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.
Wednesday, March 25, 2009
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
ESSENTIAL POINTS
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
ALLERGIC RHINITIS
Pathogenesis
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
TESTING FOR SPECIFIC IgE ANTIBODY
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
MANAGEMENT OF RHINITIS
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
PHARMACOLOGICAL THERAPY
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
SPECIAL CONSIDERATIONS
Pregnancy
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
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
ESSENTIAL POINTS
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
ALLERGIC RHINITIS
Pathogenesis
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
TESTING FOR SPECIFIC IgE ANTIBODY
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
MANAGEMENT OF RHINITIS
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
PHARMACOLOGICAL THERAPY
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
SPECIAL CONSIDERATIONS
Pregnancy
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."
45 PERCENT MORE?!?
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."
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."
45 PERCENT MORE?!?
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."
Monday, December 29, 2008
Post #12 Videogames and Violence
It seems like every time you turn around, the "latest and greatest" videogame console is coming at you.
It's not the consoles I caution parents against. It's the videogames that go with them.
With videogames, just as with television, studies show too much violent material increases the propensity for violence in children.
Games come with ratings to guide you on what's appropriate for your child, but the ratings are provided by the same industry that makes the games. It's basically self-policed, and not very objective. There's some conflict of interest.
Some experts believe the rating system is an advertising gimmick. Just as an R-rated movie might be alluring and tempting to kids, to where they might try to sneak in and see it, a videogame with a Mature rating seems edgy and mysterious to gamers.
The ratings are a start, but the best thing parents can do is take responsibility for the content they are introducing their children to.
Only about 10 percent of parents screen the games their kids play. Parents tend to be passive when it comes to this, because they don't realize the violence their kids are being exposed to.
Michael Rich MD, MPH, FAAP is a Harvard medical doctor often quoted in studies relating to videogames. His basic stance is that if there was poison in the water, or if the food supply was tainted, people would be up in arms in a second if it was hurting our kids.
But studies show there is a higher likelihood of videogame-playing leading to violence than there is smoking leading to cancer. He's asking, "why are parents so concerned about cigarettes when they are not concerned about what's going into their kids' minds?"
Dr. Rich continues, “The Center on Media and Child Health has catalogued 956 scientific articles that provide nearly unanimous evidence that exposure to media violence contributes to elevated fear and anxiety, sleep disturbances, desensitization to human suffering, and increases in aggressive thoughts and behaviors.” (Pediatrics Volume 119, Number 6, June 2007)
Avoid games that have a shooter or killing-type mentality; the games where you are the first-person shooter looking through the eyehole of a gun. The Columbine school killers were known to play these types of videogames for hours on end.
So is there anything good about videogames?
Yes.
Gaming introduces children to computer technology, practice following directions, problem solving and logic, fine motor skills, provides occasions for parents and children to play together; and they're entertaining and fun, which is the main reason kids like it.
I recommend parents look for games that encourage group play, or involve puzzle-solving.
But no matter how safe and great the game, you should still limit the amount of time your children are sitting in front of the console.
A general rule of thumb, as recommended by the American Academy of Pediatrics, is one to two hours of quality television or media time a day. That would include computers and videogames.
But the actual amount of time kids are exposed to media is far greater than that. According to an Oct. 31, 2008 study in the Journal of Pediatrics, kids average 13 hours a week of playing videogames. When it comes to boys, it's closer to 18 hours a week; and that’s not including extra television and internet time.
My concern in hearing this is that kids are not doing more productive things, like reading or being physically active. And the interactive sports games that come with the Wii console are a start, but nothing beats the actual sport.
Also, kids can develop a skewed sense of reality if immersing themselves too frequently in a fantasy world, and they are putting themselves in a secluded, isolated, individualistic environment instead of interacting in group settings with friends.
We live in a world where our children are more computer-savvy than parents. Video-gaming is at their fingertips, it's their generation, even more so than our days of Atari and Intellivision.
But we are the adults, these are our children, and it is our job to ensure their safety.
I urge you to sit down with them and watch the videogames they're playing. Better yet, play it with them. If you don't like it, get rid of it.
And remember, don't let ratings fool you.
SIDENOTE:
What are the ratings?
EC-Early Childhood: contains content that may be suitable for ages 3 and older
E-Everyone: Content that may be suitable for ages 6 and older; may contain minimal cartoon, fantasy or mild violence, or infrequent use of mild language
E10+: Content that may be suitable for ages 10 and older; may contain more cartoon, fantasy or mild violence, mild language and/or minimal suggestive themes
T-Teen: Content that may be suitable for ages 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling and/or infrequent use of strong language
M-Mature: Content that may be suitable for persons ages 17 and older; may contain intense violence, blood and gore, sexual content and/or strong language
A-Adults Only: Content that should only be played by persons 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity.
*Source: Entertainment Software Rating Board, www.esrb.org
It's not the consoles I caution parents against. It's the videogames that go with them.
With videogames, just as with television, studies show too much violent material increases the propensity for violence in children.
Games come with ratings to guide you on what's appropriate for your child, but the ratings are provided by the same industry that makes the games. It's basically self-policed, and not very objective. There's some conflict of interest.
Some experts believe the rating system is an advertising gimmick. Just as an R-rated movie might be alluring and tempting to kids, to where they might try to sneak in and see it, a videogame with a Mature rating seems edgy and mysterious to gamers.
The ratings are a start, but the best thing parents can do is take responsibility for the content they are introducing their children to.
Only about 10 percent of parents screen the games their kids play. Parents tend to be passive when it comes to this, because they don't realize the violence their kids are being exposed to.
Michael Rich MD, MPH, FAAP is a Harvard medical doctor often quoted in studies relating to videogames. His basic stance is that if there was poison in the water, or if the food supply was tainted, people would be up in arms in a second if it was hurting our kids.
But studies show there is a higher likelihood of videogame-playing leading to violence than there is smoking leading to cancer. He's asking, "why are parents so concerned about cigarettes when they are not concerned about what's going into their kids' minds?"
Dr. Rich continues, “The Center on Media and Child Health has catalogued 956 scientific articles that provide nearly unanimous evidence that exposure to media violence contributes to elevated fear and anxiety, sleep disturbances, desensitization to human suffering, and increases in aggressive thoughts and behaviors.” (Pediatrics Volume 119, Number 6, June 2007)
Avoid games that have a shooter or killing-type mentality; the games where you are the first-person shooter looking through the eyehole of a gun. The Columbine school killers were known to play these types of videogames for hours on end.
So is there anything good about videogames?
Yes.
Gaming introduces children to computer technology, practice following directions, problem solving and logic, fine motor skills, provides occasions for parents and children to play together; and they're entertaining and fun, which is the main reason kids like it.
I recommend parents look for games that encourage group play, or involve puzzle-solving.
But no matter how safe and great the game, you should still limit the amount of time your children are sitting in front of the console.
A general rule of thumb, as recommended by the American Academy of Pediatrics, is one to two hours of quality television or media time a day. That would include computers and videogames.
But the actual amount of time kids are exposed to media is far greater than that. According to an Oct. 31, 2008 study in the Journal of Pediatrics, kids average 13 hours a week of playing videogames. When it comes to boys, it's closer to 18 hours a week; and that’s not including extra television and internet time.
My concern in hearing this is that kids are not doing more productive things, like reading or being physically active. And the interactive sports games that come with the Wii console are a start, but nothing beats the actual sport.
Also, kids can develop a skewed sense of reality if immersing themselves too frequently in a fantasy world, and they are putting themselves in a secluded, isolated, individualistic environment instead of interacting in group settings with friends.
We live in a world where our children are more computer-savvy than parents. Video-gaming is at their fingertips, it's their generation, even more so than our days of Atari and Intellivision.
But we are the adults, these are our children, and it is our job to ensure their safety.
I urge you to sit down with them and watch the videogames they're playing. Better yet, play it with them. If you don't like it, get rid of it.
And remember, don't let ratings fool you.
SIDENOTE:
What are the ratings?
EC-Early Childhood: contains content that may be suitable for ages 3 and older
E-Everyone: Content that may be suitable for ages 6 and older; may contain minimal cartoon, fantasy or mild violence, or infrequent use of mild language
E10+: Content that may be suitable for ages 10 and older; may contain more cartoon, fantasy or mild violence, mild language and/or minimal suggestive themes
T-Teen: Content that may be suitable for ages 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling and/or infrequent use of strong language
M-Mature: Content that may be suitable for persons ages 17 and older; may contain intense violence, blood and gore, sexual content and/or strong language
A-Adults Only: Content that should only be played by persons 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity.
*Source: Entertainment Software Rating Board, www.esrb.org
Friday, October 17, 2008
Post #11 Darius Goes West (A Movie Review)
So why review a movie on a pediatric blog?
A couple of months ago I received an email from a blog reader who was a participant in a movie project that ultimately produced a unique documentary titled Darius Goes West.
Their ultimate quest: raise awareness and money for Duchenne Muscular Dystrophy research.
For those unfamiliar with Duchenne Muscular Dystrophy (DMD), it is a heartbreaking disease that cripples otherwise healthy children by deteriorating their muscles, eventually leading to loss in ambulation, paralysis and death. The average life expectancy for a child afflicted with DMD varies from the early teen years to the mid-30s.
As a pediatric resident, I witnessed, up close and personal, several brave patients who battled doggedly against the recessive X-linked killer. Inevitably and unfortunately, the genetic defect always prevailed.
However, there is light at the end of the tunnel; promising new therapies including stem cell replacement, DNA repair techniques, new uses for old medications and completely new medications set an auspicious foundation for the future.
For Daruis Weems, the future may not be soon enough. But rather than succumbing to Muscular Dystropy, Darius has tackled the disease head-on, creating a documentary film to assist in the fight. The documentary begins in the summer of 2005, with then 15-year-old Darius setting off on a road trip across the United States with the ultimate goal of reaching Los Angeles in the hopes of having his wheelchair souped up on MTV's show "Pimp My Ride".
Eleven of his friends (one of whom emailed me about the cause) join him on this crusade, and what ensues is a remarkable story about courage, friendship and love of life, regardless of the cards life deals you. And while the storyline revolves around the quest to "pimp" Darius' ride, the real story that is ultimately revealed is that life is only as precious and fulfilling as you are willing to make it. And Darius lives life large.
It was neither the best movie nor even the best documentary that I've watched, but I thorougly enjoyed the film and its authenticity. And for certain, it is the best money I have ever spent in purchasing a movie (10 DVDs to be exact... I wanted to share). I cried, I laughed, and I especially enjoyed the rap numbers Darius performs throughout the documentary. The boy has skillz (I doubt I'll ever use that word in another blog again), and so too does the documentary, winner of over 25 separate film awards.
Ultimately, it is an excellent way to spend an evening. And even if you do not thoroughly enjoy the film, you can walk away knowing your money went to a good cause. One day in the not-so-distant future, Duchenne Muscular Dystrophy will meet its match. Until that day comes, Darius and his team will help lead the charge in his pimped-out wheelchair.
More information (and how to purchase the DVD) can be found at www.dariusgoeswest.com, but to simplify things I have inserted a snippet from the website.
The Million DVD fundraiser has begun! The goal of the DGW Foundation is to sell one million copies of Darius's Award winning film, in roughly one year. The "year" began Sept. 1st '08 and will end on Darius's birthday, Sept. 27th 09.
The best way you can help with our "One million DVD in one year" campaign is to purchase a DVD or a set of DARIUS GOES WEST DVDs. By set we mean multiple DVDs for a group of friends or family...for your entire church, synagogue, or Sunday school class...for everyone who works in your company...or for an entire classroom (or school) of students in middle or high school. Your generosity, at any level, will not only help spread awareness for Duchenne Muscular Dystrophy, but it will also help fund promising research intended to treat or cure this fatal disease.
Because we are a non-profit Foundation, any time you buy a DVD, or a set of DVDs, a portion of the purchase is a tax-deductible donation. The fair market value of each DARIUS GOES WEST DVD is $3. When you make a purchase (of $250 or more), we will send you an official thank-you letter that you can use for tax filing purposes.
A couple of months ago I received an email from a blog reader who was a participant in a movie project that ultimately produced a unique documentary titled Darius Goes West.
Their ultimate quest: raise awareness and money for Duchenne Muscular Dystrophy research.
For those unfamiliar with Duchenne Muscular Dystrophy (DMD), it is a heartbreaking disease that cripples otherwise healthy children by deteriorating their muscles, eventually leading to loss in ambulation, paralysis and death. The average life expectancy for a child afflicted with DMD varies from the early teen years to the mid-30s.
As a pediatric resident, I witnessed, up close and personal, several brave patients who battled doggedly against the recessive X-linked killer. Inevitably and unfortunately, the genetic defect always prevailed.
However, there is light at the end of the tunnel; promising new therapies including stem cell replacement, DNA repair techniques, new uses for old medications and completely new medications set an auspicious foundation for the future.
For Daruis Weems, the future may not be soon enough. But rather than succumbing to Muscular Dystropy, Darius has tackled the disease head-on, creating a documentary film to assist in the fight. The documentary begins in the summer of 2005, with then 15-year-old Darius setting off on a road trip across the United States with the ultimate goal of reaching Los Angeles in the hopes of having his wheelchair souped up on MTV's show "Pimp My Ride".
Eleven of his friends (one of whom emailed me about the cause) join him on this crusade, and what ensues is a remarkable story about courage, friendship and love of life, regardless of the cards life deals you. And while the storyline revolves around the quest to "pimp" Darius' ride, the real story that is ultimately revealed is that life is only as precious and fulfilling as you are willing to make it. And Darius lives life large.
It was neither the best movie nor even the best documentary that I've watched, but I thorougly enjoyed the film and its authenticity. And for certain, it is the best money I have ever spent in purchasing a movie (10 DVDs to be exact... I wanted to share). I cried, I laughed, and I especially enjoyed the rap numbers Darius performs throughout the documentary. The boy has skillz (I doubt I'll ever use that word in another blog again), and so too does the documentary, winner of over 25 separate film awards.
Ultimately, it is an excellent way to spend an evening. And even if you do not thoroughly enjoy the film, you can walk away knowing your money went to a good cause. One day in the not-so-distant future, Duchenne Muscular Dystrophy will meet its match. Until that day comes, Darius and his team will help lead the charge in his pimped-out wheelchair.
More information (and how to purchase the DVD) can be found at www.dariusgoeswest.com, but to simplify things I have inserted a snippet from the website.
The Million DVD fundraiser has begun! The goal of the DGW Foundation is to sell one million copies of Darius's Award winning film, in roughly one year. The "year" began Sept. 1st '08 and will end on Darius's birthday, Sept. 27th 09.
The best way you can help with our "One million DVD in one year" campaign is to purchase a DVD or a set of DARIUS GOES WEST DVDs. By set we mean multiple DVDs for a group of friends or family...for your entire church, synagogue, or Sunday school class...for everyone who works in your company...or for an entire classroom (or school) of students in middle or high school. Your generosity, at any level, will not only help spread awareness for Duchenne Muscular Dystrophy, but it will also help fund promising research intended to treat or cure this fatal disease.
Because we are a non-profit Foundation, any time you buy a DVD, or a set of DVDs, a portion of the purchase is a tax-deductible donation. The fair market value of each DARIUS GOES WEST DVD is $3. When you make a purchase (of $250 or more), we will send you an official thank-you letter that you can use for tax filing purposes.
Wednesday, August 20, 2008
Post #10 The Changing Landscape of Fever
Fever today is not the same fever of 30 years ago.
What does this mean?
To begin with, one must understand that fever itself (for the most part) is not dangerous. Fever, defined as 100.4 degrees Farenheit or higher, is not a disease in and of itself; rather it is a symptom or a sign of an underlying disease. Viewing fever as a disease will lead to accepting common misconceptions and evoke unneccessary anxiety.
Several times a week in my office I see children with a fever reaching 104-105 degrees who recover without incident. Studies have indicated that fever itself is not worrisome until a child reaches 107 or higher. Fortunately, fever greater than 107 will usually occur only in a child with an underlying neurological deficit or, very rarely, an environmental heatstroke (e.g. being locked in a car inadvertently in the middle of a Houston summer).
When your child has a fever, his body is telling you that he is sick (or sometimes overheated by external causes). In the majority of cases, a fever indicates that your child has become infected with a germ. There are other causes of fever as well. For example, after your child has received immunizations, he may exhibit a non-worrisome fever for a day or two. In this case the body is reacting to either dead or weakened germs or germ fragments that have been purposefully introduced to create beneficial lasting immunity.
Most parental anxiety with fever revolves around the fear that there may be potential harm to the child as a result of the fever. Specifically, the parent is often worried about damage to the brain.
In truth, fever will rarely damage or hurt the child (as mentioned above), although the underlying germ causing the fever potentially could. Which is why as a pediatrician, I am seldom concerned about the fever itself; I am always far more concerned about the source of the fever. My job as a pediatrician, when presented with a febrile child, is to deduce the source of the fever and then to decide whether the source is of concern or not (and it most often is not).
If the fever is coming from a brain infection, pneumonia or kidney infection, I am very worried about the child because all of these infections are quite serious and potentially life-threatening if not treated properly. However, if the fever is coming from a cold virus or stomach virus (which is far more likely, statistically), I am not worried about the child because most of these infections resolve on their own with time and pose little to no threat to the well-being of a child.
Which brings me back to my opening statement: fever today is not the same fever of 30 years ago.
The reason is simple: vaccines. The current gamut of immunizations, while currently controversial (although the tide is finally shifting - thank goodness), are perhaps the greatest advancement of modern medicine in the past century. The vaccinations we currently administer confer protection against the deadly germs which our parents' generation grew up with. Germs which cause meningitis, diphtheria, tetanus, pneumonia, measles, whooping cough, epiglottitis . . . and the list goes on and on.
In present day, when a child who follows the recommended vaccine schedule presents to me with fever, there are many germs that I can automatically factor out while making my diagnosis. As a result of immunizations, I already know what a child CANNOT possibly have as the source of the fever. As a result, I can focus on a much more narrow list of the usual suspects as I begin my detective work.
Imagine playing the game Clue, knowing that Professor Plum, Colonel Mustard and Mrs. Peacock are already behind bars. It just makes the game that much easier (although not as easy as peeking in the envelope like my brother often did). Likewise, if I can evaluate a fever already knowing that measles, mumps and diptheria are out of the running, it makes my job a lot easier. Which is why as a pediatrician I have a leg up on my father, who had to do the same job without the benefits of many of the newer vaccines.
Of course, as antibiotic resistance is on the rise, the landscape of our usual suspects is beginning to change once again, hence the vital need for judicious use of antibiotics (but that is a topic for a separate blog). Nonetheless, fever today represents a far more limited field of possible dangerous causes than the fever of 30 years ago. That is why I sympathize when a grandmother is still apprehensive of her grandchild's fever. She lived through the years of measles, mumps and diphtheria. Many of them remember what a fever could represent in their days and understandably harbor anxiety about their grandchild's temperature.
But as a new generation grows up with a legion of vaccinated and protected children (for the most part), there will hopefully be a societal shift in the right direction concerning the fear of fever.
Let me conclude by noting that fever can still and sometimes does represent meningitis, pneumonia or a dangerous infection. As far as vaccines have advanced, there is still more work to be done. So when a child with a fever is acting sick (i.e. not playing, not eating, appears ill, doesn't smile, lacks energy) he or she must be evaluated by a doctor.
However, over time, with the proper communciation between a well-informed pediatrician and an attentive mother, a parent can begin to grasp when to be worried and when not to be worried. This maternal instinct can be honed over time if a mom is equipped with the right information and the proper guidance from her pediatrician.
I am proud to say that in my practice I now have many veteran mothers who don't come in for every fever (although they initially may have), but only when there is an accompanying noticeable change in the activity level of her child. I could write oodles of blogs to delineate this skill, but there is a level of understanding that can only come from repeated communication and hands-on experience.
The end result is a family that has a far lower level of anxiety about fever and a far higher understanding of what fever truly is and represents. It is a benefit to the parent and to the pediatrician alike. It saves the mom unneccesary trips to my office, copay money and frustration while it frees up my appointment slots for the kids who truly need to be seen.
There are many aspects of fever I did not cover in this blog, but hopefully this can serve as a primer in building a firmer knowledge base for the anxious parent who wants to learn more!
What does this mean?
To begin with, one must understand that fever itself (for the most part) is not dangerous. Fever, defined as 100.4 degrees Farenheit or higher, is not a disease in and of itself; rather it is a symptom or a sign of an underlying disease. Viewing fever as a disease will lead to accepting common misconceptions and evoke unneccessary anxiety.
Several times a week in my office I see children with a fever reaching 104-105 degrees who recover without incident. Studies have indicated that fever itself is not worrisome until a child reaches 107 or higher. Fortunately, fever greater than 107 will usually occur only in a child with an underlying neurological deficit or, very rarely, an environmental heatstroke (e.g. being locked in a car inadvertently in the middle of a Houston summer).
When your child has a fever, his body is telling you that he is sick (or sometimes overheated by external causes). In the majority of cases, a fever indicates that your child has become infected with a germ. There are other causes of fever as well. For example, after your child has received immunizations, he may exhibit a non-worrisome fever for a day or two. In this case the body is reacting to either dead or weakened germs or germ fragments that have been purposefully introduced to create beneficial lasting immunity.
Most parental anxiety with fever revolves around the fear that there may be potential harm to the child as a result of the fever. Specifically, the parent is often worried about damage to the brain.
In truth, fever will rarely damage or hurt the child (as mentioned above), although the underlying germ causing the fever potentially could. Which is why as a pediatrician, I am seldom concerned about the fever itself; I am always far more concerned about the source of the fever. My job as a pediatrician, when presented with a febrile child, is to deduce the source of the fever and then to decide whether the source is of concern or not (and it most often is not).
If the fever is coming from a brain infection, pneumonia or kidney infection, I am very worried about the child because all of these infections are quite serious and potentially life-threatening if not treated properly. However, if the fever is coming from a cold virus or stomach virus (which is far more likely, statistically), I am not worried about the child because most of these infections resolve on their own with time and pose little to no threat to the well-being of a child.
Which brings me back to my opening statement: fever today is not the same fever of 30 years ago.
The reason is simple: vaccines. The current gamut of immunizations, while currently controversial (although the tide is finally shifting - thank goodness), are perhaps the greatest advancement of modern medicine in the past century. The vaccinations we currently administer confer protection against the deadly germs which our parents' generation grew up with. Germs which cause meningitis, diphtheria, tetanus, pneumonia, measles, whooping cough, epiglottitis . . . and the list goes on and on.
In present day, when a child who follows the recommended vaccine schedule presents to me with fever, there are many germs that I can automatically factor out while making my diagnosis. As a result of immunizations, I already know what a child CANNOT possibly have as the source of the fever. As a result, I can focus on a much more narrow list of the usual suspects as I begin my detective work.
Imagine playing the game Clue, knowing that Professor Plum, Colonel Mustard and Mrs. Peacock are already behind bars. It just makes the game that much easier (although not as easy as peeking in the envelope like my brother often did). Likewise, if I can evaluate a fever already knowing that measles, mumps and diptheria are out of the running, it makes my job a lot easier. Which is why as a pediatrician I have a leg up on my father, who had to do the same job without the benefits of many of the newer vaccines.
Of course, as antibiotic resistance is on the rise, the landscape of our usual suspects is beginning to change once again, hence the vital need for judicious use of antibiotics (but that is a topic for a separate blog). Nonetheless, fever today represents a far more limited field of possible dangerous causes than the fever of 30 years ago. That is why I sympathize when a grandmother is still apprehensive of her grandchild's fever. She lived through the years of measles, mumps and diphtheria. Many of them remember what a fever could represent in their days and understandably harbor anxiety about their grandchild's temperature.
But as a new generation grows up with a legion of vaccinated and protected children (for the most part), there will hopefully be a societal shift in the right direction concerning the fear of fever.
Let me conclude by noting that fever can still and sometimes does represent meningitis, pneumonia or a dangerous infection. As far as vaccines have advanced, there is still more work to be done. So when a child with a fever is acting sick (i.e. not playing, not eating, appears ill, doesn't smile, lacks energy) he or she must be evaluated by a doctor.
However, over time, with the proper communciation between a well-informed pediatrician and an attentive mother, a parent can begin to grasp when to be worried and when not to be worried. This maternal instinct can be honed over time if a mom is equipped with the right information and the proper guidance from her pediatrician.
I am proud to say that in my practice I now have many veteran mothers who don't come in for every fever (although they initially may have), but only when there is an accompanying noticeable change in the activity level of her child. I could write oodles of blogs to delineate this skill, but there is a level of understanding that can only come from repeated communication and hands-on experience.
The end result is a family that has a far lower level of anxiety about fever and a far higher understanding of what fever truly is and represents. It is a benefit to the parent and to the pediatrician alike. It saves the mom unneccesary trips to my office, copay money and frustration while it frees up my appointment slots for the kids who truly need to be seen.
There are many aspects of fever I did not cover in this blog, but hopefully this can serve as a primer in building a firmer knowledge base for the anxious parent who wants to learn more!
Friday, July 4, 2008
Post #9 "Dry Drowning": How Worried Should You Really Be?
On June 1, 2008 10-year old Johnny Jackson got water in his lungs while swimming in the pool. He walked home, took a bath, and went to bed; he died in his sleep during a nap an hour later. The county coroner reported water in the boy's lungs.
On June 5, 2008 todayshow.com reported the following:
"According to the Centers for Disease Control, some 3,600 people drowned in 2005, the most recent year for which there are statistics. Some 10 to 15 percent of those deaths was classified as “dry drowning,” which can occur up to 24 hours after a small amount of water gets into the lungs. In children, that can happen during a bath."
While the 3,600 number is fairly accurate (3,582 to be exact), the 10-15% statistic is erroneous and the CDC enterprise communication officer Sandy Bonzo has since issued a statement as such. There are no statistics on the percentage of "dry drownings".
Soon after Johnny's unfortunate drowning, there was a full-on media blitz with the Today Show spearheading the charge. The media did what the media does best: it struck the "Moms you had better take note for your chid's sake or else suffer the consequences" nerve. What followed was a slew of stories on multiple websites, newspapers and local news channels on "dry drowning". . . the story at 10 and you had better not miss it if you care about your child. . .
Although the phrase "dry drowning" is an ideal term for a newscaster hoping to invoke fear in the heart of the average mother, it is a somewhat misleading phrase. In fact, there are so many different phrases used to describe drowning (such as wet drowning, dry drowning, near drowning, secondary drowning, passive drowning) that it leads to ambiguity in what physiologically has actually occurred in each individual case. In an attempt to simplify matters, the 2002 World Congress on Drowning held in Amsterdam defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.
So what do people mean by "dry drowning" then?
It's hard to pinpoint exactly as there is no set definition, but it seems to be any situation where a person cannot breathe and water does NOT enter the lungs. In this sense "dry drowning" could conceivably apply to laryngospasms (spasms of your windpipe) and such external causes such as a lung puncture or a heavier-than-air gas filling the lungs. Even in an underwater drowning, it is conceivable that a person could suffer laryngospasms and die from oxygen deprivation without water entering the lungs, and hence be classified as a dry drowning when in fact the person was fully submerged underwater. You can see how there is ambiguity and confusion in using these terms, which is why the 2002 Congress uses one universal definition.
So exactly what happened in Johnny's case then?
Most likely Johnny did swallow some water while he played in the pool and some of the water made it into his lungs (which then technically is not a "dry drowning" even though the death occured out-of-water). This water then led to a loss of pulmonary function after the "loss or inactivation of surfactant" of the alveoli in the lungs. Surfactant is an amphiphilic compound which reduces the surface tension of your lungs allowing you to breathe. Basically, it helps your lungs to expand easily allowing oxygen to enter. The water that made it into Johnny's lung disrupted the ability of his natural surfactant and therefore as he napped, he was unable to breathe properly leading to his unfortunate demise.
This type of situation is uncommon, however there are no exact statistics on it. And although it can be a scary concept to every mother whose child goes swimming during the summertime and then on occasion takes a nap, things must be put into perspective.
First, most drownings do not occur this insidiously. Rather, the majority of drownings happen where it is clear that the child has been submerged under water. In this sense, things can be done to avoid the obvious drowning: close supervision, fences/covers/alarms around unused pools, CPR training, etc.
Second, even in a case such as Johnny's, there will be some warning signs: accidental ingestion of water, forceful coughing >1 minute right after coming out of the water, difficulty breathing, extreme fatigue and changes in behavior. If your child clearly is having an excessive amount of coughing and difficulty breathing right after swimming, it would be evident to the observant mother.
Finally, there is more risk in driving your child to the local movie theater than there is in monitored water play.
The bottom line is that like many other risks that the media has over-hyped, "dry drowning" is a real risk but a very unlikely one if you follow safe water practices. One good thing about this media blitz has been an increased awareness about general water safety, which only benefits summer activities. In this sense, hopefully Johnny's life will serve as a beacon to every mother and child swimming this summer.
On June 5, 2008 todayshow.com reported the following:
"According to the Centers for Disease Control, some 3,600 people drowned in 2005, the most recent year for which there are statistics. Some 10 to 15 percent of those deaths was classified as “dry drowning,” which can occur up to 24 hours after a small amount of water gets into the lungs. In children, that can happen during a bath."
While the 3,600 number is fairly accurate (3,582 to be exact), the 10-15% statistic is erroneous and the CDC enterprise communication officer Sandy Bonzo has since issued a statement as such. There are no statistics on the percentage of "dry drownings".
Soon after Johnny's unfortunate drowning, there was a full-on media blitz with the Today Show spearheading the charge. The media did what the media does best: it struck the "Moms you had better take note for your chid's sake or else suffer the consequences" nerve. What followed was a slew of stories on multiple websites, newspapers and local news channels on "dry drowning". . . the story at 10 and you had better not miss it if you care about your child. . .
Although the phrase "dry drowning" is an ideal term for a newscaster hoping to invoke fear in the heart of the average mother, it is a somewhat misleading phrase. In fact, there are so many different phrases used to describe drowning (such as wet drowning, dry drowning, near drowning, secondary drowning, passive drowning) that it leads to ambiguity in what physiologically has actually occurred in each individual case. In an attempt to simplify matters, the 2002 World Congress on Drowning held in Amsterdam defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.
So what do people mean by "dry drowning" then?
It's hard to pinpoint exactly as there is no set definition, but it seems to be any situation where a person cannot breathe and water does NOT enter the lungs. In this sense "dry drowning" could conceivably apply to laryngospasms (spasms of your windpipe) and such external causes such as a lung puncture or a heavier-than-air gas filling the lungs. Even in an underwater drowning, it is conceivable that a person could suffer laryngospasms and die from oxygen deprivation without water entering the lungs, and hence be classified as a dry drowning when in fact the person was fully submerged underwater. You can see how there is ambiguity and confusion in using these terms, which is why the 2002 Congress uses one universal definition.
So exactly what happened in Johnny's case then?
Most likely Johnny did swallow some water while he played in the pool and some of the water made it into his lungs (which then technically is not a "dry drowning" even though the death occured out-of-water). This water then led to a loss of pulmonary function after the "loss or inactivation of surfactant" of the alveoli in the lungs. Surfactant is an amphiphilic compound which reduces the surface tension of your lungs allowing you to breathe. Basically, it helps your lungs to expand easily allowing oxygen to enter. The water that made it into Johnny's lung disrupted the ability of his natural surfactant and therefore as he napped, he was unable to breathe properly leading to his unfortunate demise.
This type of situation is uncommon, however there are no exact statistics on it. And although it can be a scary concept to every mother whose child goes swimming during the summertime and then on occasion takes a nap, things must be put into perspective.
First, most drownings do not occur this insidiously. Rather, the majority of drownings happen where it is clear that the child has been submerged under water. In this sense, things can be done to avoid the obvious drowning: close supervision, fences/covers/alarms around unused pools, CPR training, etc.
Second, even in a case such as Johnny's, there will be some warning signs: accidental ingestion of water, forceful coughing >1 minute right after coming out of the water, difficulty breathing, extreme fatigue and changes in behavior. If your child clearly is having an excessive amount of coughing and difficulty breathing right after swimming, it would be evident to the observant mother.
Finally, there is more risk in driving your child to the local movie theater than there is in monitored water play.
The bottom line is that like many other risks that the media has over-hyped, "dry drowning" is a real risk but a very unlikely one if you follow safe water practices. One good thing about this media blitz has been an increased awareness about general water safety, which only benefits summer activities. In this sense, hopefully Johnny's life will serve as a beacon to every mother and child swimming this summer.
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