u/kg/day until fasting is less than 100
- if still elevated need to address bolus insuin
- start at .1u/kg up to 10 units of Humalog (try pen) at biggest meal of day
- monitor pp glucose over one week
- if still high add same dose at next biggest meal of day
- monitor pp glucose over one week
- if still high add same dose at next biggest meal of day
- monitor pp glucose over next week
- now patient is on:
- Met 1000 bid
- Actos 30 qd (address potential side effects)
- Amaryl 2mg qd (cut this down from 4 mg (1/2 initial dose) when starting insulin
- or pt is on jauvia if money is not a factor
- glargine 50 units (or equivalent of .5u/kg/day)
- Humalog 10 units tid with meals
- REFER if a1c still > 9.0
- make sure pt is checking tid blood sugar
- before breakfast
- before dinner
- bedtime
- Efficacy of Metformin is about 4 years after that it becomes less effective for treating chronic type 2 disease
- If you reduce your calorie intake by 100 Cal. per day you will loose 1-2 pounds per week
- Post Parandial Goal (2 Hours after meal): less than 150
- Pre Parandial Goal less than 100
- in reality you will only get a .3-.7% reduction in A1C after adding a drug (if no dietary changes)
- 80% of after dinner blood glucose is contributed by the liver, stimulated by brain from chewing to produce glucose.
- >9% A1C liver is not shutting off at night, needs to be addressed by insulin.
- A1C < 9% Post Parandial Glucose is most important
- Aspirin Therapy Rules:
- WOMEN: 65 Aspirin
- Men: 55 Aspirin
10. Proton Pump inhibitor can cause low B12: so check B12 and Check Vitamin D
11. Glargine Insulin only causes a 2.6 lb weight gain at 24 weeks
12. INSULIN GLARGINE INITIATION based 100% on FASTING GLUCOSE LEVELS
- 80-100 no change
- < 80 decrease dose by 3
- > 100 increase dose by 1 unit per day until fasting
- Start at 0.2 Units per KG Per Day in a 200 lbs person that is going to be 18U per day
- or Start at 0.1 Unit per KG per Day
- keep going up 1 unit per day until you reach about 50 units basal insulin (up to Threshhold of 0.5 Units/kg basal, beyond this point improvement is less.
- Continue Oral Medicines will need 20-40 % less insulin
- When adding insulin cut sulfaneureas in 1/2
- Tell Patients from the Start that they will most likely need 40-45 Units per day
- 10. you could give 10-20 units there in the office and send home with regimen they will then titrate up at home and follow up in 3 weeks
- Now aim for post parandial goal
- add 0.1 units before largest meal of day up to 10 unitl
- then start doing this after each meal until PP glucose is consistently less than 150
- Weekly Titration of Basal: start biggest meal, 1 week, then next biggest meal, 1 week, then last biggest meal
Co-Titration of Basal and
Prandial Doses
- Adjust doses of basal and prandial doses on alternate days (every 3 days)
- Increase prandial dose by 1 unit to target 2 hour postmeal glucose level < 180 mg/dL
- Consider reducing carb intake or adjusting insulin:carb ratio if patient has persistent postprandial hyperglycemia Continue 303 protocol to target fasting glucose level 80-110 mg/dL
13. Insulin Syrines 1/2 cc or 1cc
14. • Can obtain about a 0.5% decrease in A1C for each 0.1-U/kg/day increment
in insulin dose Up to a threshold of 0.5 U/kg Beyond this dose, the improvement in
terms of A1C decreases is less
• add a basal insulin analog and asked initially to
test his blood sugar level 3x/day
• Before breakfast
• Before dinner
• Bedtime
Research clearly shows that achieving good control
early on prevents diabetic complications, including
nerve, kidney, eye, and heart disease for up to
20 years
- In general, the sooner insulin is started, the better off the patient will be in terms of preventing complications
- Modern insulin analogs and treatment regimens make insulin a user-friendly therapy
HYPERTENSION
Minimalist Approach
- start pt on Chlorthalidone 12.5 and see how they respond, next titrate up to 25mg
- then add ace lisinopril titrate up to max
- then add amlodipine 5mg and titrate up
- if still not working change amlodopine to labetolol
- if still not working consider adding bblocker or probably better refer
- American Heart Association (AHA) recommends you take blood pressure readings in the early morning and evening
Other thoughts:
- in diabetics ACE First
- if ace induced cough should change to another class of meicins as arb will not show any benefit for patient, what should we do if they have DM??
- Chlorthalidone is twice as potent as HCT Has longer half life than HCTZ and approaches 24 hours
- More effective at lowering night time bp
- Most positive diuretic trials have used chlorthalidone
- HCTZ most commonly prescribed in U.S.
- Chlorthalidone should now become our preferred diuretic for Rx of hypertension
- Start at 12.5 mg daily
Pt example on 3 meds (Resistant htn) pt on chlorthalidone + ACE + Amlodopine don't add a 3'rd line agent change amlodopine to Labetolol This will work just great!!!
MIGRAINE HEADACHES
Minimalist Approach:
- Apply 2 out of 3 rule
- start with Triptan
- if no relief add naproxen
- if no relief try up to 3 differnt triptans
- never use opioid or bultalbitol for more than 8 days per month
- develop relief stratisfication
- may try medrol dosepak if migraine still persists
- triptan 2x per day for up to 3 days in a row
- propranolol sustained release first line
- 10 mg of elavil and titrate up second
- verapami 180mg qd to start
- Simplified Diagnostic Criteria:
ID Migraine
Light sensitivity with headache
Nausea with headache
Decreased ability to function with
headache
Any 2 out of 3 = Migraine
Migraine should be the default diagnosis
for any headache that is brought to
the attention of a health care provider
- EPISODIC NAUSEA AND VOMITING WITH NO OTHER SYMPTOMS THINK MIGRAINE HEADACHES
- MORE THAN 8 DAYS PER MONTH OF OPOID OR BULTALBITAL AT RISK FOR CHRONIC MIGRAINES
- TRY 3 DIFFERENT TRIPTANS BEFORE GIVING UP
- NECK PAIN IS A SYMPTOM OF MIGRAINE
- THE MORE AEROBIC EXERCISE YOU DO THE BETTER IT IS FOR MIGRAINES
- MEDS THAT MAY MAKE MIGRAINES WORSE
- SSRI AMBIEN AND BONE MINERAL DENSITY DRUGS
- 5% OF WOMEN HAVE MORE THAN 15 MIGRAINES PER MONTH
10. Acutey Use Meperidine (reglan) + dihydroErgotomine IV decrease Narcotics by 10% per week
11. Chronic daily tension type headache is dfined as tension type headache occuring more than 15 days per month
12. Tricylcics are helpful in treating analgesic rebound headaches
13. In Elderly patient with new onset headache temporal arteritis must be excluded check ESR
14. TA treatment is high dose Prednisone 50mg x 4 weeks
15. Pathogenesis of migraine headache is seratonin depletion
TIA
- Therefore, most authorities recommend a non-contrast CT scan be done to
exclude a hemorrhage. If the episode is over, and MRI is available, some neurologists
recommend it.
ACUTE CORONARY SYNDROM
FOR ALL PATIENTS AFTER ACUTE CORONARY SYNDROME
- ASA 325 FOR 30 DAYS THEN CHANGE TO 75 OR 150 MG
- PLAVIX FOR 12 MONTH AND INDEFINATELY IN VERY HIGH RISK INDIVIDUALS
- ATORVASTATIN 80 OR ZOCOR 40
- LIFELONG BETA BLOCKER (41% REDUCTION IN ACS RECURRENCE)
- ACE INHIBITOR
- TRIGLYCERIDES LESS THAN 130
- 80% RELATIVE RISK REDUCTION IF ALL OF THESE ARE IMPLEMENTED
- PPI + PLAVIX SEEMS TO BE OK
SLEEP:
- Go to bed at same time every night (try not to alter more than 2 hours or cannot recover)
- if night shift worker try to stay up till 2-3am on days off and sleep till noon
- family needs to be on board with plan
GERD:
- pt should not have taken abx, ppi's or bismth within 2 weeks prior to administering the UBT
- PT should have fasted for at least 1 hour prior to administering the UBT
- should not use until 4 weeks after eradication of h-pylori
- not for age less than age 18
RAP SYNDROME:recurrent abdominal pain
"The Rule out all possibilities" approach can lead to a spiral of investigations that simply reinforces the impression that some hidden cause has been overlooked and must be unmasked even when the clinician is convinced of the functional nature of the pain.
W/up:
- CBC
- Urinalysis
- Stool for occult blood, white cells, culture, and O&P
- Flat Plate of Abdomen to look for constipation
- abdominal U/S to look for renal gyn or cystic etiologies
- egd not needed
the most convincing method of divesting the parents of this notion is to compare abdominal pain with headache in adults most adults have occaional headaches, and although the cause is rarely associated with any abnormal physical findings or investigations the pain is undoubtedly real and not immagined. Young children are highly suggestible, and parents should refrain from questioning the child about the pain if the child is not complaining. Maybe a trial of fiber and prn laxitives if sxs of constipation.
Eneruresis:
definition: involuntary discharge of urine after the age of 5
bedwetting alarms: not used in kids under 5, use for at least 15 weeks, dropout rate is 30%
Pediatrics:
Developemental Milestones:
- sits and rolls: 6 months
- fine princer grasp: 9months
- Stnds and Walks: 12 months
- Understands one step commands: 12 months
- Scribles: 18 months
- Feeds self: 18 months
- Speaks Short words and phrases: 2 year old
Cancer:
ALL: get CBC
Women's Health:
pH Measure |
Symptoms May Include |
Possible Infection |
Action |
5.0 or Greater |
|
Bacterial Vaginosis (BV) | See your doctor for further testing & diagnosis |
5.0 or Greater |
|
Trichomoniasis (Trich) | See your doctor for further testing & diagnosis |
4.5 |
|
Yeast Infection | 1st time sufferers, |
Urology:
Dermatology:
1. Diffuse Atopic dermatitis and warts on hands and mouth of a 5 year old femal
- Derm reccomends: imiquimod or aldara nighty to lesions on the mouth
- efudex 5% cream nightlyto hand warts
- cimetidine 300/5ml 4 ml tid
- triamcinalone 0.1% cream applied daily
- aquaphor on face
- because triamcinalone 0.1 did not help pt was increased to 2.5% cream on face bid as well as triamcinolone 0.1% ointment on the body's affected areas twice daily. and to continue aggresive emolliation with Vaseline and Aquaphor.
- 2 month treatement plan
Celiac Dz:
- 1 percent of population
- Test people based on risk stratification see chart in handout
- Test with IGA tTG
- If positive get endoscopy
- Check vitamin D, Calcium, ANA, LFT’s, Hepatitis Serology
- Dexa scan at the end of one year on gluten free diet
Erectile Dysfunction:
- By the time a man reaches 50 he has a 1 in 2 chance of having some kind of erectile dysfunction
- Increase you inflow and prevent it from leaving all controlled by the cavernosa nerve
- Prevention of leakage of blood is controlled by the muscle
- This is a smooth muscle function problem
- The nerve that innervates the smooth muscle is controlled by NO
- The enzyme that makes NO is androgen sensitive
- NO rapidly degrades
- The nerve comes between prostate and rectum; people who have had prostate surgery of course are at danger.
- Testosterone also controls ability to have an erection
- Test. Level below 200 impacts ability to have an erection
- Psychological
- Hormonal (Libido)
- Neurological
- Vascular
- Most common cause of erectile dsfxn was leakage (the blood leaks out and doesn’t stay there)
- Decrease in smooth muscle content and replaced by collagen, rarely is arterial flow the primary cause of erectile dsxn.
- Prevalence of Comorbidities in Men with ED: HTN has the highest relationship 70-80%
- When you age and loose that smooth muscle
- ED and HTN have the exact same prevalence. Look at the graph in the handout
- The Smooth muscle is what controls the ability of the artery to dilate (AGAIN SMOOTH MUDCLE DSFXN) relaxation is erection, contraction is normal penis… how do we get the smooth muscle to do what we want it to do what is should do?
- 3 drugs available: PDE-5 inhibitors
- Tedalafil (2-3 hours after ingestion of drug) Food in stomach does not affect absorption of this drug.
- With Sildenafil 30% reduction in efficacy with food t=1 hour, t1/2 3-5 hours.
- If you double the dose you can improve the efficacy by 20% but increase side effects
- Make sure you check testosterone, if pt.’s do not get testosterone the patient may not respond. TX for 3 months with androgens.
- A man who is normal and takes these drugs is only improving his refractory time.
- When oral drugs fail: inject the smooth muscle: alpha blockers, PGE-I, it is a self-injection, those that utilize it tend to stop but can get a good erectile response.
- 3’rd line therapy is a prosthesis
- Mechanical device is 4’th line therapy
- Start out at half the normal dose regardless of the med, especially if young 10mg and 50mg for sildenafil. The majority of patients respond at the highest dose. If it is an elderly patient with medical problems… go ahead and start at the higher dose.
- The nitrogen from nitric oxide comes from L-Arginine no studies showing affectivity in ED in Men. Not an OTC amino acid that will warrant TX.
- Tolerance to PDE-5 inhibitors does not occur. Can get continued worsening of CAD etc. No evidence to show that these work in women. DO NOT PROVIDE ANY IMPROVEMENT IN FEMALE SEXUAL DYSFUNCTION.
- PT with BPH: put on alpha blockers to treat BPH do not take Viagra until 1-2 weeks after on the drug, if no side effects can take the Viagra.
- No problem with taking Viagra on a daily basis, besides cost. If you take 2 short acting drugs after 24 hours it is out. If you take long acting drug after 5-6 days it builds up in your body. This can be a problem.
Celiac Sprue: (Handout)
- Develops secondary to antibiotic use (high risk vs. low risk)
- High risk
- Clindomycin
- Amox
- Cephalasporins
- Fluroquinolones
- Acid suppression (PPI’s or H2 blockers) 2 fold increased risk
- IBD
- Pregnancy
- Chemotherapy
- Difficult to culture (why it was called Clostridium difficile)
- 3 million cases per year in the US (416% increase from 99-2004) 4x the rate of MRSA deaths.
- Community Acquired. 10-30%
- Up to 40% no clear antibiotic use
- Cell cytotoxicity or PCR in low risk individuals
- Go ahead and start tx with metronidazole while you are waiting to get the results back
- Dx:
- Diarrhea
- Fever
- Leukocytosis
- Tests:
- Toxin EIA, rapid test back in 2-4 hours but low sensitivity
- GOLD: Tissue culture cytotoxicity:
- PCR (not yet available)
- Two step testing: EIA testing for toxin A+B if positive get sell cytotoxicity for confirmation.
- Testing only performed on symptomatic individuals with loose stools!!
- TX: (get slides)
- Metronidazole TID is the gold standard x 14 days, Vanocmycin used in pregnant or breastfeeding or with serious infections (oral Vnco TID)
- Do not treat carriers will make them worse THEY MUST BE SYMPTOMATIC
- Severe or Blood Diarrhea (they should all be hospitalized and should all receive Vancomycin: significantly superior to Metronidazole)
- Colectomy is a last ditch resort CDIFF is only in large bowl.
- Other Testing:
- First get stool
- Then cbc, BUN, Creatinine, Albumin Level
- Flex sig is not absolutely necessary, but maybe in patients with inflammatory bowel dz.
- Patients can commonly get symptom again a few weeks or months later: Very common about 20% of treated patients. NOT DO TO RESISTANCE (look at slide for recurrence)
- Test stool again
- Can be relapse
- Can be reinfection
- Very common in new mothers because such high levels of colonization in infants
- Post infectious IBS (very common)
- If recurs and stool is positive
- Second course of metronidazole no need to switch to Vanco after first recurrence
- Or probiotics and hydration (ok if patient is looking well, functioning may not need another course of antibiotics)
- Second and 3’rd relapse see handout
- Stool Transfer (stool donor – healthy family member the best) Works remarkably well.
- Cloristorm? Escalarde? Best pro-biotic
- Yogurt may provide benefit
- Probably so much c-diff because of overuse of antibiotics in the community
- Even a single dose of antibiotics (for example dental prophylaxis is enough to increase your risk)
- No recommendation for prophylaxis in patients taking antibiotics who have had recurrence, this will only create more of a problem again only treat when people are symptomatic.
Menopause:
- Menopause brain: memory problems during menopause but symptoms resolve after a short period of time after menopause.
- Hormone therapy reduces sx’s by 90 percent
- Estrogen plus progesterone has to be given to women with uterus do to increase risk of cancer in women with unopposed estrogen on the uterus.
- Vaginal atrophy will improve, but not as much as topical therapy
- Prevents colon ca while women are taking it but this does not persist
- Estrogen causes Kidney Stones!
- ESTROGEN ALONE:
- This is for women without a uterus
- Study stopped early because of increased incidence of STROKE
- Risk for stroke is low in women who are otherwise health
- Benefits:
- Treats menopause sx’s
- Probably ok to take for 5-6 years, it may actually help decrease Breast CA risk but any longer probably bad.
- MI risk is decreased but there is a stroke risk
- Estrogen and skin: Not a skin preserving modality
- Does estrogen therapy help depression: yes a bit compared to placebo.
- 25-50% reduction of hot flashes with placebo
Nonhormonal Pharmaceuticals for Hot Flashes
More Effective than Placebo in Randomized, Controlled Trials: Lowest Effective Dose, non-FDA Approved
- Venlafaxine XR 75 mg/d (37.5 mg/d also effective)
- Desvenlafaxine 100 mg/d
- Paroxetine CR 12.5 mg/d; Paroxetine 10 mg/d
- Fluoxetine 20 mg/d
- Sertraline 50 mg/d
- Citalopram 20 mg/d
- Escitalopram 10-20 mg/d
- Gabapentin 300 mg tid (up to 2700 mg/d may increase relief)
- Pregabalin 75 mg bid
- Clonidine 0.1 mg/d
- Loprinzi CL,, et al. Lancet.. 2000;356:2059–2063; [Evidence Level
- Oncol.. 2002;20:1578–1583; [Evidence Level A]; Stearns V, et al. J
- Complimentary Therapy:
- Efficacy is similar to placebo:
- Give black cohosh (because of the placebo effect)
- Other natural ways to stop menopause:
- Smoking cessation
- Weight loss really did allow a lot of improvement!!
- Exercise
- Lower temperature
- Weight loss doesn’t make much sense if you think of estrogen conversion in fat.
- SSRI, SNRI, Gabapentin, or clonidine may have a limited role
- Alternative therapies
- Treatment of Vaginal Atrophy:
- Lubricants
- Eg, KY Jelly ®, Astroglide ®, etc, as needed or on a regular basis
- Replens ® on a regular basis
- Local hormone therapies- more effective
- Estring ®
- Vagifem ®
- “Low dose” topical estrogen
- • Cochrane review found ? more risk of endometrial hyperplasia,
- Premarin ® vaginal cream .5 gm biw studied for one year
- Systemic hormone therapy
- Only indicated if also used for vasomotor symptoms
- Efficacy is similar to placebo:
Testosterone in the treatment of low libido:
- Doesn’t seem really any better than placebo
Urinary Incontinence:
- See One Note
Vitamin D:
- See notebook
Practice Updates:
Best treatment for Neuropathic pain:
- Checked b12 etc. Pain not well controlled with gapentin
- The combination of Nortriptyline plus Gabentin are superior to either alone
- Side effect profile wasn’t horrible
- Consider high dose combination therapy for refractory diabetic or post herpetic neuropathy
What can you add to a Statin: (NIACIN unless the patient can’t handle it)
- Ldl less than 100 and HDL less than 50
- Ezetamibe (Zetia) 10 mg per day or Niaspan 200mg
- Early termination of study at 14 months
- Group that had the best change is the niacin group
- Extended release niacin
- Side effects were pretty high
- ADD NIACIN ER to standard statin therapy as it seems to confer better effect, really increases the HDL
Is there a benefit to high rate control in A-Fib
- Lenient vs. Strict rate control
- Goal was to get resting HR less than 80
- 40% of patients needed a BB plus digoxin
- Bottom line for practice we should target HR from 90-105 resting. There was no value to targeting lower rates and there may be increased risk
Is Testosterone safe for men with moderate levels of testosterone deficiency:
- Example 75 year old man healthy and active want to feel better
- Topical testosterone gel 1% gel 10gm daily adjusted to 15gm if testosterone level under 500ng (target testosterone) go from 300-1000 normal range (total testosterone)
- Low normal like 258
- Their ability to generate strength was really in the legs the big muscles see the slide
- Had serious Cardiovascular SE’s Cardiac events up 10 fold and Atherosclerotic changes much higher and this is just after 6 months. Big Litany of horrible Cardiovascular SE’s
- Bottom line: testosterone will increase strength bit in this high risk but active men with at worst low normal testosterone levels
- Several died
Blood Pressure for Type 2 Diabetics
- Intensive control less than 120 in one group
- Less than 140 in the other group
- 5 year study average was 120 for aggressive group, and 135 for other group
- The aggressive management of blood pressure showed no benefit but only side effects: 2x as many bad side effects
- The Notion of being aggressive in blood pressure management
- Target should be around 135 for Pt.’s with type 2 DM
- This was a 5 years study could there have been a better outcome with more time
Calcium and risk for MI
- Is it safe to encourage calcium supplementation
- 500 mg of Calcium over 40years of age
- Out of 190 studies published 162 excluded
- They had patient level data on a very small group
- Mostly in there 70’s and mostly white
- Statistically 30% higher risk of heart attacks in people who took CA
- No increased risk of stroke or all Cardiovascular outcomes or death
- For every 100 patients given calcium for 5 years (see slide0
- Bottom line: Calcium could increase risk
- Profoundly flawed study! Should not have been done
Give gabapentin and neurotriptaline. Lyrica is a metabolite of Gabapentin (side note).
Add Niaspan to patients with low HDL (average dose of Niaspan pushed to tolerance start with 500 QHS trying to get to 2000 QHS) but stop at tolerance. If LFT’s increase would stop the Niacin. He denies knowing of a case of hepatic failure on the Statin or significant liver damage. Increases of HDL in 5 points equals a 10point decrease in LDL.
Target 98-100
Don’t give testosterone if pt.’s 300 and above. Testosterone in old men like 80 and above it may be tempting to give a little testosterone, but this is a dangerous pathway. Androgens enhance the risk of prostate CA and a host of cardiovascular events.
For men with low range of testosterone we need to follow these levels for example pt. with 150 and low free testosterone. Get to a target level of 300 -400.
Patients with type 2 dm aim for 135
Need more data on the Calcium debate
Contraception Update:
- I didn’t know eve it must have been something you ate
- BCP still the most popular method
- Condoms 10 percent share
- IUD 3.4 percent
- DMPA 2%
- IUD:
Has highest satisfaction rate
No increased risk of tubal infertility
Mirena 5 year Progesterone only
Pill had it’s 50 year anniversary last year 1’st pill contained 150 micrograms of estrogen
-
- Popularity of extended cycles
- Quick start
- First bcp taken on the same day of the office visit
- Perform pregnancy test
- Emergency contraceptive given if unprotected sex prior
- Repeat pregnancy test in 2 weeks
- Impact on Break through bleeding
- Use back up method for the first 7 days
- New Gen: reducing the pill free interval
- Lybrel 365 days per year
- 80 percent had no bleeding
- 60% of people stopped this pill because of break through bleeding
- Why shorten the pill free interval
- Reduce the risk for follicular development
- Reduces sx’s during hormone free period
- New OCP released in August 2010
- Wh new
- Contains estradiol valerate which is converted to estradiol valerate
- It is a 4 phasic OCP
- With this pill you have a higher level of breakthrough bleeding
- The First 4 Phasic Pill
- It has Dienogest (a new progesterone agent) it is anti androgenic does not have anti mineralocorticoid part
- Hormonal patch and ring:
-
- Patch around since 2001 in 2005 study came out showing 60%higher than the 35mcg ethinyl estradiol OCP
- Showed 2x higher risk of DVT compared to pill
- Another study showed no increased risk
- DO not use in OBESE women with weight of 90KG (not as effective and higher risk)
- Nuva Ring:
- Efficacy same as the pill
- Patients should leave it in for all 3 weeks
- 90% say it is not an issue during intercourse if it comes out need to put it in under 3 hours, if it is more than 3 hours need to use Condoms for 7 days
- 2006 the Iplanon
- DMPA 0.4 pregnancies among 100 women-years
- Suppresses ovulation
- Suppresses estrogen production as well
- Majority of studies show a loss of BMD especially if used prior to age 20 or more than 2-5 years.
- Black box warning, should really not be used for more than 2 years.
- Avoid use in women over 35
- Ensure adequate calcium intake, exercise and stop smoking
- In long term users, DXA scan?
- After you D/C BMD returns to baseline
- ½ of pregnancies unintended in US
- Emergency Contraception:
- 2 options:
- See slide for dosing of OCP’s that can be used as Emergency Contraception using your slide
- Plan B: take one tab and repeat in 12 hours within 72 hours. Just as effective if you take both pills at the same time!!
- Alternative to plan B: crazy amount of pills
- New Addition: ELLA
- Take one tablet as a single dose approved in August 2010:
- Able to block ovulation even after the LH starts to peak
- Has been FDA approved for up to 5 days (120 hours after intercourse)
- Condom:
- Get Printed out instructions on how to put condoms on and take them off
- Help them deal with a reluctant partner
- DOWNLOAD HANDOUT WITH GREAT INFO
- Remove IUD when menopausal
- If pt. is 35 and smoker or CAD need alternative non hormonal method
- Pt. can be on something like LIBRYL indefinitely there is nothing wrong with not having a Period.
- 2 options:
-
- Wh new
- Lybrel 365 days per year
SLEEP:
- Sleep is not something left to be done when there is nothing left to do
- What factors influence sleep
- Sleep deficit
- Circadian clock
- Sleep pressure = sleep deficit +circadian sleep drive
- Sleep drive
- Circadian rhythm runs in a 24:09 hour cycles
- Very sensitive to light
- Wake up with no pull to sleep and after lunch post-prandial drive
- Reaches its peak at around 3 am, and seems to really start building at 10pm
- Bright light in the evening delays sleep onset
- Bright light in the morning advances sleep onset at night
- 1 lux =light from candle at one meter
- 50 lux is all that is needed to alter circadian phase
- Melatonin ingested 5-6 hours prior to natural melatonin release will advance circadian drive
- If you delay the circadian rhythm by 3 hours it screws it all up
- Genetic Predisposition (owls versus larks)
- Is it possible to be an owl and a lark?
- Constant fogginess of sleepiness
Interventions:
- Keep to a fixed wake up time both weekdays and weekends, vacations
- Lots of bright light exposure, activity in the mornings
- Avoidance of naps
- Enforce good sleep hygiene
Sleep Hygiene:
- Schedule
- Light exposure
- Distractions (turn off the distractions) THIS IS THE BIG ONE
- Stimulants
- Night activities
- Use of bed for work
- Clocks
Behavioral insomnia of childhood
- Limit setting disorder
- Refusal to go to bet or refusal to turn to bed following nighttime awakening
- Insufficient limit setting by the caregiver to establish appropriate sleeping behavior in child
- Can be confused with anxiety disorder, PTSD
- Sticker chart
- Establish a regular bedtime routing
OBESITY:
- 1 out of 3 kids in California are overweight or obese
- 20 years ago bagel 140 calories and 3 inches
- Now 350 calories and 6 inches
- 55 minutes of walking to get rid of those calories
- To examine the effects on the prevention of overweight and obesity among Latino children ages 2-5years of age
- At 4 40% were obese
- Merged parent training and the addition of physical activity
- Parenting component
- FOOD INDUSTRY IS RESPONSIBLE FOR HEALTH CARE COSTS
- Praise, routines, commands, ignore, setting limits, time out
- Schedule in: nap time, TV time, meals and snacks, exercise and play time
- Assigning times: move backward, Plan for children’s speed (kids work at a slower speed)
- Common mistakes: parents get up to late and put children to bed too late.
- Children in childcare were protected from obesity compared to those cared for by relatives (probably because of routines)
- Meal as a family, nighttime sleep, and less TV time (best indicator for lack of obesity in children)
- DO NOT USE FOOD AS A REWARD or A PUNISHMENT
- No fruit juice
- Healthy breakfast
- Increase to 5 fruits and vegies per day
- 5 ingredients to avoid (Laminated Card)
- Sugar
- High Fructose Corn Syrup
- Enriched Flour/White Flour
- Hydrogenated Oils
- Saturated and Trans Fats
- No more than 2 hours of screen time per day for 2 year olds and over and 0 time for under 2
- 5-2-1-0- blast off
- Pedometers (buy Pedometers for everyone)
- Have classes in pre-school and family centers
- Education and Support
- 55--22--11--0 Blastoff! 0 Blastoff!
- • 5: or more fruit and vegetable servings
- per day
- • 2: No more than 2 hours of screen
- time per day p y y for 2 year olds and
- over and 0 time for under 2
- • 1: year or more of breastfeeding with
- appropriate foods introduced at
- Around 6 months.
- • 0: sweetened beverages
- • Blastoff: Move, be active and have fun
This is what I need to do:
- Make a card (Wendy Slusser, MD, MS)
- 54321 blastoff
- [email protected] (write her and ask for the Spanish and English versions of this)
- Fast food restaurants still take food stamps
Treatment of Depression:
- Persistence will change somebody from 30% to 80% chance of becoming better
- Persistence of symptoms is the norm
- Limbic symptoms of worthlessness helplessness
- If you ask the patients are you all the way better: they may say no, and that left over lingering part is what affects your quality of life
- Patients want to see family practice not shrink say we have a consultant
What is initial management:
- Recheck H&p and labs
- Sig E Caps
- Sleep interest guilt energy appetite suicidality
Tactic:
- Increase what is working first and then add a second agent
- Suspect 4-6 weeks to see significant improvement
- See the patient back in 2-3 weeks and then in another 2-3 weeks
- Switch agents when facing a non-response after a dose increase
- Augment with a complementary second antidepressant
- First start with celexa or Zoloft, if no effect in 4-6 weeks increase the dose, then check again in 4-6 weeks, if no improvement add wellbutrin
- Consider a more specific agent when residual symptoms are clustered
- Atypical antiphsychotic (low dose)
- Buspirone
- Traditional psychostimilant
- (ar) modafinil
- If you ask if anything is left you will see a symptom cluster, having trouble with anxiety or sleep
- Ok to be on three agents: example
- Zoloft 50-100
- Wellbutrin SR (bupropion is generic)
- + low dose atypical antipsychotic or buspirone =
- Concentration/energy is problem2.5 mg of dexophenermine if no response may titrate up to 20mg once daily
- Mildafonil or armadafonil:
- Lots of anxiety and trouble sleeping: low dose ½ of smallest pill of atypical antipsychotic. (example dyprexa 2.5 mg? look up dose)
- Email dr john r sharp
- Concentration/energy is problem2.5 mg of dexophenermine if no response may titrate up to 20mg once daily
- PEARL
- Partnership
- Empathy
- Respect
- And legitimization
- Emotional Calendar: (have people track their feelings on a colander to see the pattern that they may be developing)
- Explains seasonal shift
- Recognize and learn to anticipate periods of increased stress, distress, turmoil and drama
- Make specific doctor-ly recommendations
- If counseling does not help then they may have a major depression, it is good to be kind but maybe we are undertreating.
- After you bump up the dose with one med and no help get rid of that medicine and change to something else
- Cross taper, go down to 20 then 10 and then stop, simultaneously as you decrease this agent start the next agent and increase the dose of the other agent
- BOOK : FEELING GOOD (check it out)
- How long to treat: (dance with the gal who brought you) stay with whatever combination is necessary to achieve remission: clock starts when they are better and then have them stay on it for 6-9 months and then consider tapering.
- If they relapse consider 6 months – 2 years
- If continued relapse they may need to stay on it
Medicines for the Female mind:
- Depression in women is different in women than in men
- PICTURE OF MEN AND WOMEN ON SWITCHBOARD
- Women are 2x as likely to be depressed as men (worldwide)
- Not only true for major depression but also dysthymic
- Is life harder for women? Yes
- Women are more likely to be reumative, to blame problems on their appearance, and blame problems on what people think about them
- Women more likely to ask for help
- Women more seasonal depression
- More somatic symptoms
- More comorbid anxiety and eating
- More hypothyroidism
- More IBS, more headaches, more somatic symptoms of mood
- More suicidal ideation less suicide
PMDD:
- Not a DSM 4 diagnosis
- Physical and emotional symptoms that dissipate on the 1st or second day of menstrual cycle
- Pms is physical symptoms
- Pmdd is psych symptoms
- 3-9% of women worldwide
- Perspective rating scales for 2 months
- Aerobic exercise
- Caffeine restriction
- Calcium supplements may help
- SSRI’s will alleviate PMDD immediately in over 85% of patients
- Zoloft, Paxil, and Prozac fda approved for PMDD
- If already on low dose bump up the ssri 2 weeks before period and then go back to low dose for 2 weeks and on and on
- RX for 12 months and then see if sxs return if it returns put them back on medication
- Physical sx’s improve (no explanation for that)
- Sexual side effects:
- Viagra in women can help the sexual side effects of SSRI’s
- Oral contraceptive is also an option for treatment
Pregnancy and depression
- Women are happy when they are pregnant (hell know) pregnancy offers no immunity to depression.
- 10-16% of women will get depressed during pregnancy
- Impact of untreated depression in fetal de. Unclear
- No drugs approved in Pregnant women
- RISK:
- We don’t think there is any real risk to fetus in first trimester
- WE WORRY IN THE THIRD TRIMESTER: discontinuation syndrome can affect the baby significantly
- SSRI’s most studied, we would never even consider any other type of med
- It is a risk benefit ratio
- All are category C except Paxil, which is now category D: persistent pulmonary htn in infants
- 1st trimester fine 3’rd trimester big worry
- Pregnancy and ECT
- Safe and effective without risk to fetus
Postpartum Depression and Postpartum Blues:
- Blues do not need intervention 50-70%
- Depression 10%
Blues:
- By day 4 goes away
Depression:
- 4 weeks after up to a year
- If hx of depression at higher risk
- Marital problems etc….
- Edinburg Postnatal Depression Scale
- Fear of being labeled a bad mother
- Is there a gene, looks like there may be
- Consider bipolar illness
Breastfeeding and Antidepressants:
- Meds are excreted in breast milk but in much smaller quantities
- Seems safe, ok to give them SSRI’s as long as baby is coming in for regular well child care
- So say to mom it is OK to continue SSRI but make sure baby comes in for regular check ups
Menopause
- Can use ssri’s
- Can give Neurontin (titrate to efficacy, it is generic and therefore cheap}
OBESITY:
National Weight Control Registry
- Have to have kept of 30 lbs. of weight loss
- People on registry have lost 66 lbs.
- Intensive counseling does work
- Intensive counseling 10 year follow up showed 34% decrease in DM
- 2 yr. rct of wt watchers vs self help
- What happens 2x more likely to lose weight if you tell them they are overweight
- Motivational interviewing: Miller and Rollnick www.Motivationalinteriewing.com
- Express empathy
- Help patient develop the discrepancy
- Roll with resistance
- Express confidence that you patient can change
- On a scale of 1-10 how interested are you in losing weight
- How confident are you you can achieve your goal, if confidence level is less than 8 ask why
- Realistic goal is to lose 1-2 lbs. per week
- At 12 months all began to regain
- Average weight loss of 9lbs per person in each group
- Loss of 1 pound requires a deficit of 3500 calories for a week
- Decrease calories by 500/day
- 500 per day x 7 days
- www.thedietplate.com (9-5 dollars on amazon
- Suggest meal replacement
- Walking 1 mile is 100 kcal
- Buy pedometers
- 30 minutes 2x per day is the same as 60 minutes at one time
- BOOK THIN TASTES BETTER
- Key strategies
- Self-monitoring
- Stress management
- Stimulus control
- Problem solving
- Social support
- www.Sparkpeople.com best free diet website
- drug therapy:
- bmi >30
- pt. with BMI >27
- Orlistat: decreases fat absorption dose 120mg tid
- Low dose is OTC
- Phentermine: increases norepi can cause htn, only officially approved for 3 months
- Cost 70 bucks per month
- Longer use need informed consent
- Sibutramine taken off the us market
- Fda declined to approve 3 new obesity drugs
- Bariatric Surgery
- Bmi 40 or higher
- Or 35 or higher with comorbid conditions
- New recommendation: lap band approved for patients with bmi of 30-34 with one or more obesity related complications
- 60-70 percent of excess bodyweight is average loss in 2 years, excess body weight is pre-op- ideal body weight
- See calculation
- Affects gut hormones in wonderful ways
- Laparoscopic banding:
- Average weight loss is 45% excess body weight at 2 years
- Sleeve Gastrecomy:
- Safer than bypass
- More weight loss than the lap band
- LOOK AT comparison of procedures
- Long term: 88 % diabetes resolved
- Mortality decreases in all-cause mortality in surgical group
- Caring for patients post bypass:
- Endocrine society guidelines for care after bariatric surgery
- Anticipate 25 percent weight gain over 10 years
- Cbc lft’s lights glucose and creatinine
- Iron b12 folate, pth albumin, vit d
- Check every 6 months for 2 years
- Bmd annually
- ANOTHER GREAT SLIDE
- Motivational interviewing
- Refer appropriate patients for bariatric surgery
Dr. Jane S Sillman
What if the provider is obese what do you say to the patient
- We need to see if chbby doctors or skinny doctors do better
No data to support efficacy of one diet type over another, depends on what the patients preferences
HCG diet: seems to be very popular
Office ENT:
- Eustachean Tube DSFXN:
- Tympanogram
- Saline lavage and nasal steroids
- Oral corticosteroids
- Gerd tx
- Pinch nose closed and valsava against pressure
- Tx: antibiotics
- Tubes
- Hemotympanum: (usually as the result of a trauma)
- CAT Scan and an audiogram may be 2ndary to a temporal bone fracture.
- Tympanosclerosis:
- White plaques on the surface of the TM
- Sign that there have been infections in the past
- No treatment unless it doesn’t function right
- Tympanic Membrane Perforation:
- Oral antibiotics
- Ear drops to sterilize and prevent infection
- Dry ear precuations:
- No swimming
- Cotton ball
- 3-8 week period of time usually get full recovery
- If there is constant inflammation may need
- Otitis Externa:
- Anti Psudomonal drops and orals
- Otowick placement: remove after 2-3 days
- Malignant otitis very uncommon
- Any facial nerve weakness is an emergency: high dose antibiotics and possibly surgery
- Exostosis (surfers ear)
- Coming when they have pain and loss of hearing
- Nasal Polyps:
- Plain films of sinuses are worthless
- CT is the gold standard: LIMITED CT SCAN of the SINUSES
- Antibiotics
- Steroids
- Sinus lavage
- Lots of recurrence
- Nasal Septal Hematoma:
- Huge buldge at the tip of the nose after a trauma
- Can develop into a deformity
- Mucocele:
- Needle aspiration does nothing for this need to get the duct
- Oral Leukoplakia:
- White plaque on lateral aspect of the tongue
- Tonsillitis:
- Don’t forget to think of a Lymphoma (especially if there is an asymmetry)
- Peritonsillar Abcess:
TAKE HOME:
- DM
- Cholesterol: Use Niacin possibly adding etia
- Pain: use combo of Gabipentin plus neurotriptaline
- Depression: 1 + 2 + 3 step therapy
- Peds: Card for weight loss program
- ENT: possible Lymphoma if asymmetry
- 2/3 of all opiods given in the world are in the US number one prescribed drug!