Search This Blog

Wednesday, June 24, 2009

Post #19 Sunscreen Advice

A sure sign that spring and summer are upon us is the location of your local retailer's sunscreen shelves, which are now front and center - not to mention the dazed look of frazzled folks overwhelmed by so many options.

SPF, UVA, UVB, what does it all mean? IMO, all those TLA's are enough to make a person crazy.

Let's start at the beginning.

Sunscreen 101:
UVA/UVB – both of these are ultraviolet rays. Basically, UVA are the aging rays, and UVB are the burning rays. You don't want too much of either of these, which is why a "broad spectrum" sunscreen is the best option. Sunscreens contain chemicals that absorb or reflect UV rays.

SPF means Sunburn Protection Factor. Basically, SPF tells you the protection offered against UVB rays but not against UVA rays. If it's SPF 15, that means you can be in the sun 15 times longer than someone without sunscreen before beginning to burn. The higher the SPF, the greater the protection against UVB rays; however a high number can give a false sense of security. Furthermore, the effectiveness of the sunscreen is affected by a number of things including how often it is applied, how much is absorbed into the skin, the activity engaged in, and the skin type of the user.

Currently, there is no benchmark rating used for UVA rays. For good UVA protection look for products containing zinc oxide, avobenzone, and ecamsule.

And then, there are the water resistant and waterproof sunscreens. According to FDA regulations, "water resistant" means the product maintains its level of protection after 40 minutes of water immersion. The FDA doesn't like to see any label stating "waterproof," because no sunscreen truly is. However, manufacturers will label it "waterproof" if protection levels are maintained after 80 minutes.

The general rule of thumb is that it should take a handful of sunscreen to properly cover the body. For you, that would be an adult-size handful. For your child, it's a child-size handful. As they grow, their hands get bigger, and you'll automatically be putting enough on.

Sunscreen comes in a lot of different forms. Sprays, lotions, gels, fun colors, there's plenty to choose from. When possible, find a broad spectrum UVA/UVB sunscreen that contains either zinc oxide, avobenzone, or ecamsule.

Babies under 6 months of age should be kept out of the sun as much as possible, and try to use a wide brimmed hat and loose fitting clothing to shield them. For all children over 6 months I recommend to use at least SPF 30.

In one word – frequently. For best results, follow instructions on the sunscreen container. And while you're doing that, check the expiration date. Sunscreen loses its effectiveness beyond the expiration date or if it’s over 2 years old.

Sticking with it:
Make sunscreen application a part of the established "going out" routine, similar to how a bedtime routine includes brushing teeth.

You can say "Okay Jane, we're going to the swimming pool, but you know the drill. First, get undressed and let me put on your sunscreen. Jimmy, you can set the timer on the microwave for 30 minutes. Then go get your swimsuits on. When the timer goes off, we're off."

Hopefully, by the time Jane and Jimmy are teenagers – when they will be more inclined to think whatever you tell them is wrong - you will have established a habit of sun safety to where they won't think twice about going out without sunscreen.

If they hesitate, tell them to get on the computer and Google "skin cancer." If they find a site with photos, that's even better. Tell your daughter to Google "aging" so she can see how a suntan today means wrinkles tomorrow.

Vitamin D or sunscreen?
Lately, there's been a debate in the medical community. The AAP (American Academy of Pediatrics) has come out with a very strong statement about the need for Vitamin D, which comes from food and exposure to the sun (UVB rays).

They are tying low levels of Vitamin D to poor bone health, a higher risk of certain cancers, and diseases such as diabetes and multiple sclerosis.

Until we get more information and data, my take on this is that it's a work in progress. An appropriate level of Vitamin D is necessary for good health, but so is an appropriate level of sun protection.

One thing we do know to be fact is that too much sunlight increases the risk of melanomas and other skin cancers.

On that note, here's a question for you. Are you, or your child, the type that "tans, never burns?" If so, you're still at risk of developing skin cancer. It's a myth that only those who sunburn get melanoma. It's exposure, which adds up throughout your life, particularly too much exposure in early life.

Summer sun:
I suggest Houstonians plan outdoor activities before 10 a.m. or after 4 p.m., when the sun is not at its peak. I highly recommend full body swimwear for both girls and boys. Cover up with clothing – T-shirts can be worn over the top of bathing suits – the darker the better. A wet white T-shirt offers little protection against the sun. Wear wide-brimmed hats at the park. Sunglasses will protect your eyes – kids love wearing "cool" sunglasses. Use a lip balm with SPF on your lips, and sunscreen of at least SPF 30 on your skin.

Remember, sunscreen is only as good as where you put it. Don't forget to apply it to the tips of the ears, backs of the knees, between the toes…and anywhere else the sun does indeed shine.


The ABC's of safe sun:

A is for Away: stay away from the sun in the middle of the day, when rays are most damaging, even on cloudy days. In Houston, this means from 10 a.m. – 4 p.m.

B is for Block: Block the sun's rays by using a sunscreen with a minimum SPF of 30. Apply it 30 minutes before going out, and reapply often throughout the day.

C is for Cover up: use protective clothing such as long-sleeve shirts, hats, or clothing with a tight weave to keep out as much sunlight as possible. Use lip balm for your lips, and sunglasses for your eyes. Babies under six months of age should be kept out of direct sunlight.

Friday, May 1, 2009

Post #18 Swine (H1N1) Flu: Cautiously Optimistic

When the first reports of the swine flu (now renamed the H1N1 flu) reached my desk at the end of last week, I was curious. . . however my weekend plans were about to swing into full gear. So other then a quick glance at the fax, pigs did not cross my mind again the entire weekend (BTW, to avoid misappropriated fear about pigs/pork being a potential source of the flu, the formerly known swine flu has been renamed. . . I use thoughts about pigs for literary purposes only).

By Tuesday (4/28/09) of this week, the media was on an information blitz, inundating the public and medical community with factoids, articles and history on past flu epidemics and the potential dangers of this new swine flu. I thought of pigs a bit more.

Generally, my friends and patients know that I am not an alarmist. When their children are sick, they turn to me to offer a voice of reason, and generally I am able to assuage their anxiety. However, being a mild connoisseur of flu history, I began to get a queasy feeling in my stomach as I read each additional article on the evolving potential swine flu pandemic. All the hallmarks were there for a possible incendiary public health threat. Any time my mind idled, it turned to thinking about pigs.

Dr. Sandro Galea, director of the Center for Global Health at the University of Michigan and a professor of Epidemiology at the University's School of Public Health, says that generally speaking, at the beginning of events such as the swine flu outbreak there is confusion, which quickly gives way to rational behavior.

And this makes sense. After all, it is often the lack of information and the fear of the unknown that drives many of us to initially overreact. With more information, we can make greater and greater rational decisions.

Early in this week, many of my patients asked my advice on the breaking swine flu. Other then a few tidbits of information from CDC.GOV I had little to offer. However, each passing day has brought forth crucial information which is being used to formulate public policy.

Over this weekend the CDC and WHO will gather more information on the virus itself, the pattern of the outbreak/spread and research the known cases/deaths. Already facts are coming in suggesting a milder threat than initially perceived. I believe by Monday they will have a much better feel of the scope and magnitude of this problem.

A few things that we already know about this virus:
1. This strain of H1N1 does not seem nearly as virulent as the deadly 1918 H1N1 flu strain.
2. As of the writing of this blog there has only been 1 known death in the U.S. and it was to a child who had underlying medical issues prior to contracting the flu. Additionally, this child came from Mexico via Brownsville to Houston, Texas for the purposes of receiving greater medical expertise/care.
3. The number of deaths in Mexico are unclear. As of the writing of this blog there were only 12 confirmed deaths, which contrasts to the >150 deaths speculated by certain media sources.
4. A possible theory as to why a greater number of deaths have occurred in Mexico is that there is a cultural tendency to seek medical care later in the course of illnesses. Which may mean that this virus is not as deadly for those who are appropriately treated. See NYT Article for more details.
5. Northwestern University researchers have a computer model they say is doing a good job predicting the spread of swine flu and it is predicting the entire United States will have between 1,600 and 2,000 cases one month from now.
6. This strain of flu is a mixture of pig, bird, and human flu (although some people believe all flu strains originated from birds at some point).
7. They expect a vaccine against this strain to be ready in 4-6 months in time for the winter flu season.

An often-used analogy during this outbreak has been preparing for a hurricane. Having resided in Houston since 1982, I have lived through many evacuations, news blitzes and the hurricanes themselves. Recently, in 2005, following the fallout of Hurricane Katrina, Hurricane Rita was set to strike the Gulf Coast. In an effort to protect its constituents, Houston was advised to evacuate. Many people did. What ensued was hours of gridlock leading to cars running out of gas with people languishing under the brutal Texas sun with no AC.

Ultimately, although Rita was the fourth-most intense Atlantic hurricane ever recorded, Houston as a whole remained safe during the storm. Our family chose to stay, and after hearing the stories of friends trapped on the highway, we were glad that we had avoided the gridlock.

On the flip side, had we lived and stayed in New Orleans during Hurricane Katrina or in Galveston during Hurricane Ike, my wife and I would have regretted our decision to not evacuate as the consequences would have been quite severe.

Whether this pandemic ends in a whimper or a bang has yet to be determined. The more we know, the more it seems a whimper is the more likely of the two. However, even if things do not end in a bang, we should be prepared to expect more cases and more deaths.

In fact, every winter the United States suffers approximately 36,000 deaths from the seasonal flu, albeit mostly in the elderly and ~100 deaths in young children. And thus, as with any seasonal flu outbreak, there will be expected deaths. However, this fact alone should not create fear.

The initial fear was that many of us have never encountered this new strain of flu either by actually catching it or by being vaccinated against it. Coupled with the fact that middle aged people were dying from the flu in Mexico, the media and public were led into a frenzy. However, as stated above, it seems the flu is milder than initially thought and that the original statistics out of Mexico may need to be revised.

If things do end in a whimper, one thing to be wary of is that the virus may mutate and come back with a vengeance this winter. This is not a certainty but a distinct possibility (as this is what happened to some extent with the 1918 outbreak).

Balancing the well being of the public is not for the faint of heart. It is often a damned if you do, damned if you don't position that I do not envy.

My point in writing about hurricanes is that like weather, pandemics (and epidemics) are difficult to predict and as such public guidance is a difficult task. Like medicine, public health is as much an art as it is a science, which involves the delicate juggling of statistics, public perception, fear, medical facts and politics (yes, unfortunately politics).

And as in medicine, when decisions are made, the potential benefits must be weighed with the potential risks as well as the potential costs to form a cost-beneficial plan that minimizes risk and maximizes the well-being of the public at large.

Unlike a hurricane threat, the great thing about a potential pandemic is that for the most part, conservative measures carry little risk or cost from an individual standpoint. Currently, the safest thing for a family to do is to stay put and avoid unnecessary interaction with others. At the very least avoiding large crowds - especially places where children spread a lot of germs - will decrease the risk of acquiring the H1N1 flu. Additionally, if your child is sick, there should be greater vigilance in keeping them at home., May 1, 2009
But when it comes to slowing the overall spread of a pandemic flu, the best thing we can do is keep sick people away from everyone else. It's called "social distancing," and studies of the deadly 1918 Spanish flu showed that cities that instituted distancing measures quickly suffered lower death tolls than cities that did nothing or reacted slowly.

Employing these measures, while somewhat constrictive socially, are easy to do and carry little risk or cost other than the potential for cabin fever!

Some mothers have asked me if they should keep their kids home from school. Until more is known (which may be as soon as this Monday - I would see how this unfolds over this weekend), for children in mother's day out programs and other elective-type school settings it might be a good idea. As for regular grade school, I believe that over the weekend the government will make that decision for us. They seem to be relatively conservative thus far in shutting school downs.

Other easy-to-employ protective measures include basic hygiene, which everyone should have a firm handle on by now.

An additional measure that may also be prudent will be to get the flu vaccine in the fall. Whether they add the swine flu H1N1 strain or not remains to be seen. One potential cost to receiving this vaccine is that during a different swine flu outbreak in 1976, a vaccine was mandated by the Ford administration. Within weeks, reports surfaced of people developing Guillain-Barré syndrome, a paralyzing nerve disease that can be caused by the vaccine. By April, more than 30 people had died of the condition, in contrast to the one soldier that actually died from the virus. Note: this is NOT an issue with the current flu vaccine.

Extensive testing will need to be done to prepare a vaccine which avoids the pitfalls of the 1976 vaccine. And like everything else in medicine, the risks of this particular flu virus will need to be weighed against the potential harms of the vaccine. Speaking personally, I will almost certainly be getting the vaccine for myself and my family like I do every fall.

Besides the measures detailed above, here are a few other smart pointers from

1. Don't Rush to the ER
With the cable news networks reporting nonstop on swine flu, it feels like the disease is lurking everywhere, and that your slightest sniffle is a sign that you've contracted the virus. That would explain why people with no outward symptoms of illness are flooding emergency rooms in swine flu–affected states, afraid that they might be sick. That's a really bad idea.

First of all, having to examine people who aren't really sick only stresses the already strained resources of hospitals that are trying to prepare for a pandemic. Plus, going to an emergency room unnecessarily may even pose a slight risk to you. In past outbreaks, including SARS in 2003, hospitals were actually loci of infections — all those sick people in close proximity — and the same could be true of swine flu.

If you actually have flu-like symptoms — a fever above 100° F, headache, sore throat, body aches, chills or fatigue — and you live in an area where there have been confirmed swine flu cases, by all means report to your doctor. Otherwise, leave the hospital to the sick people.

2. Don't Be Afraid to Eat Pork
On April 29, the CDC announced that swine flu would no longer be referred to as swine flu, but as the "2009 H1N1 flu." It's less catchy, but more accurate. For one thing, there is no evidence that this virus makes pigs really sick. And the H1N1 virus actually contains genes from swine, avian and human flus. The virus also cannot be spread through pork products — you can't contract swine flu by eating bacon, hot dogs or anything else that was once a pig. Nor will culling pigs, as authorities did in Egypt, do anything to stem the spread of the disease. H1N1 has jumped to humans and is passing easily from person to person, so it's now a human flu that needs to be controlled in us, not the pigs.

3. Don't Hoard Antivirals
The H1N1 virus has so far proven vulnerable to the antiviral drugs Tamiflu and Relenza, which is good news. A cornerstone of the government's pandemic preparations was the stockpiling of 50 million doses of those drugs over the past few years, enough to ensure that doctors would be able to respond sufficiently to new outbreaks. But that capacity could be compromised if people begin stockpiling antivirals for their own use. Already there are reports of pharmacies running short of Tamiflu, and many hospitals in the U.S. have begun restricting the power to prescribe antivirals to just a few doctors. Also, the misuse or overuse of Tamiflu or Relenza by patients can promote resistance in the flu virus — effectively removing the only bullets from our gun.

Hopefully, after reading this (lengthy, I know!) blog you have a clearer understanding of the current H1N1 flu situation. However, please be advised that things may change rapidly in the very near future.

One final note: I have read a slightly alarmist email circulating that subtly recommends purchasing nutritional supplements from a Wimberley Pharmacy at the end of its message. I am not sure as to the validity of the facts in this email, but I am personally sticking to the guidance and facts put forth by the CDC and will not be purchasing any nutritional supplements to combat this flu virus.

Wednesday, March 25, 2009

Post #16 Malpractice: Wash Your Hands or Risk a Lawsuit

I was cleaning out some of the interesting articles that I have collected over the past year and came across one of my favorites from the Wall Street Journal 2008. The essential premise of the article is that certain nosocomial (hospital-acquired) infections can be 100% averted if proper hygiene regimens are followed - beginning with, of course, hand washing.

Certain facts in the article jump out at me:

1. Nearly all hospital infections are avoidable when doctors and staff clean their hands and rigorously practice proper hygiene and other preventive measures.

2. Since October of 2008 (according to the article) Medicare no longer reimburses hospitals for nosocomial infections following orthopedic or heart surgeries.

3. Beth Israel Medical Center in New York City hasn't had a central line (a large IV placed in a major blood vessel) bloodstream infection in the cardiac intensive care unit in nearly 3 years!

4. If you don't wash your hands and you pass on a nosocomial infection, you risk being sued.

Bottom line: Infections can be avoided with good hygiene beginning with hand washing. This is important not just in the O.R. but in every aspect of healthcare.

A great additional read is an entire chapter dedicated to hand washing in Atul Gawande's book Better.

Tuesday, March 10, 2009

Post #15 An Allergy Update

If you (or your loved one) suffer from allergies and you want some good evidence-based facts - keep reading. This particular blog entry is a bit tedious as I have tried to include a complete amount of information on allergies (their causes, the tests to diagnose, and treatment).

The article (published in August of 2008) posted below is essentially a doctor's CliffsNotes on allergies. It is a practice guideline reviewing a vast amount of articles and research on allergies; the actual article is 84 pages long with a bibliography of 998 articles. The task force has made the article user friendly by summarizing the essential 109 points that the group wanted to highlight.

You ask, "How essential can a list of 109 items be?"

Excellent question.

I have further pared down the article from 109 points to the 40 most essential "essential points" that the lay person would be interested in.

Each recommendation is listed with a letter demarcating the strength of evidence supporting the "essential point's" statement. For example an "A" indicates relatively strong evidence, with each lower letter grade representing lesser strength.

However, take careful notice that a weaker letter does not mean the statement is any less true; it simply denotes that currently, the body of evidence supporting the statement has not been fully flushed out in strong clinical studies (which may or may not happen in the future).

The take home points (with a sprinkling of my spin on things) are these:

1. Allergies are complex and can be confused with COLDS as they present very similarly. Treatment however is different. Colds cannot be treated (for the most part), allergies can be treated (more on this below).

2. Testing for allergies can be done by skin tests or blood tests. Generally, the skin tests are more sensitive and preferred.

3. Common sense: Avoid the things that make you allergic. A few allergen specific recommendations are listed below. For example, if you have a pollen allergy, track pollen counts and avoid the outdoors accordingly.

4. Intranasal corticosteroids (Flonase, Rhinocort, Nasonex) are the most effective medication class for controlling symptoms of allergic rhinitis.

5. Antihistamines (intranasal and oral) are also good to control symptoms. For the most part, second generation oral antihistamines (Claritin, Zyrtec, Allegra) are preferred over the first generation oral antihistamines (Benadryl) because they are less sedating.

6. Most allergy medication brands are interchangeable in terms of effectiveness, i.e. Claritin, Zyrtec, and Allegra are all equally effective.

7. In general, regardless of the cause of the allergy (whether it be pollen, dust mites, pets, etc.), the battery of medications used will be the same. Therapy only deviates when allergen immunotherapy (weekly allergy shots) are necessary. Thus, it is probably only necessary to visit the allergy specialist when medication therapy has been exhausted and the patient potentially requires either exact identification of the offending allergen (in order to better avoid the cause) and/or desires to initiate allergen immunotherapy.

8. For cases, uncontrolled by above said medications, it is probably time to see the allergist.

9. The key is to expect reasonable control of symptoms and not a cure and gear therapy towards achieving that goal.

The article's key points posted below. . .

The diagnosis and management of rhinitis: An updated practice parameter
Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. J Allergy Clin Immunol. 2008 Aug:122(2).

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology.

Classification of recommendations and evidence

Category of evidence

Ia. Evidence from meta-analysis of randomized controlled trials
Ib. Evidence from at least 1 randomized controlled trial
IIa. Evidence from at least 1 controlled study without randomization
IIb. Evidence from at least 1 other type of quasi-experimental study
III. Evidence from nonexperimental descriptive studies, such as comparative studies
IV. Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both
LB Evidence from laboratory-based studies.
NR Not rated.

Strength of Recommendation

A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recommendation from category I evidence
C Directly based on category III evidence or extrapolated recommendation from category I or II evidence
D Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence


Burden and epidemiology of rhinitis
10. The influence of early childhood exposure to infections, animals, and secondary tobacco smoke on the development of atopy and allergic rhinitis is still unknown. C


13. The symptoms of allergic rhinitis result from a complex allergen-driven mucosal inflammation caused by interplay between resident and infiltrating inflammatory cells and a number of vasoactive and proinflammatory mediators, including cytokines. Sensory nerve activation, plasma leakage, and congestion of venous sinusoids also contribute. C

Associated allergic conjunctivitis
19. Intranasal corticosteroids, oral antihistamines, and intranasal antihistamines have similar effectiveness in relieving ocular eye symptoms associated with rhinitis. A

Infectious rhinitis
24. Viral infections account for as many as 98% of acute infectious rhinitis and the majority of rhinitis symptoms in the young child. Routine nasopharyngeal cultures when bacterial infections are suspected do not add diagnostic value. C


Skin Testing
39. Skin tests are the preferred tests for the diagnosis of IgE-mediated sensitivity. The number of skin tests and the allergens selected for skin testing should be determined on the basis of the patient’s age, history, environment, and living situation, such as area of the country, occupation and activities. D

In vitro asaays for specific IgE
40. The precise sensitivity of specific IgE immunoassays compared with skin prick/puncture tests is approximately 70% to 75%. Immunoassays have similar sensitivity to skin tests in identifying those patients with nasal symptoms elicited after natural or controlled allergen challenge tests. C

41. Interpretation of specific IgE immunoassays may be confounded by variables such as potency of allergens bound to solid support systems, cross-reactive proteins and glycoepitopes, specific IgG antibodies in the test serum, and high total IgE. D

43. Nasal smears for eosinophils are not necessary for routine use in diagnosing allergic rhinitis when the diagnosis is clearly supported by the history, physical examination and specific IgE diagnostic studies but may be a useful adjunct when the diagnosis of allergic rhinitis is in question. C

46. The measurement of total IgE and IgG subclasses for the diagnosis of allergic rhinitis has limited value and should not be routinely performed. C


Environmental control measures
52. The most common allergic triggers for rhinitis include pollens, fungi, dust mites, furry animals and insect emanations. B

53. The types of pollen responsible for rhinitis symptoms vary widely with locale, climate, and introduced plantings. B

54. Highly pollen-allergic individuals should limit exposure to the outdoors when high pollen counts are present. B

57. Clinically effective dust mite avoidance requires a combination of humidity control, dust mite covers for bedding, high efficiency particulate air (HEPA) vacuuming of carpeting and the use of acaricides. B

58. Avoidance is the most effective way to manage animal sensitivity. D

59. Cockroaches are significant cause of nasal allergy, particularly in inner-city populations. C


Oral antihistamines
63. There are important differences among the second-generation antihistamines in regard to their sedative properties: fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses; loratadine and desloratadine may cause sedation at doses exceeding the recommended dose; cetirizine and intranasal azelastine may cause sedation at recommended doses. A

64. Among the newer, nonsedating antihistamines, no single agent has been conclusively found to achieve superior overall response rates. C

Intranasal antihistamines
66. Intranasal antihistamines are efficacious and equal to or superior to oral second-generation antihistamines for treatment of seasonal allergic rhinitis. A

69. Intranasal antihistamines are generally less effective than intranasal corticosteroids for treatment of allergic rhinitis. A

Oral and topical decongestants
70. Oral decongestants, such as pseudoephedrine and phenylephrine, are α-adrenergic agonists that can reduce nasal congestion but can result in side effects such as insomnia, irritability and palpations. A

71. Oral and topical decongestants agents should be used with caution in older adults and young children, and in patients of any age who have history of cardiac arrhythmia, angina pectoris, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. C

72. Topical decongestants can be considered for short-term and possibly for intermittent or episodic therapy of nasal congestion, but are inappropriate for regular daily use because of the risk for the development of rhinitis medicamentosa. C

Over-the-counter cough and cold medications for young children
73. The efficacy of cold and cough medications for symptomatic treatment of upper respiratory tract infections has not been established for children younger than 6 years. Because of the potential toxicity of these medications, the use of these over-the-counter (OTC) drugs generally should be avoided in all children below 6 years of age. A

Intranasal corticosteroids
74. Intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis. A

75. In most studies, intranasal corticosteroids have been shown to be more effective than the combined use of an antihistamine and leukotriene (LT) antagonist in the treatment of seasonal allergic rhinitis. A

76. Intranasal corticosteroids may provide significant relief of symptoms of seasonal allergic rhinitis when used not only on a regular basis but also on an as-needed basis. B

However, as-needed use may not be as effective as continuous use of intranasal corticosteroids. D

77. When comparing the available intranasal coriticosteroids, the overall clinical response does not appear to vary significantly between products irrespective of the differences in topical potency, lipid solubility and binding affinity. C

78. Intranasal corticosteroids may be useful in the treatment of some forms of nonallergic rhinitis. A

79. Intranasal corticosteroids when given in recommended doses are not generally associated with clinically significant systemic side effects. A

80. Although local side effects are typically minimal with the use of intranasal corticosteroids, nasal irritation and bleeding may occur. Nasal septal perforation is rarely reported. B

Oral corticosteroids
81. A short course (5-7 days) of oral corticosteroids may be appropriate for the treatment of very severe or intractable nasal symptoms or to treat significant nasal polyposis. However, single administration of parenteral coritcosteroids is discouraged and recurrent administration of parenteral coritcosteroids in contraindicated because of greater potential for long-term corticosteroid side effects. D

Oral anti-leukotriene agents
85. Oral anti-LT agents alone, or in combination with antihistamines, have proven to be useful in the treatment of allergic rhinitis. A

87. There is evidence that topical saline is beneficial in the treatment of the symptoms of chronic rhinorrhea and rhinosinusitis when used as a sole modality or for adjunctive treatment. A

Allergen immunotherapy
88. Allergen immunotherapy is effective for the treatment of allergic rhinitis. A

89. Allergen immunotherapy should be considered for patients with allergic rhinitis who have demonstrable evidence of specific IgE antibodies to clinically relevant allergens, and its use depends on the degree to which symptoms can be reduced by avoidance and medication, the amount and type of medication required to control symptoms, and the adverse effects of medications. A

90. Allergen immunotherapy may prevent the development of new allergen sensitizations and reduce the risk for the future development of asthma in patients with allergic rhinitis. B


100. A sufficient amount of human observational data has now been accumulated to demonstrate safety for second-generation as well as first-generation antihistamines. C

104. Intranasal corticosteroids may be used in the treatment of nasal symptoms during pregnancy because of their safety and efficacy profile. C

105. Immunotherapy for allergic rhinitis may be continued during pregnancy but without dose escalation. C

Consultation with an allergists/immunologist
109. Consultation with an allergist/immunologist should be considered for patients with rhinitis who have inadequately controlled symptoms, a reduced quality of life and/or ability to function, adverse reactions to medications, a desire to identify the allergens to which they are sensitized and to receive advice on environmental control, or comorbid conditions such as asthma and recurrent sinusitis, or when allergen immunotherapy is a consideration. C

Saturday, January 24, 2009

Post #13 A Conflict of Interest

Recently, one of my Urology friends confided in me about his personal angst over a proposition he had received to invest in a radiation treatment center. The root of the angst was not financial; he was confident that at the very least he would not lose his initial investment. Rather, his internal conflict stemmed from a 4th century oath that all physician's swear to - the Hippocratic Oath.

In some urology oncological cases, radiation therapy is considered by some the standard of care (prostate particularly). However, it is not always the best option, as there are other modalities to care for tumors, such as chemotherapy, surgery, hormone therapy, radioactive seed implants and watchful waiting. As part of his routine practice, he utilizes radiation therapy for particular tumors; and currently aside from his initial diagnosis and management of the tumor, he does not financially benefit from any referrals he makes when he sends his patients for radiation.

His concern is simple and honest: Would he lean ever so slightly towards utilizing radiation therapy greater if his pocketbook were to gain from every new referral? This question was addressed in more depth in an article in a December 1, 2006 New York Times article titled, "Profit and Questions on Prostate Cancer Therapy."

It is a question that the U.S. government addressed in 1989. Stark law, actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.

However, since the law has been passed amendments have been made to work around the law provided certain conditions are met.* Critics of the law contend that while problems exist, they are not widespread. Further, these observers note that, in many cases, physician investors are responding to a demonstrated need which would otherwise not be met, particularly in a medically under served area.

Per the Dept. of Health & Human Services Website:
"Concern about the ethical risks inherent in physician self-referral dates back at least to a 1986 Institute of Medicine study. A 1989 HHS Inspector General study documented that physicians who owned or invested in independent clinical laboratories referred Medicare patients for 45 percent more laboratory services than did physicians who did not have such financial interests."


For those wanting to read which services are exactly governed by Stark law, I posted an additional excerpt from the website at the bottom of this blog.**

Obviously, in pediatrics, the potential financial gain from self-referrals is far less lucrative than those made in a surgical subspecialty. Nonetheless, even as I listened to my friend's story, I could empathize. As honorable as I'd like to think I am, if I stood to financially gain from ordering x-rays and lab work - especially if I had money already invested in a machine - I believe that I would probably order more tests to, at the very least, recoup the costs of the machine.

This is one reason my practice has resisted purchasing our own blood work machine and x-ray machine. (Prohibitive entry costs are another reason.) Certainly, it could improve turn around time on specific tests and possibly (but likely not) improve patient care. However, in my personal experience, I have seen medical doctors aggressively utilize x-rays and labwork far more then I thought clinically necessary when there was a "financial kickback" woven into the infrastructure of their practice - as the Institute of Medicine Study cited above exemplifies.

The cost is not limited to only finances either. If children are receiving x-rays that may not have been ordered otherwise, they are receiving unnecessary radiation in addition to the small risk of detecting incidental findings that may set off a battery of additional exams (and possibly more radiation) only to discover that everything is normal; slightly akin to opening up a small medical Pandora's box. Not to mention the pain and fear needles and claustrophobic exams induce in young children.

I 100% advocate the use of x-rays and labwork, and utilize both regularly in my own office-without any financial gain whatsoever. However, in my regular day to day flow, I resort to tests only when I am on the fence about a potentially important diagnosis that requires additional insight.

Luckily for me, I am paid mostly to think and counsel. I believe that surgeons have an inherent conflict of interest in their everyday occupation. The fact is they will (in general) make more money if they perform more surgical procedures.

Levitt and Dubner write in their book Freakonomics, "In a medical study, it turned out that obstetricians in areas with declining birth rates are much more likely to perform cesarean-section deliveries than obstetrician in growing areas-suggesting that, when business is tough, doctors try to ring up more expensive procedures."

Ultimately, my friend declined to partake in the radiation treatment venture; a decision he credited to his mores and faith. The truth is even the best of doctors can fall prey to the mighty dollar no matter how straight our moral compass. It is this author's opinion that the best solution to avoiding these conflicts of interest is to steer clear of them to begin with.

*From Wikipedia regarding self-referrals:
However the exceptions designed to allow necessary testing in physicians offices have been exploited to largely nullify the intent of the law. In particular, the in-office exception, which allows testing on equipment in the physicians office, has resulted in many physicians purchasing high-tech and expensive equipment such as CT scanners, MR scanners, and Nuclear Scanners for their own offices. Such purchases were not foreseen at the time that the laws were written.

The incentive for this practice is in large part the result of rapidly declining reimbursements for what has been termed “cognitive” physician care, i.e. the time spent talking to a patient and determining what course of diagnostic testing or treatment is best for that patient. Many clinical physicians feel that in order to have a financially viable practice, it is necessary to have income streams derived from patient testing.

The risk to the physician-owner of such a venture is minimal, since the physician-owner has it in his power to increase the volume of scans to any point necessary to insure profitability.

Defense of the practice of self referral is often rationalized and cloaked in a single word, "convenience". The self-referring physician claims that he or she performs the examination in the office strictly for the convenience of the patient. This is the primary explanation for self referral. However, the convenience argument does not justify unnecessary exams, increasing medical costs to society, or the absence of peer-reviewed quality imaging performed for the sake of profit. Often, the patient cannot be seen by the physician on the same day the study is performed, negating the argument.

**From the Dept. of Health & Human Services concerning tests covered under Stark law:
"Limits on self-referral were first enacted into law as part of the Omnibus Budget Reconciliation Act of 1989. The law took effect January 1, 1992. It bars referral of Medicare patients to clinical laboratories by physicians who have, or whose family members have, a financial interest in those laboratories. The Omnibus Reconciliation Act of 1993 expanded the scope of the ban on self-referral to 10 additional designated health services, including:

physical therapy;
occupational therapy;
radiology services;
radiation therapy services and supplies;
durable medical equipment and supplies;
parenteral and enteral nutrients, equipment and supplies;
orthotics, prosthetics, and prosthetic devices and supplies;
home health services;
outpatient prescription drugs; and
inpatient and outpatient hospital services."