New techniques or gadgets for disease management : How do patients decide ?

Thanks to www....& Google,patients have access to so much of information...how do they decide?
Of course you may say "patients depend on their doctors or surgeon to decide what's best for them".Its the doctors responsibility not only to critically study the new technology but also to train themselves to handle it.
It's not unusual to get a patient who demands for a surgery using a particular technique.For example ,I recently had a young boy who wanted tonsillectomy using a particular technique.He aspires to be a singer & his teacher in the U.S.advised this new technique.How much ever I spent time explaining that I was actually involved in a nationwide study in the NHS in the U.K. & shared the outcomes,he was fixed on his idea.He went ahead at another center with this surgery & surprise comes back with all the possible risks explained!!
I have seen patients having similar faith in lasers.I fail to understand from where it's come but they think everything can be operated with laser & it's all bloodless & painless!! Ofcourse lasers are useful for selected conditions & the results are excellent if a particular type of laser is used.
Every new gadget may not be suitable for every patient.It depends on the stage of disease & also patient as well as doctor factors.
I recently came across this article about cancer advertisements in a reputed medical journal.Especially in cancer treatment, there are standard staging systems & treatment is offered according to classification or stage.Few other diseases have such protocol.
Sharing it....

The full report is titled “What Are Cancer Centers Advertising to the Public? A Content Analysis.” It is in the 17 June 2014 issue of Annals of Internal Medicine (volume 160, pages 813-820). The authors are L.B. Vater,
J.M. Donohue, R. Arnold, D.B. White, E. Chu,
and Y. Schenker. 

Summaries for Patients
Understanding Cancer Center Advertisements
What is the problem and what is known about it so far?
A new diagnosis of cancer can be frightening. Many decisions need to be made, the first of which is usually where to receive care. Throughout the United States, cancer centers are increasingly purchasing magazine and television advertisements aimed directly at patients with the intent of informing them about their centers.
Why did the researchers do this particular study?
To examine television and magazine advertisements placed by cancer centers for information provided about clinical services and the use of emotional advertising appeals and patient testimonials.
What was studied?
Advertisements in the top 269 consumer magazines and in 44 television markets that reached more than 1 million viewers in the United States. However, the researchers could not be sure whether television advertisements were local or national in their distribution.
What did the researchers find?
The advertisements tended to focus on the newest or most innovative treatments offered for particular types of cancer. They often included patient testimonials but did not indicate whether the experience of that patient was typical. In general, the advertisements appealed to a person’s emotions but did not provide more concrete information about benefits and risks of therapy, what other therapies a patient may use, or whether the centers accepted all types of insurance.
What were the limitations of the study?
The study analyzed the advertisements but did not study people watching the advertisements to see how they were affected.
What are the implications of the study?
Although it is natural for patients with a new diagnosis of cancer to look for the best news possible, they should try to view cancer center advertisements as critically as they view any other advertisements. They should not believe that the patient experiences portrayed in such advertisements are typical or that their own experience will be the same. They should choose where they receive cancer care on the basis of all issues important to them, including benefits, risks, and costs
 This article was published online first at www.annals.org on

27 May 2014. 

Dizziness Part III :Management

Dizziness...like fever or pain is just the symptom of an underlying pathology.Hence for effective treatment ,we need to diagnose the underlying cause.As I have already mentioned,sometimes appropriate diagnosis needs few visits.

The treatment of vestibular or inner ear related vertigo is divided into immediate symptomatic relief & to promote vestibular compensation.

Medications for vertigo mainly provide symptomatic relief.Drugs like antiemetic (for nausea & vomiting ) & anti vertigo drugs are given for short duration (3-5 days).In Meneire's disease Histamine agonists drugs are used for longer duration.

The mainstay of management is to promote vestibular compensation.Vestibular compensation is a natural process that allows the brain to regain balance, and minimise dizziness when there is damage to the inner ear.These include various exercise manuvers specific to a diagnosis.For example in BPPV, we usually perform Semont's Manuver or Epleys Manuver. There are also certain eye movements,neck & head exercises.I am not describing them here as I do not want any patient to perform them without doctors advice.

Appropriate referrals to neurologists,cardiologists,endocrinologists or other specialities if suspected cause is not the inner ear.

Finally lot of reassurance & regular follow up.Also concentrate on the concomitant psychological & cognitive impairment for a holistic recovery.

Picture of a rainbow over a volcanic eruption in Tanzania.....courtesy National Geographic

Dizziness Part II: Evaluation & finding the cause of Dizziness

Dizziness evaluation is a time consuming task.Sometimes the assessment process may take few visits.

The cause of dizziness could range from peripheral vestibular disorders (related to the ear & it's structures) to Central disorders(related to other pathways connecting the balance systems including brain).

The doctors also has to rule out other causes like low blood pressure,some heart conditions to thyroid dysfunction.

The most important step towards reaching a diagnosis is history i.e.patients story.I usually encourage the patients to describe their symptoms in words other than "dizzy".

Narrate your story & if possible write it before visiting your doctor.

Important information to write down will be :

-What is the feeling during the attack ?is it rotation or unsteadiness or black out,associated with nausea or vomiting 

-How long does it lasts?seconds,minutes or hours & days.Frequency in a week,month or year.

-What are the triggers?does change of position have an effect?Is it related to viral fever,cold,noise,social situations etc

-Are there associated symptoms like ringing sound in the ear,ear fullness or deafness

-other symptoms like double vision or weakness of limbs or gait problems

-Medical history of self & family

-Treatment you have received so far & carry your medical records

I also ask patients some direct questions to complete the history.

Dr Micheal Strupp,one of the pioneers in vertigo & dizziness says 90% of the diagnosis is clinical especially good history taking.All common causes like BPPV,Meneire's disease,Vestibular neuronitis & Vestibular migraine are diagnosed by good history alone.I had to opportunity not just to meet him but also attend his masterclass on this topic.

Clinical examination:

I as a doctor need to come to two main conclusions

1.Is there a deficit?

2.Is it peripheral or central?

Bedside examination includes examination of vestibular & oculomotor system 

I am just naming them as complete description is beyond the preview of this blog meant for patients education.However just to prepare you for the doctors visit ,I must say this will involve the doctor asking you to follow the instructions to move eyes in different directions(nystagmus & saccades).It will also involve shaking your head in either direction (head tilt).The doctor will also hold your head & bring you down on the couch from sitting to lying down on each side.Finally gait or your walk will be tested with eyes open & closed.

These clinical tests are namely

1.Ocular tilt

2. Nystagmus -peripheral versus central

3. Vestibulo Ocular Reflex / head impulse test

4. Central oculomotor,vestibular or cervical reflex

5. Gait

As already mentioned 90% of diagnosis of common presentations of dizziness is clinical.Rare presentations like Multiple Sclerosis,Brain stem encephalitis or infarction will need radiology imaging like MRI.Some conditions like Meneire's an audiogram is advised.

Some Causes of Dizziness and Vertigo

1.Benign paroxysmal positional vertigo

Severe, brief (< 1 min) spinning triggered by moving head in a specific direction

2.Meniere disease

Recurrent episodes of unilateral tinnitus, hearing loss, ear fullness

3.Vestibular neuronitis (viral cause suspected)

Sudden, incapacitating, severe vertigo with no hearing loss or other findings

Lasts up to 1 wk, with gradual lessening of symptoms

4.Trauma (eg, tympanic membrane rupture, labyrinthine contusion, perilymphatic fistula, temporal bone fracture, post concussion)

5. Ototoxic drugs

Treatment with aminoglycoside drugs recently instituted, usually with bilateral hearing loss and vestibular loss

6. Chronic motion sickness 

Persistent symptoms after acute motion sickness

7.Central vestibular system disorders

-Acoustic neuroma

Slowly progressive unilateral hearing loss, tinnitus, dizziness, dysequilibrium

-Brain stem hemorrhage or infarction

Sudden onset

-Cerebellar hemorrhage or infarction

Sudden onset, with ataxia and other cerebellar findings, often headache

8. Migraine

Episodic, recurrent vertigo, usually without unilateral auditory symptoms (may have tinnitus that is usually bilateral)

Possibly headache, but often personal or family history of migraine

Photophobia, phonophobia, visual or other auras possible, helping make diagnosis

9. Multiple sclerosis

Varied CNS motor and sensory deficits, with remissions and recurring exacerbations

10. CNS-active drugs' (not ototoxic)

Drug recently instituted or dose increased; multiple drugs, particularly in an elderly patient

11. Hypoglycemia (usually caused by drugs for diabetes)

12. Hypotension (caused by cardiac disorders, antihypertensives, blood loss, dehydration, or orthostatic hypotension syndromes including postural orthostatic tachycardia syndrome and other dysautonomias)

13. Other causese

Psychiatric 

Syphilis

Thyroid disorders

List is in rough order of frequency of occurrence.

Note: drugs, including aminoglycosides, chloroquine ,Lasix  including most antianxiety, anticonvulsant, antidepressant, antipsychotic, and sedative drugs. Drugs used to treat vertigo are also included.

Dizziness Series-Part I "What is dizziness or vertigo?"

Dizziness forms about 15 - 20 % of my practice.Dizzy patients are given symptomatic treatment by general practitioners & usually they are referred to specialists like Physicians,ENT's,Neurologists,Neurosurgeons,Cardiologists and to Psychiatrists.

I thought of dividing the topic into 3 parts

1. Introduction & brief anatomy

2. Clinical Approach:Good history & targeted neurotological examination

3. Management 

"What is dizziness or vertigo?"

The term Dizziness or vertigo is synonymously used.

The term dizziness tends to be used by patients to include a wide spectrum of sensation from dizziness or disequilibrium through spatial disorientation to simple faintness,blackouts  or light headedness.Some of the patients simply refer their symptoms to Meneire's or Positional vertigo.

Literally the word vertigo has come from Latin word "Vertere" which means whirling ie to turn.Other effective definitions are "a subjective sense of imbalance "which may or may not include sense of rotation"(Kerr) & "illusionary sense of unidirectional environment and/or bodily rotational movement "(Daroff).

Balance is maintained by visual apparatus (eyes & it's neural connections ),vestibular system (includes inner ear structures -3 semicircular canals & 2 otoliths) & the proprioceptive organs (proprioceptors sensory receptors in muscles, joint capsules and surrounding tissues, that signal information to the central nervous system about position and movement of body parts).

Above chart courtesy vestibular disorder association who have a very informative website vestibular.org

Though we have three organs as mentioned above to maintain balance,two are sufficient to maintain balance.Brain decodes the signal send by these organs through respective nerves.

Disclaimer :Kindly note the above information is over simplified for a lay man to understand & in no way depicts exact neuro anatomy which is not the intention of this blog)