Aspirin Should Not Be Stopped Perioperatively, from Medscape

Olongapo City, Philippines by Zero Mella MD — It’s still a popular belief of IM consultants that aspirin should be stopped 7 to 9 days before surgery. The belief is that it may cause increase bleeding risk especially in major abdominal surgeries. Some old cardiologists still adhere from this belief. A medscape article tells us that they may be doing more harm than good.

A phenomenon termed aspirin withdrawal effect causes platelet rebound and prothrombosis which could lead to a cardiovascular event with a mean onset at 11 days from stopping the aspirin.

Although the literature “strongly supports” that aspirin should be continued preoperatively, a new trial hopes to elucidate the matter regarding aspirin use before surgery. The study is called the POISE-2 trial and the first phase showed a good safety profile pre-operatively. The researchers are unanimous in continuing the study.

“…there was no increase in cardiovascular events in patients who had aspirin held preoperatively.” – Dr Deveraux, POISE-2

There were exceptions noted in the medscape article regarding aspirin continuation. Operations involving the middle ear, posterior chamber of the eye, intracranial, intramedullary spine, and TURP confers the highest risk for a complicating hemorrhage during receipt of aspirin therapy. It is advised to stop aspirin in these procedures for at least 3 days.

Other salient points in the article states that ACP, ACA, ADA, ACCP, and ACC (all american bodies of cardiovascular and diabetes health) recommends uninterrupted use of aspirin perioperatively. There is no change in transfusion requirements for operations with increase in blood loss. The net benefit of aspirin continuation is seen more clearly in high-risk patients.

Here in the Philippines, we still have biases and qualms among respected consultants and specialists that aspirin discontinuation preoperatively is still practiced. It may still take some years and probably the completion of the  POISE-2 trial to convince a revision of current practice guidelines.

Modifying the CAGE Questionnaire for Filipino patients: An effective but underused alcohol screening method

Olongapo City, Philippines by Zero Mella MD – “It’s in the first chapter of Bates,” mused one medical student as they were asked what CAGE questionnaire is about.

The problem is that it’s overall utilization in Filipino medical practice is little or nil. Amazingly, textbooks and respected authorities place emphasis on this screening tests as alcoholism is the most important cause of preventable deaths worldwide.

The CAGE questionnaire is an easy and effective way of suspecting an alcohol problem. It’s in English and it goes like this:

Have you ever felt the need to Cut down on drinking?

Have you ever felt Annoyed by criticism of your drinking?

Have you ever felt Guilty about your drinking?

Have you ever taken a morning Eye opener?

Two “Yes” answers is considered a positive screen. One “yes” answer indicates a possible alcohol abuse going on.

The questionnaire is asked verbally and never put out on a form. Check out the direct translation (courtesy of me):

Pakiramdam mo ba’y kailangan mo na itigil ang paginum mo ng alak?

Pakiramdam mo ba’y nakakaasar ang pagkutya ng iyong paginum ng alak?

Pakiramdam mo ba’y kasalanan mo ang paginum ng alak?

Pakiramdam mo ba’y kailangan mo ng isa pang inum sa umaga?

I use my version of the direct translation a lot and I always come up with negative screening results despite the protest of relatives. The idea is that most Filipinos know they are being screened especially with formal questions like this. They often get castigated for being labeled an alcoholic. Blame for whatever reason placed them on the ER prohibits them from admitting they have a problem.

Using Filipino slang and positive assumptions create a more effective approach. Check this:

Titigil ka na ba sa paglaklak?

Ayaw mo ba na pinagsasabihan ka tungkol sa alak?

Nagsisisi ka na ba at nakainum ka?

Ilang bote ng alak ang iniinum mo sa umaga para mawala amats?

Amazingly, I was able to identify a positive screen with direct questions such as these. You have to assume they are taking alcohol even if they aren’t. They are usually polite enough to tell you if they have abhorred alcohol for a long time and it’s ok for Filipino patients to know your sorry if you assumed alcoholism. They know its a test.

Should You Fire Your Specialist? – my comment on the Huff Post article

I’m a GP and I also refer to specialists. I’m not against any specialty since specialists give what is the best evidence-based medical care according to their practice. But there have been instances in my practice when patients came back to me complaining about how specialists handle their management. “It’s too costly,” or “I have no more money to shell out.” My patients always say that the management is great but it’s not for them. Specialists tend to give out their best opinion about any case but often, they forget to tailor the management to the patient’s capability.

I got the author’s point in this post and I don’t really think it’s an attack to specialists. It’s just a wake up call. As for the author’s self promotion, he wouldn’t be a best selling author if he didn’t.
Read the Article at HuffingtonPost

Trust your doctors: ethical dilemmas in remote medical consults

A 35 year-old female came in at Afable Medical Center, with severe 10/10 (NAS) hypogastric pain of sudden duration. Palpation revealed a tender abdomen to deep palapation at the left lower quadrant. There was no fever and no relief to Mefenamic Acid, an over the counter analgesic.

Initial Assesment was a possible Nephrolithiasis. CBC and Urinalysis were normal except for 2-4 WBC on the urine sample. No crystals were seen. Tramadol and Buscopan per IV were given to the patient with substantial relief. Admission was offered for observation and to prep for an ultrasound. A referral to a urologist was recommended.

The patient agreed and was admitted.

It was a Sunday and, since Olongapo City was short of medical practitioners, I had to wait for an available urologist to examine my patient. For temporizing measure, I gave Tramadol and Cefuroxime (a broad spectrum antibiotic). I also have to wait until a sonologist would have to be available for an ultrasound.

All my management was sound and under protocol.

After a few hours, she bursts out in anger.

“Uuwi na po ako; wala daw po ako sakit. [Trans. I’m going home, they told me I have no illness]”

“Who told you?” I asked.

She gave me her cellphone and I talked to a Dermatologist who was very angry that I admitted her sister-in-law with 2-4 WBC.

I told her that I saw the patient in severe pain and that she had to undertake more tests.

She told me that I was an ingrate and that I know nothing about her sister-in-law’s condition.

She dropped the phone. I asked my patient for the doctor’s name and she refused. She paid for the bill after signing a HAMA agreement.

This was four years ago and I regret I did not sue. The attending physician, or the one that is actually present, has precedence over a medical case. Medical opinions outside of the case are just that, medical opinions. Having a board certified specialty training in Dermatology doesn’t make you an expert over matters you cannot see. You can have a triple specialty or subspecialty but if you do not oversee the case, you shouldn’t make inferences that can damage the reputation of the attending.

The dermatologist violated the PMA Code of Ethics and is liable for slander. My story is one of many I have encountered in clinical practice. I have met patients time after time asking for a second opinion hoping to discredit the previous doctor in their care. I always tell the patients about differences in practices and that their previous doctor was doing the best he can. I do not wish to stain anybody’s reputation but time after time, I hear my own patients telling me that some specialty consultant said something bad about me, or that another patient I knew, is spreading a nasty rumor after his/her kid is not feeling well despite the  meds I gave. Each of us doctors graduated with a degree of Medicine and sworn to uphold an oath. Each one had a different set of teachers and a different set of values. In a time when teamwork is needed, I see a crab-mentality issue going on.

“Hindi yan magaling… [Trans. That doctor is no good…]”

I actually heard this comment coming from another doctor. The doctor he was referring to was a specialist that has serviced the community for more than 20 years and has done a ton of charity work. I actually found out that the commenter had a daughter who has graduated with the same specialty as the victim and needed a recommendation of patients to see.

This has got to stop! This is bad practice. This is unethical practice. Medical Doctors are becoming scarce and the remaining Filipino doctors are discriminating each other.

Coffee and Alzheimer’s Disease: A possible link to preventing this disease

by Zero Mella MD, Afable Medical Center, Olongapo City, Philippines — The Mella Clan has been plagued by Alzheimer’s Disease (AD) for the past century alone. My late grandmother Dolores Licup Mella was the last known person to be afflicted. Being with her for the remaining decade of her life, I have learned how debilitating this disease can be. She can’t even remember her own children. In her last days, she acted as if though she was six years old and that her daily activities were dictated by her parents which were no longer living. It was hard for us to see her brilliant mind deteriorate like so. She was an Elementary School Teacher for a greater part of her life and she was responsible for making a difference to thousands of students that came to her guidance. She will be remembered well.

Alzheimer’s Disease is a condition where long term memory is lost because the brain loses all access to it. The mechanism is still hardly understood by neuroscientists but evidence shows degeneration by formation of plaques and tangles. It’s like forming a scar on the brain that hinders access to memory.

Two studies conducted on Alzheimer’s disease were found to have a correlation with coffee intake:

Does caffeine intake protect from Alzheimer’s disease?

Risk Factors for Alzheimer’s Disease: A Prospective Analysis from the Canadian Study of Health and Aging

Both studies found significant statistics that show that there is a significant inverse relationship with caffeine intake and development of Alzheimer’s disease. What this means is that coffee drinkers with moderate consumption (less than 4 cups a day) have lesser risk of developing AD than those who have low or no caffeine intake.

Coffee seems to affect also the development of late-life dementia in this article:

Midlife Coffee And Tea Drinking May Protect Against Late-Life Dementia

Image courtesy of Mikael Häggström and Wikipedia. This file is part of the public domain

This coffee effect is related to its neuro-stimulant properties that is largely not yet explained by neuroscience. The substance is still believed to be caffeine but how this affects the brain is still a mystery.

This is a good news for my relatives in the Mella Clan who are avid coffee lovers. How this may effect the management of AD in the future is still subject for debate. There is still no guidelines to recommend coffee for high-risk patients to date. Neurologists still need to establish this link in a possible long term cohort study.

But in light of retrospective studies, it’s not harmful to recommend it to my patients just as long as they take the beverage in modest amounts.

Medical Misconception: Is Tylenol better than plain old Paracetamol?

Counter-intuitive case

My patient came to me for a consult regarding a different case. He had no fever but he brought with him a Tylenol bottle. It was sold to him for 500 pesos by a balikbayan claiming that “it was better than Paracetamol.” He was selling it to me for the same price.

“It’s a nice offer but no,” I said with a smile. I told him that his balikbayan friend was lying. Acetaminophen, the generic name of Tylenol, is the same as Paracetamol.

He was confused. He told me that they were different names. They can’t be right.

He was getting closer to realizing he had been duped.

Reality

Paracetamol is regarded by many Filipino doctors as the best remedy for Fever. Apparently in the US, Ibuprofen is the leading antipyretic. This isn’t a cultural difference. Asian livers react more to Paracetamol than Ibuprofen or Aspirin. This is a genetic difference.

In the Philippines, Ibuprofen is regarded as the best initial pain reliever followed by Mefenamic Acid and then Paracetamol. In the US, Acetaminophen (the US name for Paracetamol) is regarded as the best initial pain reliever. All medicines mentioned are over-the-counter. You can buy them even in online sites. However, certain conditions require frequent dosing and thus a consult with your local doctor is still best.

Balikbayans usually get generic medicines for free in the US and take them here. Some sell them, some just gave it away. A politician visited one of my health centers and gave me some of these generics. I examined each closely. The reason they were given away free is that most of them are near expiration. These products are surplus and regarded as pharmacy spoilage. They are still as good as brand new when you open them but if it nears the expiration date, they lose their potency and may actually be dangerous for your health.

The confusion of some balikbayans have created a misconception that Tylenol and Paracetamol aren’t different drugs. These happens too in drugs like Albuterol which is the same as Salbutamol. They are already happening too frequently that I hope it doesn’t turn into another medical myth. There are dangers to this misconceptions and it is best to consult your family doctors.

Learn more about Filipino Medical Myths with Lulu Publishing!

by Zero Mella MD, Olongapo City, Philippines

Updates in Philippine Expanded Program on Immunization in Region 3

by Zero Mella MD, Sajorda River Park, Iba, Zambales — The  Expanded Program on  Immunization has been around since the 70′s when the WHO implemented it on our country. There is now a move to incorporate EPI for children and mothers with adult and elderly immunization. This will be managed by the National Immunization Committee of the DOH. This will be implemented in the future.

EPI, or the free vaccines given by the Philippines Department of Health (DOH), covers the following

• Tuberculosis;
• Diphtheria, tetanus and pertussis;
• Poliomyelitis;
• Measles;
• Mumps;
• Rubella or German measles;
• Hepatitis-B;
• H. Influenza type B (HIB)

Lailani Mangulabnan MD, Region III Director for EPI, states that since 2009, the DOH has been monitoring and supervising aggressively the barangay and provincial centers regarding implementation of the EPI. With the help of the CDC, the office of Dr. Mangulabnan have found major problems regarding implementation in some remote barangays including:

• improper training
• Injection issues
  • use of prefilled syringes
  • improper use of aspirating needles
• improper disposal
• improper temperature monitoring of cold storage

Despite these problems identified, EPI in region 3 has been able to provide 97.9% coverage in 2011 which is very satisfactory.

Recommendations

Dr. Mangulabnan was able to create recommendations for the provincial, regional, and city health offices for Region 3. These include:

1. Strengthen Stock Management

This would include proper inventory keeping and reporting to the EPI office; proper use and training for cold chain storage , and proper utilization and disposal techniques.

2. Eliminate Dropouts and Missed Opportunities

The office of Dr. Mangulabnan has found certain regional and provincial hospitals with provisional requirements for the EPI and have found a lot of missed opportunities for education and implementation of the EPI. Philhealth coverage may provide some incentive in private clinics as it covers first doses of the immunization. The suggestion is still to utilize every visit to update both maternal and child immunizations.

3. Target outreach and community mobilization to depressed areas

The EPI target coverage is still 100%. Doctors, Nurses, and Midwives are called to utilize the various barangay health workers to educate the unimmunized population. The vaccines are free and are life-saving.

4. Ensure all health facilities receive at least quarterly intensive supervisory visits and are trained in REB

Supervisory visits provide a way to create standardization of care in every barangay. REB is a program of the EPI to educate hard-to reach communities. The goal is to educate them to utilize the various free vaccines provided by the government.

5. Strengthen data management and surveillance

Reporting is crucial in managing the day to day decisions and budgeting of the EPI. To ensure continuous supply of vaccines, local municipal and city health offices must provide correct data flow regarding inventory, coordinator programs and activities.

The EPI Regional Office hopes to ensure that by 2012 we will be able to reach the targets and reconcile the deficiencies found in the present.

 

 

Filipino Medical Myth: Bawal Tumalon Pagkatapos Kumain

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Filipino mothers keep this epic advice to their kids — “Bawal tumalon pagkatapus kumain at magkaka-appendicitis ka!” [Translation: Stop jumping after you eat; you'll get appendicitis] I actually grew up hearing this advice over and over. The  funny thing is I kept jumping just to piss my mom off.

This was awfully popular in the 90′s and I have noted various spinoffs. Some were “your stomach will explode” or “worms will come out of your butt.” These and other more ridiculous variations did not last long enough because they cannot carry their own weight. Only the appendicitis myth survived.

I discuss its perverted origins in my book and provide a real-life celebrity example. There have been at least 1 doctor that lectured impaction of feces when jumping as a cause of appendicitis. No scientific paper nor any experiment holds this to be true. There is no predisposition to appendicitis.

Anybody can have appendicitis.

Surgeons know this as this is their bread and butter. So if you’re Filipino, stop blaming your brethren who is going to have his appendectomy. His jumping or doing any vigorous activity did not cause this disease.

Find out more from this and other medical myths from Dr. Zero Mella’s book at Lulu Publishing here.

Home Remedy for Fever: The Correct Approach

Fever is the most common pediatric symptom I encounter in my clinics. There are a lot of myths surrounding it so I’ll be discussing those in a separate FAQ. For now, I am planning to impart to you the correct approach in handling a fever at home.

Taking the temperature

There is a lot of difficulty regarding how high a fever is simply by touching a patient’s forehead. I have met 2 and 3 year-old patients with seizures at the ER. Touching (or palpating) their foreheads and body gave only subtle warmth to my hands. But their temperatures where very high, 40-41°C or 104-105.8°F! If I couldn’t estimate my own’s patients’ temperature using my hand, I don’t think mothers at home can do better without a thermometer.

Don’t rely on intuition or guessing, buy a thermometer.

There are a lot of good thermometers out there that can help you. To my patients, I don’t tell them to buy a specific brand. Eighty percent of my patients couldn’t afford even branded medications so I tell them  to buy cheap. I need them to have at least a basic thermometer at home.

What is the BEST thermometer I can buy?

Braun Thermoscan Pro 4000 Ear Thermometer, Aural Thermometer

If you ask for the best, I’d recommend an item from my wishlist. I don’t have this yet as this is valued like gold. ExacTemp technology that comes with this gadget is already standard in modern thermometers. Just point inside the ear and click. The only problem I’ll have with this is that the reading faces away from the handle which adds a few seconds to view it.   This comes with an anti-theft feature which I would love to have.

What is the cheapest thermometer I could use?

Vicks Digital Thermometer

Mercury thermometers are being phased out by most hospitals but they remain THE standard against which digital thermometers are compared. Digital thermometers can be bought for under a dollar (or below Php 50.00)! So I tell my patients that there is no excuse for not having a thermometer at home. It is life-saving. These thermometers are used orally, rectally or under the armpit. They require longer periods of measuring the temperature and varies by up to 0.8°C or 1.6°F compared to aural (ear) temperatures. However, since this will be for personal or family use only, this could be the answer for you.

What thermometer do you use?

Braun Thermoscan Ear Thermometer – IRT3020

I bought mine second hand and I have loved it ever since. I rely on it in my clinics and the temperature readout is awesomely placed on the side of the thermometer. Since most of my nurses and midwives are right-handed, they document fevers faster. The efficiency is reduced though if you’re left handed. Since I have plenty of patients, i need to get exams done fast. So this, thermometer is perfect for me.

The correct definition of fever in terms of temperature

To many geeks or smart aleck persons out there, I hate to disappoint you but it’s a range. According to Harrison’s Principles of Medicine 18th Edition, the definition of fever is

“an a.m. temperature of >37.2°C (>98.9°F) or a p.m. temperature of >37.7°C (>99.9°F)”

Sorry kids, but the old 37.5°C (99.5°F) has been rendered defunct in light of some studies. However due to differences in practice and treatment guidelines, fever at this range is not yet treated. I only tell my patients to take certain medications on certain temperatures.

Best remedy before taking any medications

On my book, Filipino Medical Myths You Should Know, Filipinos are hesitant when it comes to water in fever. I discussed this in Walang Pasma! A tepid sponge bath is always indicated when it comes to fever. As the fever rises, the need for a cooler agent becomes urgent. Yes, we sometimes resort to ice baths in the ER to rapidly cool a patient.
Little Fevers Cooling Cloths for Infants & Children
Pediatric patients can be given Cooling Cloths which works the same way as a tepid sponge bath without the discomfort of bathing. These are available without a prescription and contain herbs that are known to cool skin and increase evaporation.

Over-the-counter medications

The decision to treat a fever is best met on clinical grounds by your family doctor. This is the reason for consult. A blood, and urine workup is usually necessary after a thorough physical examination as to the cause of the fever. Antipyretic (anti-fever) medication is not automatic and most doctors prefer to observe rather than treat. The use of antipyretics is largely a quality of life issue and addresses only the comfort of the patient. Fever is a natural response to any infection and is actually an indicator that your immune system is working fine.

However, antipyretics are not contraindicated in fever as studies show it does not interfere with the immune response.

Three drugs are available without a prescription. The best remain to be Ibuprofen, followed by Paracetamol (Acetaminophen), and then Aspirin. Aspirin is contraindicated in pediatric patients. Other drugs do exist but are given with prescription and under the discretion of your doctor. You may take this drugs at home however, you must still seek professional advice after doing so. Your fever may be the first sign of an underlying serious illness.

Disclaimer: The writer is not affiliated with any of the brands
mentioned or previewed in this article. 
The author carefully selected current best evidence 
for the topic and is valid as of the time of this writing. 
The reader should be informed that changes in medicine 
may not be reflected immediately in this article. 
It is the responsibility of the reader to report 
and seek professional advice before taking these medications 
and also to do the same if untoward or adverse effects develop.

Best OTC drugs you can buy over the internet

Seek Consult

Always seek consult with your doctor. Fever, however trivial, may be a sign of an important   illness. Some think it is prudent to wait it out a few days and yet even some (including a good proportion of my patients) try their luck to wait it out for more than 10 days. It may not be worth the risk. The earlier, the better. We want to insert our management at the earliest possible time so we can prevent complications from happening.

Zero Mella MD Releases First E-book about Filipino Medical Myths

Now available via Lulu Publishing! For only $ 3.99
Learn about bizarre Filipino Medical Myths and the science to debunk it

Olongapo City, Philippines – Dr. Zero Mella debuts in writing with his first literary piece, Filipino Medical Myths You Should Know: A Legacy of Wrong Medical Advices. This eBook features 11 chapters of entertaining medical nuisances that Filipino Doctors hear almost everyday. He attempts to explain the theories behind the myth and declares the sound scientific evidence that disputes it.

Filipino Myth 1: Coca-Cola can cause Urinary Tract Infection

This is one of the  most common medical myth today. Brought about by scares that Coke is bad for your health, Filipinos tend to not only avoid the drink but others as well.Find out why this myth is absurd by medical standards.

Filipino Myth 2: You’ll get  appendicitis when you jump after eating

He calls them non-surgeons, physicians who try to explain events leading to appendicitis after jumping with a full stomach. Surgeons know better, find out why!

Filipino Myth 3: The Great Pasma Myth

Ever wondered what is PASMA? With various modern definitions for it, some people have lost the true meaning of the word. But is it real. Dr. Mella says NO!

Find out more with this book from Lulu Publishing and the Mella eBook company!

*The book is available in the popular ePub format which
 can be read in various PC and smartphone readers.
* ISBN 978-1-105-60708-0