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Pain relief in your knee is the main reason why you opt for total knee replacement, arthroplasty (TKA). But, most studies that talk about the success of TKA haven’t actually taken a look at the factors that predict the freedom of pain in the years that follow the surgery.

In a study published in the summer of 2008 this subject was addressed noting that 13% to 30% of people who had a TKA have a slow, painful or incomplete recovery from surgery, the researchers also found two new key factors that will help predict who among those people with osteoarthritis (OA) would be likely to still feel pain after two years from their surgery. The two factors were other medical problems and people’s particular way of experiencing pain.

The study followed 55 consecutive OA patients scheduled to have a TKA in a hospital in Nova Scotia, Canada. The patients, 35 women and 20 men averaging 69 years old, completed pain questionnaires before surgery, and then again 3 months, 12 months, and 2 years later. Researchers used standard surveys to assess the pain of the men and women in the study and used their medical records to find out about their other health problems. The problems included, OA in joints other than the knee, high blood pressure, smoking, diabetes, under active thyroid, heart disease, depression, and being overweight. Researchers also looked at a psychological feature of how the men and women experienced pain called “catastrophizing.” A widely used survey called the Pain Catastrophizing Scale (PCS) that ask these men and women to rate how often 13 statements about pain would apply to them. These statements gauge how much they reflected on their pain; how much they magnify its potential impact; and how helpless they feel about managing their pain.

Scientist found that the men and women catastrophizing was a stable trait, unchanging over the two years of the study, and on average, their pain dropped dramatically after knee replacement surgery, but there was a wide variation among the men and women in the study. The goal of the study was to identify which presurgery factors are responsible for the variance and can they be used to predict whose pain will persist.

Age, gender, length of hospital stay, and the type of anesthesia the men and women received didn’t predict pain after two years and not surprisingly, the patients who reported the most presurgery pain were more likely to be in the group still in pain at two years. Researchers suggest that this calls into question the practice of delaying TKA until pain is unbearable.

The men and women whose catastrophizing score, especially the reflecting about pain, was a significant predictor of who would have pain after two years. The other predictor of pain two years on was the number of other medical problems the men and women who participated had at the time of surgery. The scientists tried to explain how catastrophizing could lead to the continuing experience of pain, they said that reflecting and focusing attention on pain may make cells more sensitive, actually amplifying pain. Medical problems just might, likewise focus constant attention on pain, therefore, altering the pain experience compared to individuals whose only medical problem was the OA in one knee. The drawbacks to the study are its small size and that the study didn’t examine whether pain immediately after the TKA surgery predicts long-term pain.

The hope of the researchers is that the results of their study will help to identify those at risk for persistent pain following knee replacement. It could make it possible to take special measures, such as aggressive pain management or psychological intervention, to prevent long-term distress and disability in total knee replacement patients.

I have had total knee replacement, in 2007, but before I had the surgery I had asked my orthopedic doctor if the pain I was experiencing would go away after the surgery. His answer was “No.” There wasn’t any explaination, just a “No.” I couldn’t help but ask myself, “Why am I having this surgery then?” It’s been almost three years since the surgery and I still have pain but not the intensity I had before.

The most important thing for you, if you have a chronic condition, is to have an understanding of birth control methods and how they can affect your health. Some of these methods can present specific concerns for certain rheumatic conditions. If you have antiphospholipid syndrome or antiphospholipid antibodies in your blood, lupus or RA, here is what is known about the concerns and the appropriate birth control methods.

Antiphospholipid antibodies and antiphospholipid syndrome: APL or antiphospholipid antibodies are proteins that affect the balance in the blood between clotting and bleeding and are a risk factor for blood clots. APS or antiphospholipid syndrome, is an autoimmune disorder that is characterized by antiphospholipid antibodies, blood clotting, and miscarriages and the syndrome can happen alone or with lupus, even though you have the antibodies you may not have lupus.

If you have antiphospholipid antibodies you are more likely to develop blood clots if you have another risk factor for blood clotting such as a severe illness, surgery, prolonged bed rest, malignancy, or pregnancy or it can be a lifestyle risk factor such as smoking or using combination contraceptives. That’s why this second risk factor can be one of the variants in the blood that makes clotting possible. When you have lupus and antiphospholipid antibodies you are more likely to have other medical risk factors for a stroke or heart attack, like migraines, atherosclerosis or clogged arteries, or elevated cholesterol levels.

Contraceptives with estrogen are know to increase the risk of blood clots and when you have moderate to high antiphospholipid antibodies you should stay away from combination hormonal contraceptives. If you have low or borderline levels of the antiphospholipid antibodies, it may depend on whether you have had other risk factors for blood clots, to determine if you should stay clear from the combination hormonal contraceptives. Progesterone-only contraception is a good alternative for you if you have antiphospholipid antibodies and are unable to safely take estrogen. This method is also an effective way to decrease the heavy menstrual flow if you are on blood-thinning medications like warfarin, also known as Coumadin, which is often used to treat APS, Antiphospholipid syndrome.

Systemic lupus erythematosus: It was thought for many years that estrogen increased disease activity in lupus. This assumption was based on the findings in laboratory animals, and the fact that lupus is found mostly in women, 4 out of 5 people with lupus are women, and the reports of birth control pills and pregnancy where women said their lupus got worse. There are early reports that suggested there was an increase risk of lupus flares with the use of contraceptives containing estrogen. But, there are more recent studies that were better-designed, using large numbers of participants and standardized methods of measuring flares that found that estrogen-containing contraceptives are safe in some women with lupus.

And there were two randomized clinical trials published at the end of 2005 that found combination birth control pills don’t significantly increase the risk of flares in women with inactive or stable, moderate lupus. The Safety of Estrogens in Lupus Erythematosus National Assessment, or SELENA, trial included 183 women with inactive or stable, moderate lupus and compared the effects of a standard combination birth control pill with the effects of an inactive placebo pill. Women who had active lupus, a history of blood clots, or antiphospholipid antibodies couldn’t take participant in the study and the number and severity of the lupus flares showed no difference in the two groups. There was another study of 162 women with stable mild-to-moderate lupus that also found no adverse effects on flare rates whether the women used a combination pill, a progesterone-only pill or a copper IUD.

Based on these studies, it would appear that combination pills are safe for you if you have inactive or stable, moderate lupus and don’t have antiphospholipid antibodies. Remember, though, that you may not even be able to tell how active your lupus is and often lupus activity can only be detected through blood test or other tests. So if you have lupus and you want to use a combination pill, your rheumatologist must be involved in the decision making. Since about 1/3 of the women with lupus have antiphospholipid antibodies, you have lupus you should be screened for the antibodies before starting a combination birth control pill.

It seems that it would be smart for you if you have lupus to avoid the contraceptive patch, Ortho Evra, given the recent FDA warning that it increases the risk of blood clots above that of combination pills. There’s also the birth control pills that contain drospirenone, Yasmin, Yaz, that are more likely to elevate blood levels of potassium, an important consideration for you if you have lupus-related kidney problems. The safety of IUDs, if you are taking immunosuppressive drugs to treat your lupus, is not certain, because the drugs and the IUDs can raise the risk of infection. If you have active lupus, barrier methods or progesterone-only contraceptives are your options. Depo-Provera injections may be a problem if you are taking corticosteroids, because both the Depo-Provera and the corticosteroids increase the risk of bone loss.

Rheumatoid arthritis: There are some who believe that if you have RA you might actually benefit from treatment with estrogen-containing birth control pills because your symptoms improve during pregnancy. But, there’s little research into using the pill to treat RA and research does suggest that women with RA have normal estrogen levels but lower than normal androgen levels, so hormonal therapy attempts have focused on supplementing androgens (androgens are primarily male sex hormones, but women have small amounts of them), with mixed results and no clear benefit. Postmenopausal estrogen therapy has also been studied in women with RA but showed no effect on the activity of the RA, and although there are no grounds for saying that combination hormonal contraceptives reduce the activity in Ra, there’s no evidence that suggest their use would make a flare more likely to happen. Combination pills or the patch, may be effective and convenient for you if you have RA, but there is a concern that the risk of blood clots from the patch is higher than the risk from the pill. Inserting a vaginal ring or a diaphragm may be difficult if you have severe RA and like with lupus, it’s not sure how safe IUDs are if you are taking immunosuppressive drugs such as ethotrexate, corticosteroids, or cyclosporine to treat their RA. There are no studies that have addressed this question specifically with newer RA medicines such as the biologics, among them Enbrel, Remicade and Humira.

There are other concerns as well and they are the hormone containing contraceptives can interact with other medicines, and this can reduce your medicine’s effectiveness or increase its side effects. Some of these medicines are used to treat arthritis and related conditions. Some anticonvulsants like anti-seizure medications that are used to treat seizures, headaches, or chronic pain disorders may decrease the effectiveness of birth control pills. There are also, corticosteroids, warfin, and cyclosporine that can interact with the contraceptives even though the interactions are weak. Other medications that are used to treat other health conditions, some antibiotics, may also interact with hormone containing contraceptives and if you are using one of these contraceptives you should always remind your doctor of that fact when your doctor prescribes you new medications.

When you have rheumatic conditions and you have to stay in bed for a while, maybe because of a flare-up of the condition, or after surgery you should stop using combination birth control pills, the patch and the vaginal ring. Also, and especially if you have antiphospholipid antibodies, your doctor should give you low doses of a blood-thinning medicine. If you are planning elective surgery, you should talk to your doctor about stopping you combination hormonal contraceptive two months in advance, because estrogen’s effects on blood clotting takes up to six weeks to reverse.

There are so many different types of birth control available to you today that if you have a rheumatic condition you can choose a safe and effective method. There are also many factors that have to be taken into consideration and it’s essential that you, your gynecologist, and your rheumatologist work together to decide which of these methods is best for you.

There comes a point in our lives when most of us will need to visit a new doctor. There are, however, those times when the experience can be stressful to say the least. There will be those times when on our way home we remember the question we really wanted answered. Here is some advice to help take away any regrets you may have on your first visit with the new doctor. You may want to use this advice to help others on their first visit.

Step One: The First Steps

There are several reasons why you may need to see a new doctor:

Maybe you are dissatisfied with your current doctor Seeking a second opinion. Changes in your insurance coverage.

Maybe your new doctor is a specialist and your symptoms are beyond your primary care doctors expertise. If this is the case then you will want to make sure you understand the reason for the specialist. Be sure to write down the specific reasons for seeing the specialist.

Be sure to request the specialists name and specialty in writing so you can prepare for the first visit. This way you will be able to do some research so you will feel confident that the specialist has the right training and credentials and that he or she will be a good fit for you.

Before seeing a specialist you should check with your insurance company to make sure you follow their rules for specialist referral. It will depend on the insurance company and the specialist you are seeing, but the insurance company may require your primary care doctor to submit a record of the referral to them. Your primary care doctor’s office more than likely will have information on different insurance procedures for referral. It’s been my experience that most health care providers do this on their own. But it is still good to have it sorted out before you get to the specialist’s office. You must have the proper referral the doctor will not be able to see you.

Step Two: Preparing Your Medical Records

Once you have your appointment scheduled with your new doctor you should make sure that he or she is able to get a copy of your medical records. It’s been my experience that you can get a copy of your medical records yourself, for around $15 and sometimes they will even give them to you for no charge. Without you medical records, including any test results, it is much harder for the new doctor to get to the root of your problems. You could find yourself repeating test you already have the results to and they are both time consuming and costly.

With the changes in information technology, providing your doctors are in the same health care system, your records can be brought up through the electronic medical record on the computer. If, however, your records are not on the electronic medical record system your new doctor will have to have the hand written charts from your primary care doctor. In order for your new doctor to get your records you will have to sign a “Release of Medical Records” request form that allows your primary care doctor to send your medical records to the new doctor. It could take up to a week or so for your new doctor to receive the records in his or her office, be sure to include all records dating back to the first time you started experiencing symptoms, including test results since that time.

Step Three: Preparing for Your Visit

Your medical records won’t tell the whole story of your health. You will have to fill in the blanks, that’s why you should prepare for your first visit by writing down a complete description of your past and current medical conditions and treatments. Microsoft Works has a template that you can use and using a journal to document your symptoms also helps with this process. A symptom journal is a daily record of the symptoms you are experience over a period of several weeks or months. You will start with a description of your symptoms followed by the time of day the symptoms occurred, the length of time they lasted, anything that may have relieved the symptoms, and any other factors associated with their onset. If you keep this diary for any length of time you will start to see patterns. These patterns will make it easier for you to either avoid whatever is the trigger or at least prepare yourself for them. I used this method when I was first diagnosed with fibromyalgia and I kept it for over 10 years. I was able to determine my triggers for the fibromyalgia and now I can prepare for them and there are several I totally avoid. This method has helped me to manage my fibromyalgia.

If you put all this information together ahead of time it will reduce the likelihood that you will forget important information that will help your new doctor to make a diagnosis or prescribe effective treatments. This is a list of information you will want to collect:

your current health conditions. any over-the-counter and prescriptions medicines you take, as well as any vitamins and supplements. any allergies you may have. your health history, including conditions you’ve had, medicines you have taken, procedures, surgeries and medical tests you’re gotten. your family’s health history and this includes any conditions that your parents, grandparents, siblings, and children have or had. the names and contact information of other doctors you have seen.

Having all this information on hand can help the doctor by informing him of any symptoms you have that are related to medications, he will be able to make the connection. If you take a lot of medications and supplements, it might not be a bad idea to bring all the bottles with you. Just put all your medications into a plastic bag and bring with you.

Your new doctor may send out the papers for you to fill out at home before your appointment instead of having you wait until you get to the office, or if it is possible you can fill out the information needed online.

Also, don’t forget to bring a list of questions with you that you will want answered in your first visit. A list will prevent you from forgetting to ask something that is important to you. It also helps to eliminate that last minute “Oh by the way can you explain…..” as you walk out the office door.

Here are examples of some questions you may want to ask your doctor.

What condition do I have? What are the potential short-term and long-term effects of my condition? Is there anything I can do to prevent further problems or complications from my condition? What are my treatment options? How do they work and what are their potential benefits and drawbacks? Side effects? Cost? What would be the consequences of “waiting it out” and not following through with treatment? Where can I find reliable information about my condition?

Now it is the day of your appointment and here are a few things you will need to do for your first visit:

You will need to get directions if you are not familiar with the location and also parking information if you are arriving in a car. I usually take a dry run to the doctors office to determine where it is, and how long it will take me to get there.

Next you will want to plan to get there at least 15 minutes early. Every doctor’s office has a different check-in procedure. The front best staff may want to verify or update your information, including the insurance information. There are always changes that will or can occur between appointments, and it is crucial that the staff be up-to-date.

Take your insurance card with you because the staff may want to make a photocopy of it and it will give the co-pay and contact information for requesting prior authorization for medical tests or drugs.

Make sure you get answers to all the questions on the list you made up and any that may have come up during the doctors consultation. At least make sure that you understand everything the doctor is saying to you. Don’t hesitate to ask the doctor to spell difficult terms, or write down information that is hard to understand. It is also a good idea to bring someone with you. I always had a hard time trying to relay what the doctor had to say, back to my husband because I was usually in a fibro-fog when I went to see the doctor. I started caring a tape recorder with me on my office visits so I could play it back for my husband and myself.

Toward the end of the this initial visit you should have a clear understanding of how and when you will be following up with your doctor. If test results are involved, you should know how you should know how you will get these results once they come in. Before you leave, ask for the name and phone number of the person to contact should you have questions later.

I’m sure that you are thinking that this seems like an awful lot of work, but in the long run your first doctors visit will go much smoother if you prepare for it and you’ll walk out of the office with a better understanding of just what is wrong with you.