June 30, 2016
Faculty at the College of Community Health Sciences presented about dementia, obesity in the media, pediatric limp and other topics at the annual meeting of the Alabama Academy of Family Physicians, which was held June 15-19 in Sandestin, Florida. The meeting allows family medicine physicians throughout the state to connect, earn continuing medical education and learn more about representing family medicine in the legislative, regulatory and public arenas. Pediatric Limp Your child can’t sleep because his or her legs ache, something parents call growing pains. Doctors refer to this as non-specific limb pains of childhood and estimate that 20 percent of children aged 2 to 12 report mild to severe pain in their legs at night. There are no symptoms in the morning. “The leg pain must be bilateral and it only occurs at night. The cause is unknown and there is no pain, limp or symptoms during the day,” said Dr. Richard Friend, an associate professor of family medicine for the College and director of its Family Medicine Residency. “We think it’s related to increased activity – moving around a lot during the day, and increased sports.” Growing pains are often described as an ache or throb in the legs, often in the front of the thighs, the calves or behind the knee. Studies indicate the pains could be a sign of overused muscles. In addition to growing pains, Friend also touched on other walking-related pain children might face in his presentation, “Pediatric Limp.” Juvenile rheumatoid arthritis can onset between the ages of 4 and 10, he said, and leg pain in children ages 11 to 16 often is a result of overuse. Friend said when physicians exam children with leg pain, they need to take a good health history of the patient and perform a physical exam. “Observe the patient crawling and walking. Get the child or caretaker to localize the pain. Is it morning or evening pain, or all-day pain? This is important because arthritic pain is a morning pain while leukemia is mostly a night pain.” When performing a physical evaluation, Friend said “listen to the sound of the feet hitting the floor. Have them stand on their toes and heels and hop on one foot.” If needed, take x-rays of the area in question, from the hips to the feet, he said, adding that ultrasounds and bone scans can also be useful. Dementia: Differentiating the Types Physical and mental activity are among the best ways to treat or slow dementia, which affects 25 million people in the developed world and is the sixth leading cause of death, said Dr. Tom Weida, a professor of family medicine for the College and associate dean for Clinical Affairs. Alzheimer’s dementia is the most common form of dementia and is a clinical loss of memory. “It’s the inability to lay down new memory, and it can lead to paranoia, delusions and an inability to swallow,” Wedia said in his presentation, “Dementia: Differentiating the Types.” He said the clinical presentation of Alzheimer’s dementia is a loss of: memory, executive function, visual-spatial orientation and social graces. While age is the most common risk factor for dementia, family history, head trauma, depression and obesity also contribute to the risk. Weida said a strong screening tool is a verbal fluency test that requires patients to name as many animals as they can in 60 seconds. If patients name fewer than 15 animals, “it is suggestive of dementia. This is a highly specific and highly sensitive test.” There are medications that can be prescribed for dementia, but they have side effects and there is limited evidence that they are effective, although they might slow dementia a bit, Weida said. He said non-medication treatments like physical activity and cognitive activity “seem to work the best. Brain stimulation seems to quell dementia states – art, music, reading, crossword puzzles and number puzzles.” Good health is also important, Weida said, particularly a diet low in saturated fat, and high in fruits, vegetables and folic acid. Interviewing for Residency The College’s Family Medicine Residency, a three-year program that provides specialty training for physicians, accepts 16 new residents each year but annually receives approximately 2,000 applications. Of those, 150 applicants are interviewed. “You are competing against a lot of people,” residency Director Dr. Richard Friend told an audience of more than 50 medical students ready to enter residencies. Across Alabama, family medicine residencies accept only 55 medical school graduates per year. There are just 470 family medicine residencies in the United States. Funding for residency training slots is provided by Medicare, the US health program for the elderly. “There won’t be any new slots any time soon,” Friend said, which makes residency interviews vitally important. When medical school graduates apply for residency positions, they use the Electronic Residency Application System, or ERAS, which is a system that collects common information from all graduates. “Interviews provide what can’t be seen in ERAS,” Friend said. “Applicants can explain their strengths and weaknesses … and showcase themselves.” He said the interview process starts when the application is submitted to ERAS. “Don’t do your application the night before. Work hard on it and don’t take it lightly. Proofread it and make sure it’s complete. Spend time on your personal statement. Remember, you’re competing against a lot of people. Friend said the College’s program, The University of Alabama Family Medicine Residency, ranks the applicants it brings in prior to their interviews. “Some candidates have moved up in rank after the interview,” he said. Other advice? “Have a professional email address and voice mail message. And find out how you appear online. Social media is a good resource for us,” Friend said. Updates in Adult Primary Care Dr. Scott Arnold, chair of Internal Medicine for the College, provided a review in literature of the previous year in primary care and shared his recommended changes in practice. One study he shared looked at the relationship between the use of lipid-lowering statins and a heightened risk for diabetes. More than 3,000 non-diabetic statin users and more than 3,000 non-diabetic statin non-users were studied retroactively, and diabetes developed in 31 percent of the statin users versus 19.4 percent of the statin non-users. This is consistent with other prior studies, Arnold said. “This appears to be a real entity,” he said. “It should give us pause only with those with primary prevention patients with borderline benefits. When do the benefits outweigh the risks?” Another study he shared looked at identifying the community acquired pneumonia (CAP) pathogen and whether or not antibiotics should be used to treat this pathogen. The study examined 2,200 adults in five hospitals in Chicago and Nashville who demonstrated CAP. Only 38 percent of the cases had an identifiable pathogen, and of those, 23 percent were viruses, 11 percent bacterium, 3 percent were both and 1 percent fungus or mycobacterium. “We are overusing antibiotics for CAP,” he said. “We need to figure out in the future who needs antibiotics and who doesn’t.” Obesity in the Media When doctors have conversations with their patients about weight loss, realistic goals must be set, said Dr. Alan Blum, the Gerald Leon Wallace Endowed Chair of Family Medicine for the College. One-third of the United States is obese and Alabama has led the nation in obesity trends, Blum said in his presentation. But with the media littered with advertisements for sugary drinks and supersized fast food portions, coupled with magazines and TV advertising touting extreme weight loss goals, like losing 30 pounds in 30 days, reality gets skewed, he said. As a result, many patients arrive into the exam room with unrealistic expectations. “Many people might suggest that a pound a week is normal weight loss,” Blum said. “But we’re really not ever giving good advice if we’re going to suggest that to our patients. I ask instead, ‘What would you like to weigh?’ People usually have a number. Then I ask, ‘When was the last time you weighed that much?’” The reality test, he said, is when he asks the patient how long they think it will take to lose the weight. “If it took 10 years to get there, why would they think it should take three months to get it off?” he says. Blum thinks more action must be taken to prevent obesity in the first place. He says physicians should make the following suggestions to patients: support breastfeeding, limit sugary beverages, encourage family meals with less fast foods and more fruits and vegetables, get exercise and spend two hours a day or less on a phone or at a TV.
