First line of treatment:

A word in the patient's ear

Dr. Dennis J. Aloysius (Family Practitioner, visiting Lecturer PGIM, a past President of the SLMA and a member of the HealthWatch Medical Advisory Panel) observed last week that "A word in the patient's ear is the first line of treatment."

He was delivering Dr. A. D. Premaratne oration at the North Western Chapter of the College of General Practitioners, Sri Lanka on the topic 'Rational Prescribing'.

Rational prescribing means intelligent prescribing, and it demands that the appropriate drug be prescribed, in the right dose, at the right intervals and for the right length of time. It is dependent on the fact that the drug is available at a price people can afford, is dispensed correctly, is effective and is of acceptable quality and safety.

Prescribers such as McNeil Love have realised that "the first line of treatment is a word in the patient's ear" and that there is no doubt that a major part of therapy is the consultation itself.

The behavioural response of a patient to disease which is an important outcome of therapy, is largely determined by the manner in which a consultation takes place. Sensitivity to the individuality of a person who feels unwell is a precious part of the healing art of a doctor.

There is also no doubt that programmes to improve sanitation, housing, nutrition and the provision of safe drinking water are the ultimate answer to many of the diseases which doctors are now called upon to treat in developing countries.

But till these programmes are implemented pharmaceuticals will continue to play a vital role in the alleviation, treatment and prevention of disease.

Patients are human beings, whose response to drug therapy is the result of several factors, some more important than others:

1. the pharmacodynamic effects of the drug and the interaction with other drugs the patient is taking are the main factors.

Other important determinants are:

2. state of the target organ on which the drug acts and

3. the manner of medication and the route of administration.

4. the doctor's mood, personality, attitude and beliefs. Often the doctor himself is the therapeutic agent and the drug he prescribes assists in the cure.

"the doctor who cares, is the doctor who cures".

On numerous occasions it has been noted in general practice that different doctors giving the same drug therapy, produce different results. This is to be expected as we are not dealing with unconscious patients or animals.

There are five other factors that influence response to drug therapy.

They are -

5. the patient's mood, personality, attitudes and beliefs.

6. what the doctor tells the patient.

7. the patient's past experience with the doctor.

8. the patient's estimate of the effects of the therapy and what he thinks might happen as a result.

9. the social environment of therapy, whether the patient is alone or in company, at home or in an institution.

There are certain persons who tend to view the practice of medicine as a science and not a happy marriage between a science and an art.

Those who practise medicine as a science and an art are the ones who produce better results. We cannot be too scientific or pompous about the effects of drugs.

The placebo effect of therapy will continue to confound purely scientific prescribers.

The doctor must cultivate techniques for the psychological potentiation of drugs, because his aim is to help the patient.

Adverse effects

Anyone who believes that any drug can combine efficacy with no adverse effects whatsoever in every patient is due for a nasty surprise. It is a truism that if a drug has no adverse effects whatsoever, it has no beneficial effects either. Whenever a drug is prescribed, the rational prescriber always weighs the benefits against the risks.

As Kaminetzky said "there are no biologically active safe drugs, there are only safe physicians".

A prescriber should be also influenced by what Napoleon Bonaparte said "I do not want two diseases - one nature made and the other doctor made".

And by what Proust said succinctly "Nature scarcely seems capable of giving us any but short illness but medicine has developed the art of prolonging them. Remedies produce a simulacrum of illnesses".... This should caution him regarding adverse effects and help ensure that his prescription is appropriate to the clinical needs and the individual requirements of the patient.

Costs

Costs play a very important role in rational prescribing. It is wrong as some do, to equate cheap prescribing with high quality practice and conversely, expensive prescribing with poor quality practice. The prescription must be objectively assessed. Low prescribing costs are desirable, but cost-effective prescribing is more important. Cost of drugs is only one aspect.

The loss of economic productivity is important. Patients may continue to work while taking medication, and so symptomatic treatment becomes rational.

Sustained release or long acting pharmaceutical products do improve compliance because they need to be taken less frequently. They may be more expensive but since patient compliance is important, it is rational to prescribe them to selected patients.

Generic prescribing

Generic prescribing is said to be desirable, since it is presumed that it is less expensive, but the generic drug should be of quality. There are good generics and bad generics - just as there are good branded drugs and bad branded drugs.

Strict quality control is the answer to this problem. It is however logical to expect a branded product from a reputed manufacturer to be of better quality than a generic product from a relatively unknown source. Poor quality generics could result in unnecessary expense, unacceptable side effects and prolonging the suffering through poor therapeutic effect.

The recent elevations in the USA on generic drug registration should caution us, to ensure that generics receive the same registration scrutiny as do the patented products.

The prescriber should have confidence in the products he prescribes, especially in the areas of safety and efficacy.

What you should know about CT Scans

Kelum Pelpola (Final year Medical Student, Colombo Medical Faculty)

CT scan: A CT scan is a frequently done investigation nowadays. The aim of this article is to give the readers a basic idea about what a CT scan is and what they should know before getting a CT scan done.

CT is the shortened form for computed tomography.

A CT scan uses X-rays to make detailed pictures of structures inside of the body.

During the test, you will lie on a table that is hooked to the CT scanner, which is a large doughnut-shaped machine. The CT scanner sends X-ray pulses through the body area being studied. Each pulse lasts less than a second and takes a picture of a thin slice of the organ or area. One part of the scanning machine can tilt to take pictures from different positions. The pictures are saved on a computer.

Why is it done?

A CT scan can be used to study many parts of your body, such as the chest, abdomen, pelvis, or an arm or leg. It also can take pictures of body organs; such as the liver, pancreas, intestines, kidneys, lungs and heart. It also can study blood vessels, bones and the spinal cord. Abnormalities in any of these could be detected by the CT scan.

An iodine dye (contrast material) maybe used to make structures and organs easier to see on the CT pictures. The dye may be used to check blood flow, find tumours and look for other problems.

Dye can be put in a vein (IV) in your arm, or you may drink the dye for some tests, or the dye may be put into other parts of your body (such as the rectum or a joint), to see those areas better. CT pictures may be taken before and after the dye is used.

How to prepare

Before the CT scan, tell your doctor if you:

Are or might be pregnant.

Are breast-feeding. (Plan to use formula feeds for 1 to 2 days if you are given the dye so you will not pass the dye to your baby.)

Are allergic to any medicines, including iodine dyes.

Have a heart condition, such as heart failure.

Have diabetes or take metformin for your diabetes.

Have a history of kidney problems.

Have asthma.

Have a history of thyroid problems.

Have a history of multiple myeloma. (a type of cancer)

Have had an X-ray test using barium contrast material (such as a barium enema) or have taken a medication that contains bismuth (such as Pepto-Bismol) in the past 4 days. (Barium and bismuth show up on X-ray films and make it hard to see the picture clearly.)

Become very nervous in small spaces. You need to lie still inside the CT scanner, so you may need a medicine (sedative) to help you relax.

Arrange for someone to take you home in case you get a medicine to help you relax (sedative) for the test.

If you have a CT scan of your abdomen, you may be asked not to eat any solid foods starting the night before your scan. For a CT scan of the abdomen, you may drink contrast material. For some CT scans, you may need a laxative or an enema before the test.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean.

How it is done?

A CT scan is usually done by a radiology technologist. The pictures are usually read by a radiologist. Other doctors, such as a family medicine doctor, or surgeon, also may review a CT scan.

You may need to take off any jewellery. You will need to take off all or most of your clothes, depending on which area is studied. You may be able to wear your underwear for some scans.

You will be given a gown to use during the test.

During the test, you will lie on a table that is hooked to the CT scanner, which is large doughnut-shaped machine.

The table slides into the round opening of the scanner, and the scanner moves around your body. The table will move while taking pictures. You may hear a click or buzz as the table and scanner move. It is very important to lie still during the test.

During the test, you may be alone in the scanning room. However, the technologist will watch you through a window.

If dye (contrast material) is needed, it will be given in one of several ways, depending on the body area being studied.

A CT scan usually takes 20 to 60 minutes but could take 2 hours.

Drink lots of liquids for 24 hours after the scan to help flush the dye (if you were given a dye) out of your body.

How it feels

You will not have pain during the test. The table you lie on may feel hard and the room may be cool. It may be hard to lie still during the test.

Risks

The chance of a CT scan causing a problem is very small.

There is a chance of an allergic reaction to the dye (contrast material), but the risk is low.

If you have diabetes or take metformin (a drug taken to control diabetes) the dye may cause problems. So, tell your doctor, if you are using it.

The following may stop you from having the test or may change the test results:

1. Pregnancy - CT scans are not usually done during pregnancy.

2. Barium and bismuth show up on a CT scan. If a CT scan of the belly is needed, it should be done before any tests that use barium, such as a barium enema.

3. You cannot lie still during the test.

4. Metal objects, such as surgical clips, in the belly or metal from joint replacements may cause a problem in seeing the body area clearly.

Magnetic Resonance Image (MRI) may give more information than a CT scan about certain conditions. However, a CT scan often gives better pictures of bones and sudden (acute) bleeding than an MRI scan.

Reference: WebMd health