Dental illness

Was aware that bisphosphonates have been linked to 'jaw rot', or the potentially devastating osteonecrosis of the jaw, but hadn't truly appreciated the implications until Ruby, one of my favourite patients, had a disappointing visit to the dentist. Largely edentulous besides a small plate, Ruby's diet is restricted to mush and she'd been hoping the removal of her remaining teeth would allow her a full set of dentures and the ability to chew on a steak. To her distress, once the dentist noted she was on Fosamax, he pulled the plug on any extractions. No discussion was entered into, and what's more, it seems the effect on bone is longlasting, so going off the drug is no help.

Apparently, the risk if far greater with IV therapy, but has been reported with oral treatment, and although rare, there's no predicting which patient's going to be the unlucky one.

According to dentist Peter Foltyn, from Sydney's St Vincent's Hospital, osteonecrosis of the jaw (ONJ) is probably associated with the failure of the extraction socket to heal properly due to a combination of invasion of oral microorganisms and the bone compromise. It is also thought that for some patients it may actually be symptoms related to ONJ, such as tooth pain or tooth mobility, which lead the patient to seek dental care. And while there are common sense measures to limit infection, such as antibacterial mouthwashes, there's no management strategy proved successful so far. Dr Foltyn has put together a useful patient handout on this very issue which he will email to you on request (pfoltyn@stvincents.com.au).

While the absolute risk is small to each individual, given 280,000 Australians take the drugs, it could become a significant problem.

On the other hand, I wonder whether some dentists are taking the easy way out, refusing to perform extractions for all patients on bisphosphonates to avoid legal action.

There's no doubt Ruby needs a bisphosphonate, but I felt bad I hadn't warned her of the consequences when she started the drug. The way she sees it, and I dont blame her, is that by starting her on Fosamax, I've quashed her chances of ever having a decent meal.

Rang my Mum, who's also on a bisphosphonate, and her doctor hadnt warned her either. suspect few of us routinely do so.
Not sure now what exactly to tell osteoporotic patients, or whether I should reconsider my therapeutic options for osteoporosis in future.

Or should Ruby just shop around till she finds a dentist willing to let her make an informed decision?

Not my emergency room

A busy Saturday morning and I'm the only doctor on duty in my urban practice. My next patient, an elderly woman slowly making her way from the waiting room, has a black eye to rival an opponent of Kostya Tszyu. But she's not concerned about the eye, it's her tongue that's the problem - she bit it last night. On examination, a jelly-like mass where her tongue should be strenthens my suspicion that she's overanticoagulated, and blood oozes down her chin as she tells her story. Pretty switched on despite her four score plus years, she's already had an INR the previous day, which was 3.0, not near as high as I'd expected. I still consider giving vitamin K until I note the plethora of conditions for which she needs to be fully anticoagulated and think again. In all truthfulness, this woman will do better with tertiary level care, located just 5 minutes down the road.
But although my patient and her husband are less than unenthusiastic about a trip to the ED, history tells me that the greatest hurdle to a smooth admission will be a bolshie admitting officer. An INR of 3.0 is pretty unimpressive.
Not that I've ever let such a doctor dissuade me from a well-considered clinical course, but I do resent the tone with which some hospital doctors address their general practice colleagues in general, or me in particular.
Seemingly, the starting point of this species is that GPs are idiots and that our patients shouldn't clutter their emergency department. Even when convinced the patient does deserve admission, they often have one more trick up their sleeve. "Where do they live?" they ask, hoping to be able to play the 'out of area' card.
This time, in an effort to not get annoyed, I try a new tack. Rather than presume to send a patient to their personal emergency department, I'll ask their advice about how I can manage the patient myself.
As expected, and realistically, the ED doctor had no faith that I, a GP, could handle a bleeding woman with a list of conditions including chronic renal failure. "You'd better send her in", he said. A win for reverse pschology.
Sadly, my victory was shortlived, when I had a brush with the other end of the hospital system.
My patient died four days after admission. I have no idea of the cause of her death, and I'll get zip info from the hospital.
And I'm all out of ideas to remedy this recurrent problem.

If there's one issue the lay media has to get its collective head around, it's that by not making a definitive diagnosis, a doctor hasn't made a 'misdiagnosis'.
Generally, the former will result in a vigilant parent and doctor, whereas the latter will more likely prompt inappropriate monitoring and treatment.
Take for instance the Sydney girl pictured on page 13 of this week's Sun Herald with the caption, "Close call: Brittany Pine, 7, with her mother Kristy, is lucky to be alive after her GP misdiagnosed her symptoms".
At a glance, you'd think the GP endangered this young girl's life. But closer scrutiny reveals that although Brittany's GP entertained the subsequently incorrect diagnosis of measles, they had a sufficiently open mind to send her directly to the ED. In short, they recognised a sick girl when they saw one and managed her totally appropriately. In all likelihood, they saved her life.
This knee-jerk 'blame the doctor' type story doesn't do the public any favours, and ironically increases the likelihood that serious acute illness will be missed. By promoting the idea that parents need only see a doctor to ensure the safety of a sick child, is a dangerous message.
Sick kids can deteriorate quickly, and regardless of a doctor's skills, a one-off visit gives merely a snapshot of the course of an illness. Sometimes that consultation is just too early, and the possible diagnoses extensive.
The best way to keep kids safe is to empower and educate parents to monitor their children rather than rely on a one-off doctor's appointment.
Unfortunately captions like this one send precisely the opposite message.

Transparent PBAC decisions unclear

It seems I was naive in expecting last year's changes to the reporting of PBS decisions to make for enlightening reading. Although pharma companies were antsy about the rationale behind PBS decisons going public (playing their usual get-out-of-jail free card, "commercial in confidence"), lucid and compelling arguments to the contrary won out (link Aust Prescriber, Ausdoc). While not really expecting the whole story, especially behind a negative decision, I certainly expected more transparency than has been forthcoming.
For instance, when new patent-protecting versions of Coversyl and Coversyl Plus were approved (link to 2 articles on this topic), I expected the public summary on the PBAC website to justify its position. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pbacrec-pbacrecmar06-positive#peri
But alas, it was merely stated - in the minor submission category - that: 'The PBAC had no objection to the Secretariat listing of the change of perindopril salt from erbumine to arginine.The PBAC noted the sponsor’s advice that it will be implementing a communication strategy to inform prescribers of the change.'
The explanation of the approval of a bisphosphonate/vitamin D combination, Fosamax Plus, was no more revealing. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pbacrec-pbacrecmar06-positive#alen
On the one hand, the PBAC notes that 'alendronate plus vitamin D provides access to a combination product for patients with established osteoporosis who may require vitamin D supplementation'. and while the taxpayer will pay no more for the new formulation than the garden variety of Fosamax, notably the submission to the PBAC didn't claim greater efficacy in fracture prevention either.
Furthermore, patients without a vitamin D deficiency don't need vitamin D supplementation, and the 400IU per day in Fosamax Plus is inadequate for those with a vitamin D deficiency, so the patient group who will benefit from the new formulation remains elusive. Apparently, the PBAC was concerned (Radar link) that the product might be inappropriately used to treat vitamin D deficiency, which prompts the question - why did they approve it?

dont worry Hendo

After a bombardment of emails about the new GPTV from the boys at Genesis Ed, and eventually sorting out the software, I had a good look yesterday. Hate to be one to throw stones at a competitor, and such a nice guy as Dr Michael Johnston, but rivetting stuff it ain't, except perhaps for the GPTV survey of how often GPs want to be updated with news. The very serious Dr Johnson tells us a 'staggering 52% of GPs want their news three times a week'. No details about the number of respondents to the survey, nor acknowledgement that an online survey might just skew the sample a little, but it's bad news for the weeklies, Medical Observer and Australian Doctor, according to Dr Johnson, who interestingly had nothing but a copy of AusDoc on his desk in the previous segment.
If GPs really want 'news' so often, I guess it's all good news for 6 minutes, but I actually dont believe it.
Perhaps we can do our own less than credible survey of 6 minute readers. What is it that GPs want so often that they're not getting elsewhere?
If it's news, why not read the papers? And do you really need to find out about the latest randomised controlled trial on clopidogrel before lunch?
Let us know and we'll try to oblige.

3 rumours about MD3

Heard a few interesting things about MD3.
If my informant, admittedly far from a technogeek, is correct, the new version throws up ads that stay onscreen until the GP hits the 'go away button'. There's no suggestion, as yet, that the ads are in any way tied to the patient's history or script writing, although reader's comments would be welcome.
From what I hear though, mightn't be too much of a problem n the future, with some of the big advertisers having already stopped advertising on MD, presumably due to price considerations.
And, it could be a coincidence, but an important state based ehealth pilot trial is finding that all of a sudden, GPs involved in the project are converting to MD3. A targeted sales push perhaps? Trouble is MD3 is incompatible with the software used in the project. You've got to think changes could be incorporated into MD3, but sounds like the clever Dr Bateman might just have the relevant health department over a barrel. Chances are, he's not going to do it cheap.

Trust me, I'm a dog owner

Another week, another dog attack. This time a 9 year old Melbourne boy has undergone facial surgery, and no doubt been scarred for life, after a mauling by a Staffordshire terrier cross labrador. While still outraged, I'm no longer surprised when I read of viscious dog attacks. Are they just reported more lately or are they on the increase?
Anyway, what doesn't surprise me is the response of the owner, quoted as saying the dog's actions were out of character.
If there's one thing I dont expect to hear from the owner of a dog that's just chewed someone's face off, it's this:
"I'm not at all surprised Rex went bezerk. He's a nasty bastard. Why just last week he bit three or four children."

Meanwhile, contrary to my children's belief, it turns out I'm not the world's most extreme food Nazi after all. According to the Sun Herald (link), preschool teachers are now performing random tests on lunch boxes, and sending anything deemed unhealthy home in the lunch box.
It's not clear what the guidelines are, or whether indeed there are any, but cakes, roll-ups, chocolate frogs and lollies are definitely out.
While cross my teenage son's state school still has a Coke machine, telling kids they cant eat the lunch their parents packed for them seems rather a blunt way to deliver parents a message.

is it only specialists who get the pens that work?

OK, I'm outing myself. There's a skeleton in my closet desperate to escape, so here goes.

In 1996, or thereabouts, but before my days at Australian Doctor, I went to the races. Not just any races, but Randwick Races, sitting in a box and with a free lunch. I got to take my non-doctor husband too. No education, no experts, just a couple of GPs and partners, and a few bottles of wine.

Oh, yes, and a few drug reps. In fact, the event was the most exciting drug company junket I recall attending as a GP.

As a mother of two small children who didnt get out much except to work, and had rarely been to the races, I spruced myself up, dropped the kids at my Mum's, and popped off to Randwick, parking of course in a VIP spot paid for by the company.

Unfortunately, even armed with tips from my patients with gambling problems, I came out behind financially, but who cares?

I can't remember the name of the drug being flogged but it was a non-steroidal. And I have no evidence either way as to the outing's influence on my prescribing habits, but suspect it probably did have one. I'm one of those people brought up to return a favour.

Of course, these days are now gone, and today's junkets, at least for GPs, have to be educational, and not of the 'who won the fifth at Randwick?" or "what wine goes best with the rare duck in pomegranite sauce' variety.

The issue of drug companies 'entertaining' doctors has been splashed around in the lay media a lot lately, with 'investigative' journalists working themselves into a lather about oncologists having a night out on Roche at Guillaume at the Bennelong in Sydney. smh, age url

Dont know what the educational component of this posh do was, but since then there's barely been a day without another 'expose' in the media.

In their defence, many doctors argue that entertaining clients is just standard business practice, and they're right. In most industries, wooing clients with a night out at the theatre, or opera, or Guillaume wouldnt turn a hair.

What I'm not so sure about is whether, in the case of drug companies and doctors, the practice itself is right.

I'm not talking pads and pens here or even cheap torches, paper clip holders or biscuit tins. In fact, given the deteriorating quality of drug company pens, if anything, they influence my prescribing in the unintended direction. But more substantial gifts, such as weekends away, are a different matter. As a part-time GP, I'm never offered gifts of this calibre, but am told they still go on, especially for specialists, and especially the group the industry dubs KOLs, or key opinion leaders. (The rationale here, put simply, is that the views of these doctors at the top of the food chain eventually filters down to us bottom feeders)

But when I'm a patient, I want my doctor to decide my treatment on the basis of what they think is the very best for me, not who took them to Tahiti. Whether it's conscious or unconscious influence isnt the point.

Anyway, most specialists I know earn quite enough to buy their own dinner at an establishment of any calibre.

You're on your death bed on dialysis and hooked up to the machine that goes beep. No longer blessed with the power of thought, let alone speech. You've made it clear to your family in more lucid times that you dont want your life prolonged in such circumstances, and they gather around to say their teary eyed farewells before the switch is flicked.
But wait, here comes your business partner at the eleventh hour. Seems like you're worth more to him alive than dead, so he calls a halt to the proceedings. The matter goes to the state guardianship board, which rules the machine stays on. Other parties only have the right to approve initiating a life-extending intervention, such as dialysis, they cant authorise its turning off.
Hard to believe, but something very like this just happened in NSW.
Unfortunately, living wills wont necessarily fix the problem either.
Read the judgement at ......

urban myth or heartbreak hotel?

Ok, this is totally non-medical but it is the weekend, and this is important stuff. I have it on good authority (pop culture junky and guru who lives across the road) that Elvis was a natural blonde. A quick flick on google at least repeats the claim, albeit on a website called suicidegirls, saying that Elvis dyed his sandy blonde hair black.
Any further light on the hue of Elvis's locks would be appreciated.

Medicare Australia stuff-up

I'm beginning to wonder how many staff Medicare Australia (formerly the HIC) actually employ. In the midst of the "it takes 3 weeks to provide you with computer prescription forms" debacle, now there's 1200 unprocessed applications for provider numbers, leaving some GPs who've moved locations unable to see patients. How would the bureaucrats like to go without pay for 3 weeks? Great timing too for patients in the middle of cold and flu season.
In its defence, Medicare Australia says it's "under-resourced".
Hey, I've got an idea. Hire someone.

patent protection

Saw the Coversyl rep yesterday and heard the spiel re the new formulations. Hard to know whether she believed her own spin on the reason for the change, to extend shelf life. Have never heard of a shelf life problem but have indeed heard of patent protection - change of formulation, clinically irrelevant change in chemical strutcture, new indication .... the list goes on.
May sometimes have a positive result if a company puts cash back into R and D, but wish the companies would let their reps be honest. It's hard to communicate effectively with someone when you both know they're telling porkies.

Back to the future.
Writing scripts now by hand after stuff up in our practice meant we ran out of computer scripts, and Medicare Australia says two to three weeks for delivery.
Wonder why it's OK for government to be so inefficient.
According to GP chat line, we're not alone, meanwhile am seeing if I can get away with printing on blank A4 paper, no bounces so far.
Does anyone know if there are any problems for patients with doing this for PBS drugs, especially if concession holders? Authority script has a script number, private scripts obviously OK, but will the patient still be eligible for a benefit if there's no script number?

Was fascinated to read of the Australian doctor who diagnosed what was presumably a thyroid mass in a Big Brother contestant.
Predictable jokes about university graduates watching Big Brother aside, this he or she may have just saved a life.
Would love to know their identity and subspecialty.
Meanwhile, received my Medical Observer yesterday and was struck by its cover sheet featuring a computer screen with a certain company's professional development program. Only problem is, clicking through to the publication's CPD program reveals the old "this site is under construction' message. Why would a newspaper heavily promote something that doesnt exist? Mmmm.

if i wanted to eat with kids at a restaurant i'd bring my own

Saturday night at the local Italian. Husband, teenage children and I gathered for quiet 'quality time' dinner for daughter's 15th birthday. No family fights so far and things are looking good. Busy waitress even smiles indulgently when asked by 15 year old to list the manufacturers of all non-alcoholic drinks on the menu - just so she can avoid anything made by the Coca Cola company.
Just into meal and a bit of bonding when two toddlers at a nearby table decide the restaurant has the makings of an athletics track - up and down the restaurant they run, stopping at our table at each lap for a victory screech. Or three.
Oblivious, or pretending to be, the parents chat merrily to their table companions, a young slightly horrified childless couple. Once or twice, Dad makes a half hearted effort to control his offspring, who by now are positively screaming their way between and under the tables.
I tried to curb my rising temper, reminding myself of a radio program I'd heard not long before by an ex-children's magistrate preaching tolerance of children. You know, 'it takes a village to raise a child" yadda yadda.
Echoing the current consensus on prevention, the magistrate stressed the importance of intervening with disadvantaged families before the kids turned three. Much youth crime and distress had its origins in the 0 - 3 age group, and the impact of helping parents at this stage couldnt be overestimated, she said.
"Children are the responsibility of the entire community", the magistrate argued, and she sure had the runs on the board to comment after 12 years on the bench.
Since I'd heard the talk I'd been somewhat inspired, and uncharacteristically offered to help young mothers on trains, buses, in shopping malls, and smiled supportively when 2 year old Michelin men struggled to escape their stoller in the supermarket queue. No more judgemental glances, just a friendly, "I know how hard it is, I've been there too" kind of expression.
But my generosity failed me Saturday night.
This wasnt a disadvantaged couple doing it tough in any sense of the word. Laughing, well-heeled, North Shore thirty-somethings using pasta as baby-sitter. It's not the kids' fault, they were just being kids - noisy and boistrous - and having a ball.
Sadly, they and their family were the only ones.