APPROACH TO THE PATIENT

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APPROACH TO THE PATIENT HEALTH
MAINTENANCE

• CHAPTER 1

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PATIENT COMPLIANCE

• WHATS THE PROBLEM?
• Compliance is difficult, and is a problem.
• 50 fail
• 1/3 never take their meds.
• drop out prematurely.
• Short-term compliance better
• Long-term difficult
• Compliance better with-
• Medication taking
• Not good with non medication advise

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PATIENT COMPLIANCE

• HOW CAN WE HELP?
• 1) Define / agree on treatment goals.
• 2) Spell out the treatment plan.
• 3) Emphasize the importance of compliance, and
  the consequences of non-compliance.
• 4) During follow-up, ask detailed questions about
  how they are complying.
• 5) Educate, educate, educate!Tell them why you
  want them to do X
• 6) Enlist Family help
• 7) Set up mutually understood goals for
  compliance
• To cure sometimes, to relieve often, to comfort
  always.
• The secret of the care of the patient is in
  caring for the patient.

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National Commission Prevention Priorities

• 2004 data (lt50 utilization)
• Aspirin usage for prevention
• Tobacco use screening and interventions
• Immunizing children, older adults
• Young women screens for chlaymydia

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HEALTH MAINTENANCE DISEASE PREVENTION

• GENERAL.
• PREVENTION OF INFECTIOUS DISEASE.
• PREVENTION OF CARDIOVASCULAR DISEASE.
• PREVENTION OF PHYSICAL INACTIVITY.
• PREVENTION OF OBESITY / OVERWEIGHT.
• CANCER PREVENTION.
• PREVENTION OF INJURIES VIOLENCE.
• SUBSTANCE ABUSE.

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HEALTH MAINTENANCE DISEASE PREVENTION 2009

• GENERAL
• ESTIMATED DEATHS FROM PREVENTABLE CAUSES
• TOBACCO- 467,000
• HGH BLOOD PRESSURE 395,000
• POOR DIET- 216,000
• PHYSICAL INACTIVITY- 191,000
• HIGH BLOOD GLUCOSE- 190,000
• HIGH CHOLESTEROL - 113,000
• HIGH SALT DIET- 102,000
• HIGH TRANS FATS- 82,000
• LOW SEAFOOD- 84,000
• LOW FRUITS/VEGS- 58,000
• LOW PUFA- 15,000
• ACLOCHOL ABUSE- 64,000

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CARDIOVASCULAR PREVENTION

• Abdominal Aortic Aneurysm (AAA)-65-75 smoking
  males
• Aspirin Use-
• BP Screening
• Serum lipid screening
• Counseling healthy diet
• Counseling to promote physical activity
• Diabetes screening
• Smoking cessation and quit

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HEALTH MAINTENANCE DISEASE PREVENTION

• GENERAL
• The 1 cause of preventable death in the U.S. is
  from tobacco-related diseases.
• Therefore, if you had to tell patients one thing
  they could do to improve their health and alter
  the age at which they die, and from what they
  die, it would be smoking cessation.
• Of the 70 of smokers who see a physician each
  year, only 20 receive information on quitting.
• Smokers whose physicians advise them to quit are
  1.6 times more likely to attempt to quit.
• See text pages for smoking cessation strategies,
  tricks, etc.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF INFECTIOUS DISEASES
• IMMUNIZATIONS- Best means of preventing many
  infectious diseases.
• In the U.S., have nearly eradicated measles,
  mumps, rubella, polio, diphtheria, pertussis,
  tetanus.
• Still have work to do on hepatitis A B,
  influenza, pneumococcal infectious (50,000-70,000
  deaths per year in the U.S.).

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Last update10/28/2007
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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF CARDIOVASCULAR DISEASE
• CIGARETTE SMOKING.
• LIPID DISORDERS.
• HYPERTENSION.
• CHEMOPREVENTION.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF CARDIOVASCULAR DISEASE
• MODIFIABLE RISK FACTORS
• 1) Smoking.
• 2) Lipid disorders.
• 3) Hypertension.
• 4) Lifestyle / behavioral factors- activity
  level, diet, weight control, alcohol, etc.
• 5) Diabetes.
• 6) Type A personality, stress.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF CARDIOVASCULAR DISEASE
• NON-MODIFIABLE RISK FACTORS
• 1) Gender.
• 2) Age.
• 3) Family history.
• The good news is that many of the modifiable risk
  factors can be addresses by the same
  modifications diet, exercise, weight control,
  etc., which happen to be the same things one
  would do to prevent physical inactivity and
  obesity.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF PHYSICAL INACTIVITY
• An older non-smoking male who walks at least 2
  miles per day has a 50 reduction in
  cardiovascular mortality.
• Relative risk of stroke is less than 1/6th that
  of those who are inactive.
• Benefits are dose-dependent there is a major
  difference between no exercise and
  mild- moderate exercise, but less difference
  between moderate and vigorous exercise.
• Any activity is better than no activity.
• Gym membership, fancy-schmancy equipment,
  organized sports not required activity can be
  incorporated into anyones daily routine
  stairs instead of elevator, park farther away
  from the office / H.E.B, etc.
• Baby steps.

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LIFESTYLE MODIFICATION
Category BMI range kg/m2
Emaciation less than 16.0
Underweight from 16.0 to 18.5
Normal from 18.5 to 25
Overweight from 25 to 30
Obese Class I from 30 to 35
Obese Class II from 35 to 40
Obese Class III Over 40

• DIET OBESITY
• A risk factor for cancers of the
• Breast, colon rectum, and lung, even in
  non-smokers.
• Increased BMI and hypertension associated w/
  increased risk of renal cell carcinoma in men.
• BMI body mass index kg/m2
• http//apps.usa.gov/bmi-app/
• 2007 Survey 63 of Americans are overweight,
  with 26 now in the obese category (a BMI of 30
  or more)

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF OBESITY OVERWEIGHT
• These data show an increase in the prevalence of
  obesity of 74 compared to 1991.
• Obesity is associated with an increase in type
  II diabetes, hypertension, cancer (lots of em),
  osteoarthritis, cardiovascular disease,
  obstructive sleep apnea, and asthma.
• With the rise in obesity since 1991, the
  prevalence of type II diabetes has increased
  30-40.
• BMI gt 40 associated with a death rate from
  cancer 52 higher for men and 62 higher for
  women compared to the non-obese.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF OBESITY OVERWEIGHT
• Nine million are obese and also smoke
• Obesity and smoking are primary risk factors for
  from early death from several chronic conditions
• 5.3 of men and 4.2 of women are in the
  dual-risk subgroup (African Americans (7) than
  among other racial or ethnic groups, and also
  among people in lower-income (6.5) and
  low-education brackets (6.1).)

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http//www.hsph.harvard.edu/nutritionsource/what-s
hould-you-eat/pyramid/index.html

• Start with exercise.
• Focus on food, not grams
• Go with plants.
• Cut way back on American staples.
• Take a multivitamin, and maybe have drink.

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HEALTH MAINTENANCE DISEASE PREVENTION

• CANCER PREVENTION
• Primary prevention.
• Screening and early detection.

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HEALTH MAINTENANCE DISEASE PREVENTION

• CANCER PREVENTION PRIMARY PREVENTION.
• Smoking.
• UV exposure.
• Obesity- esp. of breast and colon.
• Occupational- asbestos etc.
• Not mentioned in your text is dietary, such as
  diets rich in fiber, Vitamins A, C, E, and
  lower in sugars and fats are associated w/ a
  decreased risk of colon cancer. (ONLY Calcium
  and Aspirin!)

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HEALTH MAINTENANCE DISEASE PREVENTION

• SCREENING EARLY DETECTION
• See text, table 1-2, 1-9 for specifics.
• High yield w/ screening for breast, colon, and
  uterine cervix.
• Controversial for prostate.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF OBESITY OVERWEIGHT
• Weight management is simple, but it isnt easy.
• Its about the balance of calories consumed and
  calories burned. Thats the simple part.
• Its about permanent life-style, dietary,
  behavioral, and psychological changes. Its not
  about dieting, magic bullets, supplements or
  any of that burn fat while you sleep stuff,
  which I cant believe we let them get away with.
  Thats the part that isnt easy.
• Did I mention that these changes need to be
  permanent? As in for life, forever, and always.

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HEALTH MAINTENANCE DISEASE PREVENTION

• PREVENTION OF INJURIES VIOLENCE
• MVAs- seat belts, helmets, etc.
• Domestic violence-
• Alcohol (again)- as it relates to MVAs, domestic
  violence, suicide.
• Prevention of falls in the elderly.

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HEALTH MAINTENANCE DISEASE PREVENTION

• SUBSTANCE ABUSE
• Alcohol, prescription drugs, illegal drugs
  including inhalants.
• Clinician identification and counseling may
  improve the chances of recovery.

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COMPLEMENTARY ALTERNATIVE MEDICINE
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(No Transcript)
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CAM

• AN OVERVIEW.
• HERBAL MEDICINES.
• DIETARY SUPPLEMENTS.
• ACUPUNCTURE.
• (see reading resource supplement f-MRI datasets)

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WHAT IS CAM?

• ACCORDING TO THE NIH, IT IS
• A group of diverse health care systems,
  practices, and products that are not PRESENTLY
  considered to be part of conventional medicine.
• Maybe what is considered to be conventional is in
  the eye of the beholder.

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WHAT IS CAM?

• 5 MAJOR CATEGORIES
• 1) BIOLOGICALLY BASED- substances found in
  nature- herbs, special diets, vitamins.
• 2) ENERGY MEDICINE- Reiki, external Qigong,
  therapeutic touch.
• 3) MANIPULATIVE / BODY-BASED- massage,
  chiropractic, etc.
• 4) MIND-BODY- meditation, prayer, imagery, etc.
• 5) WHOLE MEDICAL SYSTEMS- acupuncture, ayurveda,
  homeopathy, naturopathy, shaman, (Tibetan)
  traditional Oriental medicine,

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FACTS AND FIGURES

• CDC NHIS SURVEY 2003
• 38 of American Adults used some form of CAM in
  the previous 12 months.
• When prayer and megavitamins included ? 68.
• Most popular therapy was prayer, 2nd were the
  biologically-based therapies herbs, dietary
  supplements.
• 1997- 36 billion, mostly out of pocket.

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CAM Usage

• 55 percent use CAM combined with conventional
  medical treatments
• 50 percent CAM interesting to try
• 26 percent used CAM as prescribed by MD and
• 13 percent used CAM because conventional medicine
  was too expensive.

• Prayer-Self, 43
• Prayer by others, 24
• Natural products 19
• Deep breathing exercises,12
• Prayer group for own health, 10
• Meditation, 8
• Chiropractic care, 8
• Yoga, 5
• Massage, 5
• Diet-based therapies (such as Atkins, Pritikin,
  Ornish, and Zone diets), 4 .

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?CAM Users

• women
• people with higher education
• those who had been hospitalized within the past
  year
• former smokers, compared to current smokers or
  those who had never smoked

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FACTS AND FIGURES

• CDC NHIS SURVEY 2003
• These patients used CAM therapies for
• Musculoskeletal complaints.
• Colds.
• Anxiety, depression.
• GI problems.
• Sleep disorders.
• Same as for most primary care practices.

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FACTS AND FIGURES

• THE BAD NEWS
• Only 12 sought CAM treatment advice from a
  licensed CAM practitioner.
• The rest used CAM on their own.
• THE GOOD NEWS
• The other 88 is your potential patient base.
• CAM spending by public 47billion (1997)
• Includes 20billion out of pocket spending

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HERBAL MEDICINES

• FACTS FIGURES
• Used by 1 in 3 Americans.
• 40 billion annually.
• Fewer than half discuss the matter with a
  conventional health care provider.
• Why is this?
• What does it matter?

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HERBAL MEDICINES

• REGULATORY ISSUES
• DSHEA - 1994 Dietary Supplement Health
  Education Act.
• Classified vitamins, minerals, herbs, and amino
  acids as dietary supplements, and allows for
  their marketing (and sale) as long as no claims
  are made for their use in the diagnosis,
  treatment, cure, or prevention of disease.

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HERBAL MEDICINES

• REGULATORY ISSUES
• DSHEA - 1994 Dietary Supplement Health
  Education Act.
• Can make structure and function claims
  supports urinary health, for example.
• No need to show it is safe and effective, which
  is the standard required by the FDA of drugs.

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ACUPUNCTURE

• The NIH Consensus Conference on Acupuncture,
  1993.
• JAMA. 1998 Nov 4 280(17) 1518-24.
• Berman BM, Lao L, Langenberg P, Lee WL, Gilpin
  AMK, Hochberg MC. Effectiveness of Acupuncture as
  Adjunctive Therapy in Osteoarthritis of the Knee
  A Randomized, Controlled Trial. Annals of
  Internal Medicine. 2004 141(12)901-910.

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NIH CONSENSUS

• Promising results have emerged showing efficacy
  of acupuncture in
• vnausea and vomiting adult postoperative and
  chemotherapy related
• v in postoperative dental pain
• v addiction
• v stroke rehabilitation
• v headache
• v menstrual cramps
• v tennis elbow
• v fibromyalgia, myofascial pain,
• v osteoarthritis, low back pain, carpal tunnel
  syndrome
• v asthma
• Further research is likely to uncover additional
  areas where acupuncture interventions will be
  useful.

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COMPLICATIONS

• adverse events.
• Frequency estimated at between 110,000 -
  1100,000.
• 14 year review of the world literature identified
  193 complications (I suppose they meant adverse
  events also), another 30 year review identified
  300.

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Potential adverse events associated with
acupuncture

COMMON ADVERSE EVENTS RARE COMPLICATIONS
Fainting during treatment Pneumothorax
Nausea and vomiting Spinal cord injury
Increased pain Hepatitis B
Diarrhea Septicemia
Local skin irritation Punctured organs
Bruising Convulsions
Needle site bleeding Argyria
Psychiatric disturbance  
Headaches  
Sweating  
Dizziness  
Aggravation of symptoms  
Needle breakage  
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Precautions for needling certain areas of the
body
Pregnant women, avoid needling points on the abdomen and lumbar region, and certain points known to cause strong sensations (large intestine 4, spleen 6, bladder 60, bladder 67) Avoid points on the scalps of infants with open fontanelles

Needling points close to the eyeball requires definite angle, depth, and skill (stomach 1, gallbladder 1, bladder 1). Avoid using these points and avoid manual manipulation, such as lifting or thrusting
Avoid deep perpendicular penetration of points on thoracic and lumbar regions due to risk of puncturing internal organs

Deep penetration of gallbladder 21 puts patients at risk of pneumothorax
Deep penetration of ren/governing vessel 17 puts patients at risk of heart injury
Avoid deep penetration of points at base of skull inferior to occiput (gallbladder 20, ren/governing vessel 16, and bladder 10) due to risk of injuring the medulla oblongata
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Risk factors for complications of acupuncture
BLEEDING
Hemophilia can affect clotting factors
Advanced liver disease could compromise production of clotting factors
Patients taking blood thinners could bleed for longer periods
INFECTION
Patients with HIV infection or immunocompromised patients are at increased risk of opportunistic infections
Patients with diabetes are subject to poor wound healing neuropathy can reduce sensory ability, leaving them at increased risk of undetected infection
Patients who have had transplants often take immune suppressants that make them prone to infections
High-dose steroids suppress the immune system
Open wounds increase risk of infection
FAINTING
Hypoglycemic, nervous, or very fatigued patients might faint
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COMPLICATIONS

• Most frequent are vasovagal syncope and sedating
  reactions, drowsiness.
• Cardiac Tamponade (Chest. 20001171510-1511.)
• If ya do it right, there shouldnt be any cases
  of transmission of blood-borne infections.
• HOWEVER
• According to Memorial Sloan Kettering.
• ? Pregnant women
• ? Patients with lymphedema
• ? Those wearing pacemakers, or
• ? Those with low platelet count
• should inform
• their practitioners before receiving treatment.

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COMPLICATIONS

• Can be reduce by Excellent Training!
• less than 1 years training resulted in 2.07
  adverse events per year
• 37 to 48 months training reduced this to 1.35
  adverse events per year and
• 49 to 60 months training reduced this further to
  0.92 adverse events per year
• Bensoussan A, Myers SP. Towards a safer choice.
  The practice of traditional Chinese medicine in
  Australia. Sydney, Australia Macarthur 1996.