FAQ'S - FOR MY PATIENTS


FAQ’S – FOR MY PATIENTS WITH GASTRO-INTESTINAL PROBLEMS

Many of the questions asked my patients can be answered from this American College of Gastroenterology Web-based resource for patients with chapters from a Digestive Health  "Web Book" written by experts from some of the most distinguished medical centers in the United States. These chapters provide an in-depth review for  patients with digestive problems and their families, including cutting edge  information about diagnosis and the latest treatment options of these entities.

I will ask you to read the specific chapter dealing with your disease before responding in more detail to any further questions you may have.

Abdominal Pain Syndromes 
Belching, Bloating and Flatulence 
Biliary Tract Disorders, Gallbladder Disorders And Gallstone Pancreatitis 
Celiac Disease 
Circulatory Problems of the GI Tract - Ischemia 
Colon Cancer 
Common GI Problems in Women 
Constipation and Defecation Problems 
Diarrheal Conditions 
Diverticular Disease of the Colon 
Foodborne Illnesses 
Gastrointestinal Cancers (Esophageal, Gastric, Liver and Pancreas) 
Gastroparesis 
How do I Know Whether I’m Getting Too Many X-Rays and Too Much Radiation?
Inflammatory Bowel Disease  
Pancreatitis 
"Pediatric Gastroenterology 
Primary Sclerosing Cholangitis and Primary Biliary Cirrhosis 
Small Bowel Bleeding and Capsule Endoscopy 
Should I have Surgery to Cure my Ulcerative Colitis?:
Ulcerative Colitis Surgery from a patient's point of view:
Miscellaneous Medical and Surgical Questions and Answers


FAQ’S FOR MY PATIENTS WITH OTHER MEDICAL INQUIRIES:

Many answers can be found in the following sources

MedlinePlus Health Information from the National Library of Medicine
This site can be entered by clicking on http://medlineplus.gov/

See also Medline Plus Medical Encyclopedia
This site can be entered by clicking on http://www.nlm.nih.gov/medlineplus/encyclopedia.html

What about Avian Flu?
I also get many questions from patients and others as to the very much feared pandemic of Avian [Bird] flu which had a lot of publicity in 2005 and also much more in 2006 and beyond. I advise all my patients to follow the impending influenza crisis on the special CDC site specifically updating the facts that are known. These sites can be entered by clicking on
http://www.cdc.gov/flu/avian/

Influenza: [ updated from the Southern Medical Journal, Jan.2006]
- Avian Influenza, 38 pages, 230 references
http://www.influenzareport.com/ir/ai.htm

- Vaccines, 22 pages, 82 references
http://www.influenzareport.com/ir/vaccines.htm

- Pathogenesis and Immunology, 18 pages, 80 references
http://www.influenzareport.com/ir/pathogen.htm


- Pandemic Preparedness, 18 pages, 61 references
http://www.influenzareport.com/ir/pp.htm



Also I get regular inquiries from my medical patients of the past 30 years about other scares picked up by the media. These scares include “mad cow disease” and also of crucial importance where to find out about new threats of medical emergencies caused by bio-terrorism and chemical/medical emergencies. I believe the best information can be obtained about “mad cow” diseases from England where they have had the most experience. The main site is located in the U.K. where a trained team monitor the incidence, and summarizes the research in progress of these human spongiform diseases throughout the world, including the US



The National CJD Surveillance Unit
http://www.cjd.ed.ac.uk/



As far as keeping up-to-date with the medical effects of Bioterrorism, and other mass medical emergencies the very best site is the U.S. Center for Disease Control [CDC].Several sections include Bioterrorism Agents; Mass [Medical] Casualties; Chemical [Medical] Emergencies; Natural [Medical] Disasters; Radiation [Medical] Emergencies, and Recent [Medical] Outbreaks.
http://www.bt.cdc.gov/


What to Discuss With Your Doctor Before You Leave the Office
I'm often asked by my patients what information to get from the specialist who will be doing a procedure on them. I usually list a page full of questions that should be answered in the presence of a family member or friend to make sure that the patient retains most of the information . In crisis situations 4 or more ears are better than 2, because the patient usually screens out information s/he does not want to hear. This article by Ms Parker-Pope however is however excellent for the questions I usually get from my patients and the web sites linked to in the article provides an excellent source of data, which if digested makes it much easier for me as a consulting physician to answer any remaining questions. [from WSW-10/11/04]

The Five Questions You Should Ask if You...Have cancer, are worried about heart disease, or need surgery


I. FIVE QUESTIONS TO ASK WHEN YOU ARE DIAGNOSED WITH CANCER

CANCER•LINKS
http://www.cancer.org
http://www.oncolink.upenn.edu
http://www.acor.org
http://www.clinicaltrials.gov

1.Are you sure? Research at Johns Hopkins University in Baltimore has shown that about 1.4% of the time, a pathologist mistakenly diagnoses cancer, gets the type of cancer wrong or misses a cancer altogether. Errors that can significantly change the type of treatment are even more common. The risk of error depends on the body part and type of cancer. In the Johns Hopkins review, 5% of biopsies involving the female reproductive tract and 3% of skin-cancer pathology reports had errors. In prostate cancer, mistakes are made about 20% of the time in staging and grading, findings that can make the difference between conservative treatments or aggressive surgery. A Northwestern University study of 346 breast cancers resulted in pathology
changes in 80% of cases, including major changes that altered lumpectomy or mastectomy plans for 8% of the women. So, ask for a second opinion from a pathologist who specializes in your type of cancer. Insurance almost always covers the cost. Major cancer centers typically have several specialized pathologists, and the results usually only take a few days.

2.Has my cancer been properly staged? The staging of cancer from 0 to IV indicates the extent and severity of the disease and is the deciding factor in treatment. Patients on the extremes -- with early-stage cancer or late-stage disease -- have the most to lose from a staging error because that's typically where the biggest differences in treatment occur.

3. Are there molecular markers or laboratory tests to show what drugs will work best on my cancer? Selected online resources to help find answers to your health questions

Even if your cancer isn't a candidate for molecular profiling right now, your treatment could be guided by chemo sensitivity and resistance assays - [CSRA]. The CSRA test uses a sample of your tumor in the laboratory
against several combinations of chemotherapy drugs. Most oncologists don't use the tests, instead prescribing drugs based on how they did in clinical trials. But just because a drug performed best in a clinical trial doesn't mean it will work on your cancer. Studies show that patients who get CSRA-guided therapy are more likely to respond to treatment, but the experts disagree on whether using CSRA tests improves survival.

4. Is this the best place for me to be treated?
To start, patients should find out whether their hospital's cancer program is accredited by either the National Cancer Institute or the American College of Surgeons Commission on Cancer. The groups review the quality of the education, monitoring and outcomes.

5. What are the newest treatments for my cancer? Even the most conscientious doctor can't always keep up with recent developments. So keep asking the question, looking to other doctors, patients, support groups, clinical-trial databases, medical journals and the Web to learn for yourself.


II. FIVE QUESTIONS TO ASK TO BETTER ASSESS YOUR HEART-ATTACK RISK

HEART DISEASE.LINKS

http://www.americanheart.org
http://www.clevelandclinic.org/heartcenter

1. What is my Framingham risk score?
Patients should start checking their score as early as the age of 20 and no later than 40, but many doctors still don't use it. If your 10-year risk is greater than 20%, you don't need to know much else. Your risk is high, and most doctors will treat you aggressively and encourage major lifestyle changes, like weight loss and exercise. But patients with a risk of 5% to 20% should probably keep asking questions. The Framingham score doesn't factor in family history or new emerging risk factors, so a prediction of low or medium risk isn't always reliable.

2. What do some of the novel risk factors say about my heart health?
20% of people who have heart attacks -- or more than 200,000 people annually -- don't have one of the four major risk factors.
One of the most useful tests for better predicting heart-disease risk may be a $20 C-reactive protein test, a blood test that measures a protein that can signal inflammation in the coronary arteries. A score of three or higher puts you at high risk, while a score below one is ideal. Some doctors still argue that the test is unreliable or that arthritis or gum disease could trigger a false positive, but nearly two dozen studies support its use. Doctors at the Cleveland Clinic now use CRP as a routine test for patients as young as 20, says Stanley Hazen, head of the clinic's section of preventive cardiology and cardiac rehabilitation. Other novel risk factors include the blood markers homocysteine, fibrinogen or LP(a) (pronounced L-P-little-a), all of which can signal
hidden heart disease. Some doctors are using heart scans to measure calcium in the coronary arteries. Knowing some or all of these risk factors can help a patient decide just how aggressive treatment should be.

3. How is my waist size?
The size of your waist -- greater than 35 inches for women and 40 inches for a man -- is an important predictor of your heart health and may be one sign that you are at risk for metabolic syndrome, a collection of risk factors that make you vulnerable to diabetes and heart disease. A tape measure around the waist is a way to measure the unhealthiest fat in your body -- the visceral fat that accumulates in the abdominal cavity. The fat around your middle is believed to be particularly insidious, secreting damaging proteins and interfering with liver function. Waist size isn't a reliable marker in African-Americans, but for many patients, abdominal fat can signal looming heart disease. Big-waisted patients should carefully monitor triglycerides, HDL (so-called good cholesterol) and blood glucose and exercise to reduce abdominal fat.

4. Is my blood pressure low enough?
Nearly one-third of patients with high blood pressure don't realize it. And nearly 70% of patients with high blood pressure don't have it under control. Hypertension is defined as blood pressure of 140/90 or higher. But people with readings between 120/80 and 140/90 have "prehypertension" and may be at risk for future problems. New research has found that the risk of death from heart disease and stroke begins to rise at blood pressure as low as 115/75. That means damage can start long before people traditionally get treatment. Increasingly, doctors are paying attention to pulse pressure, the difference between the first number (systolic pressure) and the second (diastolic pressure). Pulse pressure is an indicator of stiffness and inflammation in the blood-vessel walls, and studies have shown it to be a strong predictor of heart attack and stroke risk. The ideal gap between the
two readings is between 30 and 40 -- anything above or below that range signals increased risk for heart problems.

5. What can you tell me about my short-term risks?
Much of the focus on risk factors like cholesterol, blood pressure and weight is aimed at lowering a person's risk of heart attack or cardiac complications in the future. But increasingly, doctors are working on identifying those patients who may also be at risk for heart attack in the next few months. Last month, a study in the medical journal Circulation found that very high levels of C-reactive protein in patients with stable angina can signal risk for very rapid narrowing of the arteries. Within the next year, a simple blood test for the enzyme myeloperoxidase, or MPO, can help alert patients with chest pain whether they are at immediate risk for a heart attack. About 26,000 patients a year have a heart attack after being sent home from the emergency room because
existing tests showed they weren't at risk. Women and younger patients are most likely to be sent home by mistake. The MPO test not only indicates who is at imminent risk, but also can help identify those patients most likely to need a major heart procedure or suffer a heart attack during the next six months. Although an angiogram can gauge heart-attack risk, it's an invasive
catheter procedure and typically isn't performed on an otherwise healthy patient. Now, however, doctors using a combination of CT and MRI scanning can assess whether plaque buildup is benign or risky, without subjecting a patient to a catheter, sedation or hospitalization.

III. FIVE QUESTIONS TO ASK IF YOU NEED SURGERY

SURGERY.LINKS
http://www.facs.org/public_info/operation/wnao.html
http://www.usnews.com
http://www.abms.org
http://www.asahq.org/patienteducation.htm


1. How many times have you done this[ specific procedure]?
Of all the questions patients can ask their surgeons, this is the most important. Last fall, the New England Journal of Medicine reported that a patient can dramatically improve his or her chances of survival, even at high-volume hospitals, by picking a surgeon who has performed the operation frequently. In the study, Dartmouth University researchers reviewed the cases of 474,108 patients who underwent one of eight cardiovascular or cancer procedures. In every case, the number of procedures a surgeon had performed made a dramatic difference in mortality rates. Compared with those who had surgery done by high-volume surgeons, a patient operated on by a low-volume surgeon was 65% more likely to die undergoing repair of abdominal aneurysm, 44% more likely to die during aortic valve replacement and 2.3 times as likely to die during surgery for esophageal cancer. Exactly how many procedures is enough to qualify as high-volume varies depending on the surgery. In the Dartmouth study, high-volume surgeons performed more than 162 heart bypass operations a year, compared with fewer than 101 a year by low-volume surgeons. But for a complex pancreatic surgery, more than four procedures annually was considered high volume, compared with less than two by low-volume surgeons. The hospital matters as well. For four of the procedures, the volume of procedures performed at the hospital remained a factor in mortality rates regardless of the experience of the surgeon. In another study of pancreatic-cancer surgery, 16% of patients died during the surgery at low-volume hospitals, compared with 4% at the high volume hospitals. When high-volume hospitals were compared, the difference was still dramatic. The top 10 highest-volume hospitals had an average 2% mortality rate, vs. a 6% average rate by other high-volume hospitals. Hospitals can tell you how their volumes compare with those of other area hospitals. And ranking services like U.S. News and World Report list the volume of hospital discharges for the top-ranked hospitals in 17 specialties.

2. Do you know the anesthesiologist?
A good surgeon will typically work with the same few anesthesiologists.

3. Whom would you go to?
Patients are often referred to a surgeon by their regular doctor or a specialist. Almost without exception, doctors say the best question to ask a doctor is where they would go themselves or send a family member.

4. Can it be done with a less-invasive procedure?
But just because a procedure is less-invasive doesn't mean it's better. Often there's far more long-term data on traditional surgery, and even less-invasive treatments carry risks.

5. What's on the horizon?
Patients should ask if there's something that is going to become available in two or three years that will change the operation

IV. TWO QUESTIONS TO ASK YOUR DOCTOR BEFORE YOUR HOSPITALIZATION.

1. Does your hospital take these steps against acquiring a drug resistant Hospital bacteria.

For patients, the growing risk of life-threatening infections from a surgical catheter, health-care worker or contaminated bed rail is frightening. Each year, studies show, about two million patients -- or one in 20 -- contract an infection after they are admitted to a hospital. Although the Centers for Disease Control and Prevention has a voluntary infection-reporting system, only 300 hospitals participate and report only certain types of infections in certain units, such as bloodstream-infection rates in intensive-care units. The cause of hospital infections is still the unnecessary use of antibiotics, which lead to resistance and the creation of "superbugs." Bacteria that cause the most vexing hospital infections, such as the virulent MRSA strain, have become increasingly resistant to the broad-spectrum antibiotics long used to treat them.

But bacteria's resistance to disinfectants is nowhere near as common as antibiotic resistance, because disinfectants work differently, killing bacteria outright, while antibiotics go after the bacteria and either break down the cell walls or interfere with reproduction -- and bacteria can learn to resist the mechanisms of antibiotics. If microbes escape after a disinfectant is used, it may be because the disinfectant wasn't used correctly. For example, hospital studies have shown that drenching surfaces or "active damp scrubbing" more reliably removes bacteria than quickly wiping with a damp cloth sprayed with the same disinfectant.

Make sure by talking to the nurses and especially your doctor that your hospital does the single most important step in decellerating the spread of bacteria-and that is for health-care workers to clean their hands. Hospitals should also focus on reducing the amount of bacteria present on the patient's skin prior to surgical procedures, using faster-acting antiseptics like chlorhexidine, instead of less-effective iodine products. They should be uusing catheters coated with microbe-fighting compounds and taking more sterile precautions when inserting catheters and intravenous tubes, where bacteria often enter the bloodstream.

For example, a group of hospitals reduced bloodstream-infection rates for central-line catheters by 67% between 2001 and 2005 by adhering to guidelines including using chlorhexidine for skin disinfection before inserting catheters, and prompt removal of catheters when they were no longer necessary. And 14 hospitals working with the nonprofit Institute for Healthcare Improvement eliminated cases of a type of pneumonia for one year, following six relatively simple steps such as raising the head of patients on mechanical ventilators so bacteria don't get into the lungs.

At excellent hospitals bedridden patients in the intensive-care unit are no longer bathed by hand with soap and water from a basin.

Instead, nurses wipe them down with a "bath in a box" -- disposable cloths saturated with chlorhexidine combined with moisturizer. The change was made after a study found that switching to the cloths reduced by 60% the contamination of patients' skin with one of the most powerful strains of antibiotic-resistant bacteria, known as VRE.

Most hospitals aren't doing a good enough job of simple cleaning and disinfecting. Your doctor should insist that the performance cleaning staff of the hospital especially the ICU is reviewed routinely.

Hospital infection-control professionals say that the key is for hospitals to identify bacteria problems unique to their facility, and intervene.

One hospital was alerted by MedMined to a mini outbreak of the bacteria acinetobacter in the intensive-care unit, enabling the hospital to take immediate steps to halt its spread. This system culls information from hospital databases that is already being collected, such as patient admissions and results of tests, and analyzes it for trends. Before the hospital began using MedMined, , staffers had to gather data and analyze them manually: It would take hours per day just to do routine surveillance, and two or three weeks to detect the outbreak and then it's out of control.MedMined, officials say the company's data-mining system is used in 167 hospitals in 26 states. Hospitals that use the system, which costs about $150,000 a year, are able to reduce infections acquired in the hospital by 13% to 20% and cut losses by about $5.35 for every dollar they spend.

Adapted from March 9, 2006 WSJ

2. Does your Hospital have the Link Could Catch Infectious Outbreaks Early?
With the growing pace at which avian flu is spreading globally, health officials are looking to make bigger strides in the rapid detection of infectious outbreaks. Since the beginning of February, the H5N1 avian flu virus has spread in animals to several more countries in Europe, the Middle East, and Africa, raising the specter of more human infections.

For decades, doctors mailed handwritten reports that were used by federal officials to track diseases. Paper surveillance systems were becoming inefficient, but the Sept. 11, 2001, terrorist attacks and rapid spread of bird flu and SARS, or severe acute respiratory syndrome, made them obsolete.

Thus113 hospitals in North Carolina are expected to be linked to an electronic database that state officials scour at least twice a day for warning signs of infectious-disease outbreaks. The system, already up and running in 72 hospitals, recently helped health officials diagnose an illness at a college sorority as a food-borne infection rather than a stomach virus about 12 hours after the first students sought medical care. Now, the Centers for Disease Control and Prevention is developing a similar -- but national -- electronic surveillance system called BioSense that is designed to help health officials spot an outbreak soon after infected people show up at emergency rooms. BioSense is expected to link 250 hospitals in more than 30 cities to servers at the CDC's Atlanta headquarters. CDC officials will look at disease patterns in several major metropolitan areas at once. State and local health officials will be able to tap into the system to review data collected on symptoms and diagnoses of illnesses in their area.

In the event of a bioterrorism attack, or if the bird flu breaks out in the U.S., a broad, rich data that would show how big it is, where it's spreading, and how fast. The system could also help evaluate whether the public-health response is working. The federal government spent $50 million in 2005 on BioSense. But sifting through all the data that pour in from hospitals can be daunting, even electronically. And some electronic databases aren't yet connected to doctors' offices, often the first stop for patients. So those infected by diseases with the highest threat to overall public health still could slip through the safety net. Real-time electronic monitoring of symptoms seen by emergency-room doctors is a huge leap forward.

New York, which has one of the earliest electronic monitoring systems, hasn't limited itself to emergency room data. Collecting information from ambulance dispatches starting in 1998 gave New York City Department of Health and Mental Hygiene officials a "one- to two-week earlier indication of community-wide influenza than we could get from providers and labs. The program now collects data from 50 hospitals that account for 90% of emergency-room visits in New York City.

A new system from a Durham, N.C., company, MercuryMD Inc. also allows monitoring of symptoms, and makes it possible to pull up and review patient records if more information is needed.



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