Thinking about procreating?

Whatever you call it – up the duff, knocked up, a bun in the oven or eating for two, before getting pregnant there are a couple of things worth considering. Now because I am a doctor and I’m not supposed to get judgmental, I’m not questioning whether it is a good thing for you at this time in your life career or relationship, nor will I question the choice of you partner, I’ll leave that discussion to your Mum. What I would like to suggest is the opportunity to chat about some of the medical issues around pregnancy and if there are tests or other things that need to be done beforehand.

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If this is your first pregnancy, there is a lot of information out on the internet. You will find everyone has their own opinion on many aspects of pregnancy from trying to predict the gender of your baby, what foods to eat and avoid, how generally how to live your life.

If this is not your first pregnancy, many authorities suggest waiting at least 18 to 24 months before planning to try again.

New technology means you can and your partner can undertake genetic screening. Certainly if there a family history of a chromosomal or genetic disorder, testing has been recommended by RANZCOG.

For everyone else, screening for carrier status for common genetic conditions are available at a price.  These may include conditions such as cystic fibrosis, spinal muscular atrophy and fragile X syndrome. This article from The Conversation discusses whether you may or may not want to spend your money. And what would you do if you discovered both of you were carriers?

Although having a pap smear during pregnancy is not difficult and wont cause a miscarriage, it may be worthwhile getting it done beforehand. Remember that this year how we do cervical cancer screening has changed. And whilst we are talking about pap smears we should mention preventing, screening for and treating sexual transmitted infections, viral hepatitis and HIV.

Do you both need to make some lifestyle changes? Remember, to make a healthy baby it is often said you need healthy sperm and a healthy egg, Not unsurprisingly, a lot of things that many people do on a daily basis can have an adverse effect on a pregnancy. There are some obvious things, like smoking tobacco and cannabis, drinking alcohol and using other drugs.

If you are eating a healthy diet then this is a good start. You may need to be a bit more careful with food preparation to avoid germs such a Listeria and Toxoplasma. The “avoid food list” usually contains paté, soft cheeses (eg feta, brie, blue vein), prepackaged salads, deli meats and chilled or smoked seafood. In addition some fish may contain high levels of mercury which is toxic.

Should you take extra vitamins? Currently there is good evidence for taking extra folic acid and iodine, but if you are eating a healthy diet then multivitamins, including those pregnancy vitamins, are probably a waste of money.

Challenging yourself to keeping to a healthy weight through regular exercise and a healthy diet can help make pregnancy safer. Maintaining a healthy weight may improve the chance of getting pregnant or fecundity. For some women this may mean gaining weight or for others loosing weight.

Prescriptions medications, and I’m not just talking about the contraceptive pill can affect a pregnancy and may need to changed. Medications available over the counter or from the naturopath may also need to be discussed.

We should also talk about known medical illness like asthma, epilepsy, high blood pressure and diabetes before embarking on a pregnancy. How’s your mental health. Are there any pregnancy problems that seem to run in your family?

Do you need to see a dentist? There is some evidence that having periodontal disease can can have an adverse effect on your pregnancy.

Are your immunisations up to date? Some immunisations can’t be used in pregnancy as they contain live virus. These include Rubella and Chickenpox. Both of these illnesses can cause harm to your developing baby and a vaccination will provide protection from these illnesses. Other vaccinations such as influenza and whopping cough (pertussis) are recommended in pregnancy.

Have you planned an overseas holiday when you could be pregnant? Will it be safe to fly, will the airline let you fly. Would you travel insurance cover you having a baby out side of Australia. What would you do if you went into premature labour in Mongolia? Malaria can be bad for a pregnancy. There are some uncertainties around other infectious diseases such as Zika and Dengue fever, to name but a few.

Are there any test that need to be done apart from those mentioned already? I would usually check your blood group and consider other tests as guided by the consultation.

Now lets talk about how you need to have sex to get pregnancy…..oh you already know that. And when is the best time to have sex for a baby not just fun? Great.

 

 

 

 

 

 

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Please ask!

Too often I am told whatever you think doc.

I can see the point of this question, after all, I spent four years training to be a pharmacist, then another four to be a doctor, and six more years to pass my fellowship exams to become a GP with ongoing active education. Not a day goes by when I cant say I learn’t something new. My patients are often my greatest teachers.

But may I encourage you to questions your doctor, because it is after all your health we are talking about.

Choosing Wisely Australia is helping healthcare providers and consumers start important conversations about improving the quality of healthcare by eliminating unnecessary and sometimes harmful tests, treatments, and procedures.

Here are 5 questions to ask your doctor

1. Do I really need this test, treatment or procedure?

Tests may help you and your doctor or other health care provider determine the problem. Treatments, such as medicines, and procedures may help to treat it.

I have been taught that you order a blood test to answer a clinical question, for example, could this patient have an over active thyroid? Tests are not for fishing expeditions!

I have had some challenging consultation after a patient has seen a naturopath trying to determine which tests might be clinically necessary. The RACGP has come out with this document to support the decision making process.

2. What are the risks?

Will there be side effects to the test or treatment? What are the chances of getting results that aren’t accurate? Could that lead to more testing, additional treatments or another procedure?

Some tests, treatments and procedures provide little benefit. And in some cases, they may even cause harm. For example, for most lower back pain an x-ray may lead down a path of ending up with more invasive treatments which may not help. 

Even blood tests are not without risk. Any sharp instrument going through the skin can lead to infection!  An imperfect screening test for prostate cancer, Prostate Specific Antigen may lead a bloke on the pathway to a painful biopsy, then surgery which may leave him impotence and incontinent for the rest of his life. All for removal of a potentially slow growing cancer that he may have died with rather than from.

3. Are there simpler, safer options?

Are there alternative options to treatment that could work.

To reduce the risk of a heart attack, should you take a cholesterol lower medication with the risk of side effects or cut back on fast foods and exercise more?

Is it safer to take a tablet or injection to improve you B12 or iron levels?

4. What happens if I don’t do anything?

Ask if your condition might get worse — or better — if you don’t have the test, treatment or procedure right away.

This is a most challenging question because a doctor is trained to do something. Push on a chest, give a drug, order an x-ray, cut out badness…..
But sometimes doing nothing is all that is required. Recently, I chatted with a palliative care nurse who told me about a patient’s distress that the doctor who operated on her cancer didn’t visit in her final week. I replied it was probably because the doctor felt he had nothing to offer, that he had failed to cure her. But the patient wasn’t angry that the surgery didn’t work, she didn’t want more procedures, tests or medicine, she just wanted him to be present for a moment, to be seen at her door, to care. That was all. Sometimes it is okay to do nothing.

5. What are the costs?

Costs can be financial, emotional or a cost of your time. Where there is a cost to the community, is the cost reasonable or is there a cheaper alternative?

I meet people who seem genuinely surprised that they don’t necessarily need to see a specialist dermatologist for a skin cancer check; that a GP is able to do this usually then and there.

 

Why I don’t see Drug Reps

It’s not just about the pen!

A very small part of the Dr Caren’s collection of Drug company pens

Should I continue to use drug reps as my primary source of information about new drugs?

There is certainly support out there if I do go down this path. There are doctors out there who already say no to drug representatives.  http://www.nofreelunch.org/ and http://noadvertisingplease.org/

Dr Brett Montgomery has written on the subject here  https://theconversation.com/why-i-dont-see-drug-reps-a-gps-take-on-big-pharma-spruiking-32435

And it’s not just doctors that they target, nurses are also seen as a way into the prescribing sphere of influence. https://theconversation.com/invisible-influence-why-sales-reps-are-forming-relationships-with-nurses-57061

Here is the New Zealand perspective https://theconversation.com/drug-ads-only-help-big-pharmas-bottom-line-so-why-are-they-allowed-45317

As this paper entitled Following the Script: How Drug Reps Make Friends and Influence Doctors from a few years ago suggests

“Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful.”

Dr Ben Goldacre has blogged on his BadScience website and written on the influence of pharmaceutical companies on drug utilisation.  After eventually making it through his book, Bad Pharma I felt a very pessimistic about the whole process. It’s a bit like House of God, essential junior doctor reading.

A list of problems include

  • Missing clinical data which the rep probably doesn’t know about either
  • Positive paper publication bias
  • Ghost writers instead of academics
  • No decent independent head to head studies, so what if me2 is better than placebo is it better than the first drug?
  • Kick backs to medical journals
  • Half blind public agencies
  • Statistical manipulations and sub-subgroups analysis
  • Glossed over serious adverse effects. “The risk of thyroid cancer with Saxenda is over rated!” or “No that only happens in beagles”
  • Glossy brochures and advertising in journals.
  • Pushy drug reps and their inducements – which do seem limited to lunch rather than international flights these days.
  • Leaving behind drug samples as starter packs
  • Subsidising patients support groups and turning them into pharmaceutical lobby groups
  • Product familiarisation campaigns
  • Breaking news on popular media dressed up as “news” stories
  • Chatting in the ear of the clinic nurses, who also look after the sample cupboard. I wonder if any rep has suggested that the oppositions product be pushed to the back or even in the bin?
  • Paying specialists to “educate” GPs
  • Creating a “disease” to sell a product, eg fibanserin for a woman’s poor libido

As a health professional am I impervious to drug rep propaganda? I think the evidence suggests NO.

A few hints include the average sales force expenditure for pharmaceutical companies is $875 million annually and that is just in the USA. Being Australian, I am of course more skeptical and cynical but even so it has been estimated that in 2012, $30 million was spent by pharmaceutical companies trying to persuade doctors to use their product. I think it safe to assume no one would spend that kind of money if there wasn’t some return.

So where to find unbiased information?

National Prescribing Service would be a good place to start in Australia.

This paper by Richard O Day and Leone Snowden details other useful sources of drug information.

I have also listened to this podcast about conflict of interest. Sam Manger talks about how we may be able to immunise ourselves against drug rep influence.

 

I think these are pretty good reasons why we have decided drug reps don’t visit the clinic I work in.

Time Out from School – Not fun.

Sometimes your child may not be able to attend school or day-care because of an infectious disease.

Of course, this can be a very stressful time.  As a parent who has vaccinated his children, I am grateful that my children have missed out on measles, mumps, rubella, chickenpox, meningitis etc. But, they have had their fair share of colds, vomiting and diarrhoea illnesses. As a parent you don’t want your child to be unwell. But when they were unwell I (or my wife, mostly) have had to have time off from work to help care for them. Being at school would be no fun, you can’t concentrate on your lesson with a nose constantly dripping onto your writing, hiding from the bright lights that make the headache worse, or having to run off to the toilet to vomit or poo more watery diarrhoea. The best place for a miserable child is to be with a parent, unless really sick and then that would be in a hospital.

There are Public Health rules regarding how long a child has to stay out of school or day care for certain conditions. These rules help to protect other children from infectious disease such as measles, chickenpox, scabies amongst others. Here are Queensland Health version of the rules.

Why I may sign your fitness to drive form

“Well, Mr Terry I have some bad news. The results of your tests shows me that it is no longer safe for you to drive.”

“But why, young whipper snipper, you don’t understand, I’ve been driving since before you were born……”

One of the harder things I have do as a GP is to tells someone that they should no longer drive and they need to hand in their license. I have lost a few patients along the way because we have disagreed on their ability or competency.  Generally during a consultation, I consider the patient before me, and sometimes their family. But in this situation, I have a responsibility to consider the wide community. In fact, you also have this responsibility as the F3172 form you gave me to sign for your drive medical stipulates.

“If you hold a Queensland driver licence, or are applying for a Queensland driver licence, you have a legal obligation to notify the department as soon as you become aware of any permanent, or long-term medical condition that is likely to adversely affect your ability to drive safely. “

Driving gives us freedom, flexibility and independence but Driving is a privilege not a right. Here is sobering review from the Victorian Coroner on why this part of my job so important and why I should not to be swayed by desire to keep the you happy.

The rule book I use is the Assessing Fitness to Drive handbook.

Some of these rules are black and white. You can’t drive if you can’t see the third line or 6/24 on the Snellen eye chart even with spectacles.

Other rules seem sensible. For example you cannot drive for 2 weeks after a heart attack, which will be extended to 4 weeks if you needed your chest opened for a coronary bypass graft. If you had a cardiac arrest you cannot drive for 6 months and if you have had an epileptic seizure then in general it is no driving for 12 months. Some decisions may need to involve specialist doctors.

Driving and aging

As you get older, how you process information, your vision, and your ability to move changes.

Vision

  • change focus and see detail such as traffic signs
  • see objects and obstacles such as pedestrians or cyclists
  • deal with and recover from glare such as oncoming headlights or the afternoon sun
  • see things in your peripheral vision
  • adjust your vision when going from light to dark or vice versa

Medical conditions such as cataracts, glaucoma and diabetes can also affect your vision.

Movement

  • muscle strength and speed
  • flexibility and mobility
  • range of movement
  • coordination

These changes, plus health problems like arthritis, can affect the way you drive. For example, you may find it harder to turn the steering wheel, change gears or jump on the brake in an emergency.

Information processing

Consider these challenges,

  • driving at peak hour
  • merging onto a busy freeway
  • changing lanes in traffic
  • travelling an unfamiliar route
  • dealing with a busy intersection or roundabout.

All require

  • visuospatial perception (depth perception)
  • insight and judgement
  • attention and concentration
  • comprehension
  • reaction time
  • memory
  • coordination

Hearing impairment, although recognised as not as critical, can be a hindrance to driving safely.

Not all elderly people have dementia. Dementia is characterised by significant loss of cognitive abilities such as memory capacity, psychomotor abilities, attention, visuospatial functions, insight and executive functions. Some of the tests used to help with screening impaired cognition include the Mini mental State Exam (MMSE) or the  Montreal Cognitive Assessment (MoCA), Trial A and B test, General Practitioner assessment of Cognition  (GPCOG), the clock drawing test and taking history from family and friends.

Dementia may affect driving ability in a number of ways including:

  • errors with navigation, including forgetting routes and getting lost in familiar surroundings
  • limited concentration or ‘gaps’ in attention, such as failing to see or respond to ‘stop’ signs
  • errors in judgement, including misjudging the distance between cars and misjudging the speed of other cars
  • confusion when making choices, for example, difficulty choosing between the accelerator or brake pedals in stressful situations
  • poor decision making or problem solving, including failure to give way appropriately at intersections and inappropriate stopping in traffic
  • poor insight and denial of deficits
  • slowed reaction time, including failure to respond in a timely fashion to instructions from passengers
  • poor hand–eye coordination.

In some instances, it may remain safe for to drive with limitations placed, such as within a certain distance or home or during daytime hours. Having a passenger may not help.

Some people may benefit from having an Occupational Therapist assess driving skill. I have had to do this on a number of occasions usually to prove to someone that they indeed are no longer safe to drive. An OT assessment may not be cheap but it does test practical skills that I am not able to do in the consulting room. The major drawback of an OT assessment is the cost involved which may be several hundred dollars. Dementia Australia has several resources which may be useful.

Currently, in Queensland I am not mandated to report a medically unsafe driver, but in general I will. This may change as in South Australia I had to. Of course, I’m not able to take your car keys off you, but if you continue to drive despite a notification, it is illegal and your insurance will not be valid. As your doctor I am provided protection under legislation when giving information in good faith to the department about your fitness to drive.

Options may include walking, public transport, community buses, taxis, family and friends. Importantly, mobility scooters may not be the solution; they offer much less protection in the event of a collision with a car.

If you would like to listen to a podcast on this subject check out the GP Show.

RACV has a useful summary for older drivers.

Age or health related medical examinations to obtain or renew a licence to drive a private motor vehicle are eligible for a Medicare rebate, whilst a commercial license examination is not.

If you think a motorised wheelchair or mobility scooter may be an alternative you should first read the regulations for these. “In all cases, the person in control of the motorised wheelchair must be capable to safely operate the motorised wheelchair.” But this is self determine as a “medical certificates are no longer a requirement for getting your motorised wheelchair registered.”

 

Why I won’t be sticking my finger up your bum… well maybe not?

Lets make a couple of things clear first.

If you visit and ask for a check up, I’ll always start with a series of questions. You may be thinking, “Just give me the blood form” but be patient, the questions are an essential part of the consultation. If you answer No, No, No, No, No, etc…… then I’ll move onto examination like listening to your chest, pressing your belly and checking your blood pressure etc. And then maybe some tests as a way of screening for disease.

Screening by definition is looking for absence of bad stuff in someone who has no signs or symptoms of bad stuff. A good example is a screening mammogram for breast cancer. If you tick yes, I have a breast lump, then no screening mammogram for you. That requires a consultation with your GP and potentially a more comprehensive testing regimen which may require extra imaging, a biopsy and a visit to a surgeon. So, the idea of screening is to find the possible bad stuff before it becomes really bad stuff and makes you sick.

2010-3992-wu

So moving on, who now who gets a finger up the bum?

Once upon a time all men of a certain age were encouraged to attend their GP for annual digital rectal examination (DRE) and prostate specific antigen test (PSA) as a way of screening for prostate cancer. Understandably this may have made some blokes disinclined to come in for any check-up.

For asymptomatic men the Cancer Council, amongst other authorities, do not recommend a digital rectal examination.

Symptoms of prostate cancer include frequent urination, particularly at night, pain when you urinate, blood in the urine and an weakened urine stream. Once prostate cancer spreads it may cause pain in the bones, unexplained weight loss and fatigue. Unfortunately, lots of other things can cause similar symptoms to prostate cancer, such as, sexually transmitted and urinary tract infection and a gradual enlargement of the prostate with with aging that is not cancer, known as benign prostate hypertrophy. There are obviously lots of other things that may cause bone pain, weight loss and fatigue and for those you really should see your doctor.

So what can you do to screen for prostate cancer. Maybe you had a prostate specific antigen (PSA) test? Routine PSA testing for detection of prostate cancer is a controversial issue. New evidence suggests that PSA screening for most men will not provide a survival advantage even if it finds prostate cancer. The Cluster Randomized Trial of PSA Testing for Prostate Cancer trial was run in the UK over 10 years.  This trial of over 400,000 men, aged 50 to 69 years, compared those who had a PSA test to those who didn’t. Not unsurprisingly, more men were diagnosed with prostate cancer PSA group (4.3% versus 3.6%). However there was no significant difference in prostate cancer mortality (0.30 per 1000 person-years for the PSA group vs 0.31 for the control group) after 10 years.

But PSA testing is not really the focus of this blog. If you would like read more look at these links

Cancer Council Australia

“For men at average risk of prostate cancer who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years from age 50 to age 69, and offer further investigation if total PSA is greater than 3.0 ng/mL.”

RACGP

“Whilst the RACGP recommends against prostate cancer screening  we recognise many men will be asking their GPs about screening.”

Now moving back to why I may have to ask to do a rectal examination!

A rectal examination is still part of the examination should you have rectal bleeding, pain or other anal complaints and this includes the 50% of the population who don’t have a prostate.

A rectal exam can find anal warts, haemorrhoids, anal fissures, constipation and prostatitis.

And a recent recommendation from ASHM is that men who have sex with men who are over 50 and are HIV positive should undergo a rectal examination to look for anal cancer. Some suggest this examination even if you are not HIV positive.

Putting some perspective to the incidence of various common cancers.

  • Anal cancer in general population 2/100,000 person
  • Men who have sex with men without HIV 40/100,000
  • Men who have sex with men with HIV  77.8/100,000
  • Bowel cancer 73/100,000
  • Prostate cancer 170/100,000 men
  • Cervical cancer 7.1 cases /100,000 women
  • Ovarian cancer 10.8 cases per 100,000 women
  • Breast cancer 123/100,000 women and 1/ 100,000 men

More cancer statistics can be gleaned from the Australian Institute of Health and Welfare.

So I hope this has made things clearer. If you are overdue for a health check-up go and see your GP, you may not need a rectal exam!

Vitamin B3 and Skin Cancer – a bit more prevention.

A recent study has suggested that vitamin B3 otherwise known as nicotinamide may be able to reduce pre-cancerous skin lesions like actinic keratosis and non-melanoma skin cancers, such as basal and squamous cell cancers.

The Australian Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) study was run over 12 months and published in the NEJM in 2015. The study gave people who had a high risk of skin cancer 500mg of nicotinamide twice a day. The authors found that nicotinamide reduced non-melanoma skin cancer by a quarter with comparable efficacy against both basal cell and squamous cell cancers. If you want to learn about how nicotinamide may do this have a read of these review articles. Role of Nicotinamide in DNA Damage, Mutagenesis, and DNA Repair and Nicotinamide for skin cancer chemoprevention.

 

Aktinic keratosis or solar keratosis

Squamous cell cancer

Basal cell cancer

Lentigo maligna or malignant melanoma

As with all medical advances, there are some caveats.

The trial subjects were considered at high risk defined as those having had 2 or more non-melanoma skin removed in the last 5 years. In reality that would probably be most of my over 50 year patient here in North Queensland.

The benefit of nicotinamide disappeared once the medication was stopped after 12 months.

Nicotinamide was found to be safe for the duration of this study, although some people did complain of nausea. A smaller dose of 500mg once a day may help those and has been shown to have some benefit albeit less.

The nicotinamide used in this study was donated by Blackmores. Just remember that you need NICOTINAMIDE, not nicotinic acid or niacin, as at that dose you’ll end with facial flushing, headache and hypotension with the latter.

Importantly, taking nicotinamide doesn’t replace the need for protecting yourself from the sun by avoiding being out in the heat of the day, wearing long sleeves and pants, wearing a hat and using sunscreen. The study noted that even for these high risk people who have had skin cancer removed, only 50% used sunscreen. Here’s my hint, to help you remember to use sunscreen.

The study didn’t look at incidence of melanomas, apparently that is next on the authors agenda.

If you recognise any of the spots shown above on your face in the mirror go and see your GP.

May I indulge a short but very sad anecdote from a few year ago. Everyone including the butcher and baker told this bloke to get that ugly spot on his cheek looked at. Instead he put on a band aid and ignored everyone including his wife. Finally, when the spot turned into an even uglier, smelly, ulcer he saw a doctor. Alas it was far too late to save him the squamous cell cancer despite surgery and radiotherapy.


References

http://www.nejm.org/doi/full/10.1056/NEJMoa1506197#t=article

https://www.cancercouncil.com.au/blog/the-role-of-vitamin-b3-in-reducing-non-melanoma-skin-cancer/

https://www.skincancer.org/publications/the-melanoma-letter/spring-2016-vol-34-no-1/nicotinamide

https://www.hindawi.com/journals/jna/2010/157591/

http://onlinelibrary.wiley.com/doi/10.1111/ajd.12631/full

Pictures are from a great skin website from New Zealand called Dermnet