Cold and Flu Season Coming

As we head into fall and winter we see an increase in the number of viral respiratory illnesses in the community. Most of these are simple self-limited infections that healthy individuals can weather after a period of a few days to a week of being uncomfortable from runny noses, sinus congestion, sore throats, coughs, aches and pains and sometimes fever. There are studies out of Scandinavia conducted in extreme cold temperature environments that show that taking an extra gram of Vitamin C per day reduces the number of these infections and the severity and duration in elite athletes and Special Forces military troops. Starting extra vitamin C once you develop symptoms does little to shorten the duration or lessen the intensity of the illness. Vigorous hand washing and avoidance of sick individuals helps as well. Flu shots prevent viral influenza and should be taken by all adults unless they have a specific contraindication to influenza. A cold is not the flu or influenza. Whooping cough or pertussis vaccination with TDap should be taken by all middle aged and senior adults as well to update their pertussis immunity. We often see pictures of individuals wearing cloth surgical masks in crowded areas to prevent being exposed to a viral illness. Those cloth surgical masks keep the wearers secretions and “germs” contained from others but do nothing to prevent infectious agents others are emitting from getting through the pores of the mask and infecting them. If you wish to wear a mask that is effective in keeping infectious agents out then you need to be using an N95 respirator mask.

Once you exhibit viral upper respiratory tract symptoms care is supportive. If you are a running a fever of 101 degrees or higher taking Tylenol or a NSAID will bring the fever down. Staying hydrated with warm fluids, soups and broths helps. Resting when tired helps. Most adults do not “catch” strep throat unless they are exposed to young children usually ages 2-7 that have strep throat. Sore throats feel better with warm fluids, throat lozenges and rest.

You need to see your doctor if you have a chronic illness such as asthma , COPD, heart failure or an immunosuppressive disease which impairs your immune system and you develop a viral illness with a fever of 100.8 or higher. If your fever is 101 or greater for more than 24 hours it is the time to contact your doctor. Breathing difficulty is a red flag for the need to contact your physician immediately.

Most of these viral illnesses will make you feel miserable but will resolve on their own with rest, common sense and plenty of fluids.

Medical Students Return for Clinical Experience

The Charles F. Schmidt College of Medicine medical students who learn history taking, physical examinations and patient care skills have returned to the office for their second year of training. Danielle Chang Klein will be seeing patients with Dr. Reznick on Wednesday afternoons this year. Dr. Levine’s student, Tyler Anderson, will be seeing patients with him on Monday afternoons. If you prefer not being seen by a medical student then please let us know and we will make sure you are seen just by your physician. I understand that being seen by a student is not for everyone. I also understand that it presents a unique opportunity for our patient’s in a relaxed clinical setting to teach our future doctors’ how they wish to be treated as patients.

Adult Sore Throats 2015 – 2016 Flu Season

Robert Centor, M.D., of the University of Alabama at Birmingham, performed the definitive study on adult sore throats showing that 10% or less of adult sore throats are caused by bacteria particularly Group A Streptococcus . He went on to prove that bacterial Strep throats were accompanied by a cough, large swollen and tender lymph nodes, a temperature greater than 100.4 and an exudate on your tonsils. The disease is primarily seen in children age 2-7 and those who care for them and play with them. In adults who did not meet the criteria of having a cough, swollen and enlarged lymph nodes, a temperature of 100.4 and a tonsillar exudate, a rapid streptococcus throat swab was accurate 100 % of the time. If the quick strep analysis is negative you do not have a strep throat and do not require an antibiotic. We had two patients this past fall who did not meet the criteria of Dr. Centor, did not have the physical findings consistent with a strep throat, had a negative quick strep throat swab but upon performing a traditional throat culture were found to be positive for Group a Beta Hemolytic Streptococcus requiring antibiotics. Why did the discrepancy occur? According to the manufacturer they had to recall a batch of diagnostic material that was ineffective. Both patients were placed on antibiotics soon after their clinical course did not follow the path of a viral infection and both did well.

Most adult sore throats and colds do not require antibiotics. We reserve them for patient with debilitating chronic illnesses especially advanced pulmonary, cardiac and neurologic disease patients. With influenza season on the horizon we will continue to assess patient’s clinically using history, exam, quick strep throat swabs and traditional microbiological throat cultures where appropriate. I will continue to prescribe antibiotics where necessary but must admit, last years’ experience opened my eyes to a more liberal approach with the prescribing of antibiotics for simple sore throats.

2015 Changes in Medicine for Medicare Patients

CMS, the parent organization for the Medicare program has decided to reduce health care costs. One method for reducing health care costs is to pay a flat bundled fee for services to one entity and let that entity worry about how to pay for all the services and equipment. CMS first venture into this practice in the State of Florida begins shortly with Medicare deciding to pay one flat fee for knee and hip replacements. In our local area they will pay Boca Raton Regional Hospital (BRRH) one time. The hospital is expected to provide physicians, nurses, pharmaceutical goods, the orthopedic appliance (the hip and knee) and all related costs including your postoperative stay in a rehabilitation facility and physical therapy. If a patient has a medical complication of the surgery, or the surgeon needs consultative physician assistance, that too is covered in the bundled fee.

This means that your orthopedic surgeon will either need to be an employee of Boca Raton Regional Hospital or a contracted physician at an agreed upon price for that service. For several years now, CMS has been encouraging hospitals and health care organizations to organize into Accountable Care Organizations (ACO’s) which would receive the bundled payments and distribute them according to a formula they devise internally. The ACO’s have formed in most parts of the country, but Florida remains as a stronghold of fiercely independent physicians primarily in the medical and surgical specialties that are procedure oriented and generate large revenue streams. They have seen hospital systems like Boca Raton Regional Hospital purchase physician practices and try to run them at least twice in the last 25 years. In each case the hospitals lost large sums of money, the practices ran inefficiently and were returned to the physician owners as a means of cutting their losses. Over the last few years, in addition to building many new facilities , BRRH has been buying up local physician practices and employing the doctors in primary care ( Boca Care), hematology oncology ( Lynn Regional Cancer Group), plus their hospitalist service, emergency department physicians ( who additionally staff their community Urgent Care Centers) pathologists , anesthesiologists and others. By accumulating so many of the formerly private physicians’ as employees or contracted help, they were able to change the structure and bylaws of the medical staff rules and regulations and bylaws allowing the hospital administration to effectively eliminate a checks and balances arm of decision making that protected patient and physician interests.

When you enter the hospital for a knee or hip replacement, it is unclear if your personal physician will be paid by Medicare for seeing you if that physician is not a member of the Accountable Care Organization or an employee of the hospital. A non-employed, non-contracted consulting doctor may possibly bill the patient privately for their services but it is unclear whether Medicare will pay the doctor if they accept assignment, or reimburse the patient if they pay privately and submit the receipt to their insurances for reimbursement. CMS plans to bundle payments for 30% of existing conditions by 2017 and over 70% by 2023. These changes are part of the Affordable Care Act or “ObamaCare”.

I will continue to see my patients who need a hip or knee replacement and develop a fair payment option for them. This will apply to any future bundled service CMS implements as well. My patients will continue to be cared for by me! Experienced local physicians have a healthy distrust of the hospital as an employer based on their past track record. Younger physicians coming out of training with large educational debt and a desire to balance their lives by working regular shifts are more willing to accept employment positions and work for the ACO’s. The goal of the Federal Government is to reduce health care spending by fiat rather than by natural market forces. As the Baby Boomers age and develop more chronic conditions and require more care It seems to me that physicians will need to spend more time with these complex patients rather than less time in short conveyor belt type visits being advocated CMS and current health care policy makers. Feel free to contact me if you wish to discuss any of this.

Influenza Vaccine 2015- 2016 Season

The Center for Disease Control and Prevention (CDC) has recommended that all adult s receive the flu shot vaccination this coming fall. Our supply of flu vaccine is expected to arrive by September 1, 2015 and we will begin administering the vaccine shortly thereafter. This season there will be three types of intramuscular injectable flu vaccines available. All will contain a non-live attenuated version of the flu viruses. The Senior High Dose vaccine is recommended for all adults 65 years of age or older. The Trivalent or Quadrivalent vaccine is suggested for younger adults. The vaccine will contain 3 antigens including: an A/California/7/2009 H1N1 pdm09- like virus, an A/Switzerland/9715293/2013 H3N2 like virus and a B/Phuket/3073/2013 like virus. It is called a trivalent vaccine because it contains three virus types. The Quadrivalent Vaccine will contain a fourth antigen B/Brisbane/60/2008 like virus.

Please call the office to set up an appointment for your vaccination. Once you have received the vaccine it takes about ten to fourteen days for your body to develop antibodies against the flu. Influenza begins to appear in the northern United States in late October. The season can run through February into March. In South Florida we see little flu prior to Thanksgiving with the disease peaking in late January early February. Immunity in younger healthier patients will last throughout the flu season. Older and sicker individuals see their immunity decrease over time lasting as short a period as 3-4 months in some. The shortened immunity in seniors is the reason we usually suggest they receive the vaccine between Halloween and Thanksgiving. If you have any questions please call the office.

Flu Vaccine will be available at most commercial pharmacies as well as our office and at many workplaces. Please let us know if and when you obtain the vaccine elsewhere and tell us which of the vaccines you received.

I am often asked about adverse reactions and side effects of the vaccine. It is a dead virus. It cannot give you influenza. A successful vaccine will produce some redness, warmth and swelling at the injection site. That means that your immune system is working and reacting appropriately to the injected material. If this occurs put some ice on it and take two acetaminophen. Feel free to call us or set up an appointment to be seen that day so we can evaluate the injection site.

A Blood Test for Irritable Bowel Syndrome?

Researchers presented a paper at the annual Digestive Disease Week meeting which introduced a commercial blood test which can help distinguish irritable bowel syndrome (IBS) from Cohn’s Disease or Ulcerative Colitis (Inflammatory Bowel Diseases) and Celiac Disease ( Gluten Sensitive Enteropathy). The test was especially effective in identifying the diarrhea predominant form of Irritable bowel syndrome. The issue was discussed today on line in the periodical MedPage Today.

Patients with Irritable Bowel Syndrome get sudden abdominal bloating, cramping and progressively watery loose bowel movements. The symptoms often occur after a meal and leave the patient frightened and exhausted. Symptoms can be prolonged and emotionally and physically incapacitate an individual. Until now physicians were forced to schedule barium enemas, small bowel x ray series and fiber optic examinations (sigmoidoscopies, colonoscopies, upper endoscopies) to distinguish irritable bowel syndrome from the more ominous inflammatory bowel diseases. Very often we needed to collect stool specimens to look for white blood cells, red blood cells, bacteria, parasites and chemical constituents. The cost, radiation exposure and risks of invasive procedures causing complications made the experience expensive and unpleasant but necessary.

The current blood tests, used in a trial of 2700 patients, detect antibodies to cytolethal distending toxin B and vinculin. Mark Pimental, MD of Cedars-Sinai Medic al Center in Los Angeles said to the tests were successful in distinguishing IBS from the other entities with specificity well above 90% and a positive predictive value of 98.6% allowing clinicians to rule out Crohn’s Disease or Ulcerative Colitis.

This is a step in the right direction but it remains to be seen when the test will be available locally through commercial labs and if it really will allow us to eliminate the many tests we now do to distinguish these problems from one another.

Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Anthony Delitto, PT, PhD and colleagues at the University of Pittsburgh published an article in the April 7, 2015 Annals of Internal Medicine documenting that at the two year mark, physical therapy was as effective as surgical decompression in spinal stenosis of the lumbar spine. The study involved 169 patients diagnosed with spinal stenosis with imaging confirmation by either CT scan or MRI. These patients all met the accepted criteria for surgical intervention, all had agreed to and signed consent for surgery and all had leg pain with walking (neurogenic claudication). None of the patients had previous back surgery.

After all had consented to surgery they were randomly assigned to a surgical group or a physical therapy group that had exercise sessions twice a week for six weeks. They were then followed for two years. The physical therapy exercises included general conditioning plus lumbar flexion exercises.

All the participants charted their course with a self- reported survey of physical function which consisted of scores from zero to 100 on topics such as pain, function and mental health. The patients were all reassessed at 10 weeks, 6 months, 12 months and 24 months.

There was no difference between the surgical group and the physical therapy groups in the category of physical function at any time during the follow-up. Despite this 47 of the 82 patients assigned to the physical therapy group crossed over and had surgery with nearly a third in the first ten weeks. Patients crossed over to surgery for both medical and financial reasons citing the high cost of copays for physical therapy. Jeffrey Katz, MD, director or the Orthopedic and Arthritis Center at the Brigham and Women’s Hospital in Boston felt that the paper “suggests that a strategy of starting with an active, standardized physical therapy regimen results in similar outcomes to immediate decompressive surgery over the first several years.”

This paper gives us excellent data on the belief that surgery of the back should be a last resort. Since the study only looks at two years, it is hoped that continued follow-up over time will allow us to see the real life situation we see in our patients who live with this condition for decades not months.

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