Summer 2024
PMH STORY
The niece was managing her aunt’s affairs while she was living in another state. She asked me if I could take care of her aunt, and I agreed. I cared for her for 7 years after she moved into a care center. She suffered from severe dementia. Her health was otherwise good. She rarely left her room. Over time she remained in bed.
From our first visits, she was reluctant to see me. She was unwilling to see any doctor. Nurses were told to leave her alone. Most of my visits ended with her saying “go away” or “please leave now.” I visited briefly to make sure she was OK. Her goal of care was to be left alone, but in a care facility especially, a patient cannot be ignored. I understood her instructions and respected them.
She became ill with Covid. Staff called me. Her temperature was elevated, 101 o . The bedside test was positive. I ordered Paxlovid. Two days after the onset of symptoms, I went by to see her. Her room was neat and orderly thanks to the good staff at the facility. She had her TV on. The blinds were up on the window. She was in bed, and she seemed like her usual self. She was mildly ill There was slight congestion, and staff reported some coughing.
I let her know that I was Dr. Kelly, that she had been ill, and that I was there to check on her. I listened to confirm that there was no Covid pneumonia. Her examination was stable and safe. I told her the illness was caused by Covid, and that she was doing Well.
She then said more to me than she said before. She said, “Is everybody getting this?” I told her that Covid was getting to be common again but fortunately was not causing much harm, just a troubling viral infection. I asked if there was anything else her doctor could do for her. She said no. I straightened up to leave. She said to me, “Thank you for taking care of me, Dr. Kelly.”
At PMH, we think there is more to a doctor visit than checking off boxes on a sheet or computer. Visits are based on shared goals, expertise, knowledge, and experience. For her, our visit confirmed her illness with Covid and her effective treatment. It is both a PMH story and a story for doctors. You see your patients. You take care of them. You do right by them. Even if the words are unsaid, we trust they will be able to say silently or out loud, “thank you for taking care of me.”
Robert H. Kelly, MD FACP
INSOMNIA
Insomnia troubles most of us at some point in our lives, hopefully just for a day or two at odd times. But it can be a chronic condition. It is hard to say with confidence how many hours a person should sleep or what normal sleep is for each and every person. What we all desire is to feel rested when we wake in the morning. Key options to treat insomnia are cognitive therapy, sleep hygiene, sleep restriction, and stimulus control. Cognitive therapy involves changing false beliefs and attitudes about sleep, for example, the idea that one needs 8 hours of sleep, and not committing to some artificial doctrine such as “I need 8 hours of sleep”. What you need is sleep so that when you get up and go in the morning and you feel that you have rested.
Improving sleep hygiene includes abstaining from alcohol, using no caffeine or nicotine after 4pm, avoiding exercise within 2-4 hours of bedtime, going to bed and getting up at consistent times, not watching the clock when you are trying to sleep, reducing nap time during the day, and not watching television or using electronic devices in bed.
Sleep restriction is perhaps best accomplished by setting a clock to get up out of bed at a time that is proper for you and making this standard every day. This is individual, but looking back over the weeks and years, most of us know that we are best when we get out of bed by a certain time. Getting up at a consistent time everyday becomes the principal element of time restriction. If you are spending time in bed unable to sleep, then the amount of time you spend in bed should be restricted.
Finally, stimulus control is important to getting good sleep. If unable to sleep, it does not hurt to get up out of bed and go to another room. Keep the bed for sleep and not for worry, reading, or electronic entertainment. If you are not sleepy, then finish what you are doing, go on to another task, and go to bed when you are sleepy.
Robert H. Kelly, MD FACP
IRRITABLE BOWEL SYNDROME: OLD DRUGS, NEW TREATMENT
Irritable bowel syndrome (IBS) includes abdominal pain and discomfort before or after bowel movements that are disruptive or difficult for patients.
New research in The Lancet studied an old drug, Elavil. It was first approved for use in United States in 1961, 63 years ago, for depression, insomnia, and chronic pain. 463 patients with irritable bowel syndrome were randomized to placebo or Elavil. Elavil was prescribed in low doses, starting at 10mg. The use of Elavil increased the rate of resolving IBS by more than 50% compared to placebo. The risk of discontinuation due to side effects was greater in the placebo group than in the Elavil group. The study shows how there can be beneficial uses of old drugs that have not been explored. Old drugs tend to be inexpensive, and the risk and benefits are well known. Such use is considered off-label by the FDA, but it is not off target.
Allan R. Kelly, MD FACP
LOWER BACK PAIN: HOW TO PREVENT A RECURRENCE
Researchers from Australia published results of a randomized controlled trial in Lancet this year. They randomized 351 adults to routine lower back pain care or routine lower back care plus an intervention. The intervention consisted of six sessions of progressive walking with a physical therapist. The sessions occurred once a month for six months and emphasized walking at home to help with the back pain. The mean age of the participants was 54 years. The primary outcome was the number of days to recurrence of lower back pain severe enough to limit activity.
Time that passed before the person suffered serious back pain recurrence took 112 days in the control group and 208 days in the walking group. In the control group, twice as many people sought medical care for their back as in the walking group. Walking therapy markedly improved back pain outcomes.
This simple experiment showed that getting up and walking at least once a month and encouraging walking at home made a big improvement in back pain. One way to interpret this insight: encourage people with a bad back to get up and go for a walk. Walking can help relieve pain.
Allan R. Kelly, MD FACP
OVER-THE-COUNTER BIRTH CONTROL PILLS
We have previously discussed how making medical care directly available to people without requiring a doctor’s order can improve health. Whether UTI, Covid, or pregnancy, there is great value in putting reliable diagnostic tests in personal control. We have known for decades that safe medicines available to individuals can prevent medical problems, like peptic ulcers and sunburn.
Since March, oral hormonal birth control pills are available without a prescription. The product is made by Perrigo Company and is marketed as “Opill.” The cost is approximately $20 per month. The medication is a progesterone only birth control pill approved by the American College of Obstetrics and Gynecology.
The opening up of medical care to personal choice, not restricted to those with a license, will improve people’s access to care. Allowing individuals to make a personal decision about what they want and what they think is best likely improves well-being. There will be isolated stories of tragedy that will be blamed on the easy availability of this product. Time will tell where this liberation goes.
Allan R. Kelly, MD FACP
REPLACING AORTIC VALVES: AN EASIER WAY
Technology is fascinating. A life-changing, society-changing technology, like heart bypass, will itself become a target of innovation. This is as true in medicine and surgery as it is in, for example, the world of computers and automobiles.
Dr. Michael DeBakey and others introduced valve replacement surgery. It changed the world. These first artificial valves required cardiac bypass machines, a large surgical incision, multiple transfusions, and heroes like DeBakey and Cooley. Artificial valves have saved untold lives.
In the 1990s, doctors began to innovate. The new artificial valve could be introduced through a small incision in an artery and then transported via catheter to the aortic valve and expanded in the place of the native valve.
In the New England Journal of Medicine in May of 2024, researchers looking at patients with moderate to severe aortic valve stenosis randomized patients equally to open heart surgery, or transarterial catheter technique. Initial results of this randomized control trial are important: The likelihood of death from any cause was reduced by more than 50% in the transcatheter valve replacement. The likelihood of stroke was reduced by approximately 40% in the transcatheter patient compared to the surgical intervention. This is a short-term follow-up, only one year. Five-year follow-up or 10-year follow-ups are planned and could change the apparent value of the transcatheter technique.
It is wonderful to see progress and innovation in medicine and surgery in our world today. We all benefit from the insight, innovation, and experimentation created by prosperity, education, and encouragement of opportunity. We create a better world by encouraging our surgical and medical colleagues (and ourselves) to come up with better ways, better techniques, better care.
Allan R. Kelly, MD FACP
SWEETENERS: REDUCE!
It seems right when international guidelines seem to correlate with common sense. Recent WHO guidelines about artificial sweeteners seem like common sense. The focus was on obesity, body weight, and the incidence of diabetes. They find that there is no health advantage to using artificial sweeteners, especially in those who are seeking weight loss or who have diabetes. The WHO data showed that higher use of non-sugar sweeteners was associated with increased diabetes.
The WHO concluded that people should reduce sweetness in their diet altogether, starting early in life in order to improve health. That is common sense. Sweet foods are good for dessert or for treats but should not be a part of our daily or usual diet.
Reducing the use of sweeteners, sugar or artificial, is a worthwhile health goal. Artificial and sugary beverages should be avoided.
Robert H. Kelly, MD FACP
QUOTES
Technology is separating us from patients. 2500 years ago, Hippocrates wrote that “some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.”
Salvatore Mangione, M.D. 2024
“It’s brutal,” a patient told me. She was not talking about her COPD, but the loss of her third primary care physician in two years. This churn in practitioners is not examined nor benchmarked.
Walter O’Donnell, M.D. 2024
A better name for the general practitioner might be multispecialist.
Martin Fischer, M.D. 2008
Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.
Marsh, M.D. 2024