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.
Bloating and Flatulence
Tract Disorders, Gallbladder Disorders And Gallstone Pancreatitis
Problems of the GI Tract - Ischemia
Problems in Women
and Defecation Problems
Disease of the Colon
Cancers (Esophageal, Gastric, Liver and Pancreas)
How do I Know Whether I’m
Getting Too Many X-Rays and Too Much Radiation?
Sclerosing Cholangitis and Primary Biliary Cirrhosis
Bowel Bleeding and Capsule Endoscopy
Should I have Surgery to Cure my Ulcerative Colitis?:
Ulcerative Colitis Surgery from a patient's point of view:
and Surgical Questions and Answers
FAQ’S FOR MY PATIENTS WITH OTHER MEDICAL INQUIRIES:
Many answers can be found in the following sources
Information from the National Library of Medicine
This site can be entered by clicking on
See also Medline Plus Medical Encyclopedia
This site can be entered by clicking on
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
Influenza: [ updated from the Southern Medical Journal, Jan.2006]
- Avian Influenza, 38 pages, 230 references
- Vaccines, 22 pages, 82 references
- Pathogenesis and Immunology, 18 pages, 80 references
- Pandemic Preparedness, 18 pages, 61 references
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
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]
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
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
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
II. FIVE QUESTIONS TO ASK TO BETTER ASSESS YOUR HEART-ATTACK RISK
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
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
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
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
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
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
Adapted from March 9, 2006 WSJ
2. Does your Hospital have the Link Could Catch Infectious Outbreaks
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
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
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.