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Archive for the ‘Blogfinger Medical Reports’ Category

Hollywood, Ca. Resistant gonorrhea antibiotic bacteria represent the biggest current threat. There is now only one antibiotic left which is toxic to gonorrhea  (“GC”) bacteria.

 

 

New cases of chlamydia, gonorrhea and syphilis rose sharply for the fourth consecutive year in 2017, to a record high of nearly 2.3 million, according to new data from the Centers for Disease Control and Prevention.

The United States “continues to have the highest STD rates in the industrialized world,” said David Harvey, executive director of the National Coalition of STD Directors.

Bloomberg News (8/28, Edney) reports there was “a record number of cases of sexually transmitted diseases in 2017, marking the fourth straight year of sharp increases in gonorrhea, syphilis and chlamydia, according to preliminary data from the Centers for Disease Control and Prevention.” The CDC also warned that the growing prevalence of antibiotic-resistant gonorrhea is a contributing factor to the increase.

NBC News (8/28, Carroll) reports on its website that according to the CDC, there were “nearly 2.3 million cases of chlamydia, gonorrhea and syphilis were diagnosed in the U.S. in 2017, surpassing the record set in 2016 by more than 200,000.” The article adds that “less frequent condom use” may be the greatest contributing factor.

The New York Times (8/28, Zraick) reports that there is no “single reason for the increase in sexually transmitted diseases.” Public health officials point to “deteriorating public health services, like S.T.D. testing clinics,” in addition to the opioid epidemic, “as users engage in unsafe practices.”

 

Blogfinger Medical Opinion.  Paul Goldfinger, MD, FACC

One important factor in this issue is that condoms are being used less often.  That is partially because of the advent of HIV prevention drugs.

Another problem is that the infrastructure for preventing STD’s is declining across the country.  These three articles lay out all the facts.  Note that most of these infections are in men, but the numbers are on the rise in women as well.  Dating services have also been blamed, but there is no data on this.

Gonorrhea used to be the scourge of soldiers and sailors.  They called it “the clap,” but one shot of penicillin would cure it but not so now.  There now is an urgent need to develop new antibiotics for that STD.

From the NYT:     “Many cases go undiagnosed, and the diseases can cause serious problems down the line, including infertility and increased H.I.V. risk.

“Most people with these S.T.D.s do not know they are infected,” said Dr. Gail Bolan, director of the C.D.C.’s division of sexually transmitted disease prevention. “They don’t realize that these diseases are spreading silently through the country.”

Syphilis could kill people, but after penicillin was developed in the 1940’s, doctors became unfamiliar with the condition.  I saw some cases in the 1960’s.  Primary syphilis caused a lesion on the genitalia or the lips,  but secondary and tertiary forms could cause sterility, abortion, blindness, rash, brain damage and mother to child transmission.  And the advanced form may be difficult to diagnose.

All of these conditions can be present without any symptoms, so prevention methods and testing can help with diagnosis.  There are tests available to make the diagnosis of STD’s using blood, urine and some other methods.

If you have young people in your family who may be sexually active, have a talk about this or give them our link.

 

 

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Dissecting aneurysm of the aorta. Internet image.

Dissecting aneurysm of the aorta. Internet image.

By Paul Goldfinger, MD, FACC  (Re-post from 2014 on Blogfinger.net)

The simple answer is yes, and it often has to do with fear of harming a patient either through what we do to treat a disease or through missing a diagnosis.

A basic tenet of medical practice is, “First do no harm.”   During my career I thought of that warning many times, because a physician is often tempted to do something that might be risky. Oftentimes that concern is more than balanced by the potential to help a patient—-even to save their lives.

I think that certain diagnoses also strike fear into the hearts of doctors.  In my years as a cardiologist, the condition which worried me the most was dissecting aneurysm of the aorta. This is a life threatening emergency which usually affects men, ages 60-70, but anyone could be a victim. The aorta is the large blood vessel that leaves the heart to carry oxygen-rich blood all over the body and especially to vital organs such as the brain and heart.  A tear develops in the aorta, for a variety of reasons, and the wall of this large artery begins to split apart lengthwise and may even rupture. The condition usually develops suddenly and evolves quickly,  resulting in high mortality rates.

Aside from the obvious risk of such a catastrophe, one of the fearful  elements of it for the physician is that the signs and symptoms can be varied and difficult to figure out, and the chance of survival improves when treatment is initiated as soon as possible.   For example it can mimic a heart attack or a stroke.   Very often it produces excruciating mid or upper back pain, and whenever I would get a call from the ER about someone with such pain, a knot in my stomach would quickly develop. Oftentimes the varied presentation of a dissecting aneurysm would fool the doctor and send him down the wrong path.  My greatest fear was to miss the diagnosis.

Occasionally this dangerous condition would present with no pain at all—-just other symptoms like nausea or sweating or shock. I recall one patient whose sole initial symptom was fainting accompanied by a very slow pulse, initially causing us to misunderstand the situation.

If a doctor experiences fear, it is often alleviated by the certainty of  experience, knowledge, a correct diagnosis, and a hopeful treatment plan.

Another source of fear is when the doctor is involved in a surgical procedure which goes wrong. But experienced  surgeons often don’t have fear during such situations because they are trained professionals who react reflexly to correct a problem. I worked with a surgeon at Dover  (NJ) General Hospital  and Medical Center who had been in a front line surgical unit in Viet Nam. There was nothing that would scare him.

The best defense against fear is competence  and character,  and that is why a solid education during medical school and during post-graduate training at quality institutions is so important and why patients need to look at their doctors’ credentials.

Gen. George Patton said, “All men are afraid in battle. The coward is the one who lets his fear overcome his sense of duty. Duty is the essence of manhood .”  

And so it is for physicians who must put aside their fear and go ahead and protect their patients.

As for dissecting aneurysm, new diagnostic imaging methods and new treatments now available, including non-surgical approaches, provide reassurance for the doctor and the patient during this dangerous problem.

 

CARTER BURWELL   “The Deer”  from the movie “3 Billboards Outside Ebbing, Missouri.”

 

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Keep an eye on that “team” connection between doctor and patient. Don’t assume that it is working.

 

By Paul Goldfinger, MD, FACC.   Editor @Blogfinger

Several years ago I  predicted on Blogfinger  that the doctor-patient relationship and quality care would be compromised by the new medical system.  I turned out to be right, but I never imagined what is happening now, and the public is totally clueless.

Corporate entities such as Hackensack-Meridian have introduced a new way to practice medicine, and one of the core strategies is to carve out physicians from the dynamics of patient care.  This divide and conquer approach, called “team based medical care”  has succeeded in changing everything, and you, if you haven’t  noticed it, will get a shock when you do.

Here is an true example.  A man  (let’s call him X) is in a terrible car crash and is taken to the Emergency area at (Hackensack-Meridian) Jersey Shore University Medical Center.  He is sent to the Trauma ER where his care is turned over to the Trauma Team.  But that team has no physician in a hands-on role.  During this patient’s hours spent in the trauma area of the ER and later in the Trauma ICU, no physician came in to see him.

A variety of members of the team came around including medical assistants and  physician assistants but no doctor.  As a result the diagnosis of pelvic damage was delayed by hours, and that is a serious mistake.    It was simply missed by the team, each of which had certain tasks, but no one actually took charge and explained anything of substance to the patient or the family.   There was no physician involved.

About 7 hours after arrival, a man in a white coat arrives in the ICU and says that he is the “physician assistant” for the orthopedic trauma surgeon  on the team.  He tells the patient/family that the lower body CT scan reveals a broken pelvis.   Why was that CT result not mentioned hours before?  Which team member missed it?   The P.A. tells the family that surgery is scheduled for the next morning.  He explains the diagnosis and the surgery; it’s a scary problem.    But why doesn’t the doctor show up to discuss the diagnosis and treatment of such a serious problem?

The next morning the surgeon shows up just before wheeling X to the OR.  He speaks to the family and the patient. The surgery takes 3 hours and involves screws and steel plates.

A similar pattern of fragmented care is evident post-op.   The surgeon doesn’t make rounds—only “the team.”      There are no serious complications, and a few days later, X is transferred to a sub-acute rehabilitation center where similar communication issues develop, and physicians are missing  in a team approach.    As a result, a significant problem is missed.  Eventually the surgeon gets involved, and only then is the correct diagnosis made.

According to the AMA, “Team-based care is a strategic redistribution of work among members of a practice team. In the model, all members of the physician-led team play an integral role in providing patient care. The physician (or in some circumstances a nurse practitioner or physician assistant) and a team of nurses and/or medical assistants (MAs) share responsibilities for better patient care.”   But in our sample case, the “physician led” element was AWOL.

Healthcare planners associated with large corporations  like H-M love to talk like this, because they save money while providing, they say, more efficient, higher quality  and less expensive care,  but they don’t understand how medicine is traditionally  practiced:  tried and true methods with the patient at the center of a medical situation and with a physician engaged with the patient and  integrating all aspects of the case—just the opposite of what these team members did.  I do not trust those corporate types to place the patient first, and that is central to Hippocrates’ and Maimonides’ values for doctors.

Many doctors like this approach because it takes considerable pressure off them, reducing burnout, but I fear that it will allow all sorts of errors to fall between the cracks, as occurred in our sample case above. Physicians need to insist that they not be replaced by “mid-level” practitioners who think that they are as good as physicians. Such physician helpers need to be just that, and their name tags should say so.

Such examples of a broken system in a  hospital, at an inpatient sub-acute rehab center, and in an office-based setting must be identified and fixed.

When you are interacting with medical environments that use the “team based care” approach, keep your eyes peeled for mistakes, missed details, absent physicians, and over-emphasis on physician extenders who do not receive appropriate oversight.  Be skeptical and ask questions to be sure that all details are covered.  You may not be a doctor, but you may have enough common sense to actually identify a real problem.   I know that some institutions such as the Mayo Clinic have achieved success with this approach, but don’t assume anything at your local provider.

Below is a quote from an AMA article about physician led team based care:

“Physicians should maintain authority for patient care in any team care arrangement to assure patient safety and quality of care, since the ultimate responsibility for each individual patient’s medical care rests with the physician. In addition, physicians must be responsible and have authority for initiating and implementing quality-control programs for non-physicians delivering medical care in team-based practices.”

 

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CJUC on the Asbury Circle. All photos by Paul Goldfinger.©

 

By Paul Goldfinger, MD, FACC, Editor @Blogfinger.net

Four years ago I wrote a piece about the increasing successes of urgent care centers, and, specifically, the Central Jersey Urgent Care at the Asbury Circle  (731 Rt. 35, Ocean Twp).  I was impressed with their focus on convenience and quality care and their determination to improve the possibilities for patients who are acutely ill. No one likes to go to an ER, and this is an excellent option for many kinds of situations.

Here two links to articles we have posted on this subject

 

Urgent care assessment 2014

 

Blogfinger 2015 post on walk-in health clinics

 

In 2014,  I spoke enthusiastically about the urgicenter concept and about the CJUC.    Now, the CJUC doctors are operating a total of six centers in this area.  Recently the Ocean unit expanded by 1,700 square feet and they have modernized that spacious location and have updated their procedures. Their main goals remain convenience and quality, and I continue to be impressed by the success of their operation.  As for convenience, they are about 10-15 minutes from Ocean Grove, and their records indicate that many Grovers go there.  You just walk-in; no appointment is needed.   All members of my immediate family including myself have received fine care at the CJUC.

Part of the waiting area at CJUC. 7/13/18 ©

 

Vikram Varma, MD,  collaborates with one of his advanced practice colleagues. He is the Medical Director of the Ocean facility.    Paul Goldfinger, MD photo. 7/13/18 © Blogfinger.net

Today I interviewed their Practice Manager Anthony Orzo and two of their physicians  and I learned of the progress they have made in the last 4 years.

The main theme for the physician directors of the CJUC  is to address many of the problems that patients now face in accessing healthcare, particularly urgent care, and then finding solutions to make the experience as excellent as possible. Here is a summary of what I learned:

a.  All their doctors are board certified ER physicians who work part time in hospital ER’s to maintain their acute care skills.  Today I met Chiraq Patel, MD and Vikram Varma MD. We spoke doctor to doctor, and  I was impressed with their desire to operate the finest urgicenter in the area and with their intense emphasis on quality. I found that they have examined their operation top to bottom to insure the best results.

b. The doctors now work with physician extenders, ie nurse practitioners and/or physician assistants.   When a patient enters their facility, a triage decision based on the complaint determines whether he will be initially evaluated by an “advanced practitioner” or by an MD. This team of two is always present and often collaborate on patient care. Generally the most worrisome cases go right to the doctor, but their advanced practitioners are instructed to consult with the physician if there is any concern.  If you wish, you can request an MD regardless of your complaint.

c. The facility is open from 8-8 every day of the year. Parking is easy. Leaving can be a bit of a challenge on the circle.   The staff is welcoming. The waiting area is divided so that potentially infectious patients are placed in one location. They will offer a mask if it is desired. If someone looks worrisome in the waiting area, they will bring them inside immediately. They try to expedite waiting times.

The recent renovation has produced 5 new examining rooms including one where they can offer treatments such as IV’s.  There is a welcoming pediatrics area with a colorful hand painted seashore scene on the wall  and a very efficient central operations station for personnel to interact and monitor care. It looks like one that you might find in a hospital.

d. The doctor enters a patient’s room with a “scribe” which enables him to focus totally on the patient instead of on a computer. The scribe deals with the computer and the written documentation of the visit.

e.  The staff is able to perform a variety of blood tests and other diagnostics such as a Strep throat and  HIV testing. They give vaccinations such as flu shots and they  do Xrays and ECG’s. The Xrays  are over-read within 2 hours by outside radiologists. You can get a physical exam, travel medical counseling, and pediatric care for 6 months and up.

f.  Although the CJUC doctors will not function as  your primary physician, you can go there for followup of issues that they initially saw you for.

g. The experience is much better than going to an ER, but if necessary, they will arrange to have a patient transported to the hospital. If you need a referral to a specialist, they will help you make that contact.

h.  The CJUC offers a phone app which lets you check on waiting times.  They also have a brilliant “membership plan” which offers a number of guaranteed visits outside of your insurance. As for the latter, they accept most insurance plans including Medicaid.  Their goal is to turn no one away.

On Sunday July 15, they will have an open house from noon to 4 pm, and the public is invited. There will be tours, food, face painting and giveaways. You can see the facility and meet the staff.  You will be impressed.

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Note the increased number of cases of hypertension if the 2017 cut-offs are used.

 

Paul Goldfinger, MD, FACC.  Editor @Blogfinger

Here is a link to our post last year about the new 2017 guidelines. This is the most recent information available in terms of guidelines for diagnosis and treatment.

2017 blood pressure guideline update on Blogfinger

 

In 2015 the SPRINT Trial appeared, but it provided more aggressive treatment than many doctors would accept.

And below is a link to the JNC 8 guidelines of 2013.

2013 JNC 8 blood pressure guidelines. Review in Blogfinger

 

For those of you with an active interest in the topic of hypertension, you would do well reviewing the BF posts linked above to appreciate that doctors may disagree about guidelines.

All these guidelines come together now in 2018 as doctors try to figure out what method is best and  how to resolve discrepant results.

Currently physicians are trying to come up with a lucid and uniform approach to diagnosing and treating hypertension. Below are some of our conclusions at the Blogfinger Off-Shore Medical School in Ocean Grove, NJ.

a. The 2017 guidelines found that following that cutoff (130/80) reduces risk of stroke  and cardiovascular complications if the target readings are achieved, but that can be difficult. We think that the 2017 guidelines, applied carefully to patient care, would be best.

But some major physician groups  (American College of Cardiology and the American Association of Family Practice) say that for those over age 60, this cutoff is too dangerous and for that group, the cutoff should be 150 mm Hg systolic.  But if the patient is high risk  (eg someone who has had a heart attack) a cutoff of 140 would be best.  They are using the 2013 JNC 8 recommendations.

b. Most medical groups have embraced the 2017 guidelines.

c. This is not a trivial issue because with the 2017 guidelines for diagnosis, 45% of the US population would be considered to be hypertensive.  But the more people who are placed on drug therapy, the more people will show up with complications such as hypotension (excessively low BP) which can result in falling  (with injuries,) dizzy spells, fainting, and kidney problems.

d. It seems to me that the 2017 guidelines make sense and will produce better outcomes than the less aggressive cutoffs that existed for many years.  Unless all the doctors get it together and agree, there will be a sort of free for-all with individual physicians deciding on their own. Hopefully the smoke will clear and most physicians will be on board.

But what is clear, and I suspect most doctors will agree, we do need to lower BP readings more than in the past, and we do need to diagnose hypertension at lower cutoffs than the past.

e.  Finally, patients should follow medical advice which should include preventive measures  (diet, weight, exercise, etc.) and usually medication.  Regarding the latter, oftentimes combination therapy of 2-4 different drugs may be required to achieve the desired cutoff. Such combinations allow individual drugs to be used at safer lower doses.

Hypertension is the “silent killer,” so follow good medical advice and participate in your care with home BP monitoring and adherence to medical regimens even if you feel fine.  That is the essence of prevention.

f.  Ask your doctor about his targeted plan for you.  Make sure that you are not a therapeutic failure.   Know your target reading and keep a written record.

And, to cheer you up, here is Jerry Seinfeld in the drugstore:

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Internet cartoon.

 

Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups. But some relief appears to be coming, as the AMA and joins forces with some payers to fix this broken process. Read more at AMA Wire®.

This quote is from the AMA Morning Rounds:  “Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,”

Blogfinger Medical Commentary:  Paul Goldfinger, MD, FACC

Some of you may have experienced rejection of a particular prescription drug by your drug plan. But such rejections typically get reversed by enlisting your doctor’s help, and that would require his time and that of his staff to deal with the insurance company.  The process is called “prior-authorization.”

In the article above, from the AMA, they discuss the problem from the perspective of the physician, but I have experienced it myself, from the perspective of the patient.

And, without a doubt, the episodes of prior authorization have increased noticeably for patients, but, as discussed above, also for the prescribing physician and his staff.

And now we see insurance companies questioning even cheap generics or chronically used stable medications,  and the issue isn’t always the drug choice itself.

For example, I recently ran into this situation related to my use of a high blood pressure medication that is perhaps the number one or number two choice prescribed by doctors for their patients with hypertension.

In my case, I was doing very nicely with two 5 mg. tablets each morning of that drug   (10 mg per day)—lisinopril, an ACE inhibitor. However recently my doctor wanted me to increase the dose from two tabs each day to two tabs twice per day  (20 mg per day), ie 4 tabs per day instead of 2.

So I would need 360 tabs per 90 days instead of 180 tabs per 90 days—-a perfectly reasonable dose change.    I was notified that they would not send me my medication because it required the prior authorization process.     Meanwhile I was running out of medications while the plan would try to get my doctor to respond.  And the drug plan was contacting me by mail and phone messages to raise the PA alarm.

I couldn’t understand why this innocuous dose change was a problem—it’s a cheap drug with a zero  copay.  I was baffled, so I called the company, but the customer service representative couldn’t figure out why prior authorization was being applied to my prescription.  She advised me to wait for the process to play out.  This was unacceptable.

I  thought about the problem, and it dawned on me that maybe the number of pills was the issue, and not the medication itself.

Maybe the problem was the 360 tablet requirement, every 90 days.   Being a physician I was able to call and  speak to a pharmacist at the mail order plan. He verified that the number of pills was the problem, not the dose.

So I asked if we could change the tablet size from 5 mg. to 10 mg, making the daily dose two tabs each day.  He said “fine” and a few days later I received 180 of the 10 mg tabs.

But the warning letters and phone messages continued.  Finally I called the “prior authorization” department and told her that I fixed the problem myself. And she said, “Oh, when you get the letters and phone calls just ignore them until the matter is fully resolved.”

The best resolution available for most patients is to make sure that your doctor’s office staff has done their job with the paper work. It might  be easier to resolve if you buy your meds from a local pharmacy.  If you have a mail order pharmacy, as I do, and you are running out of pills, one of the local pharmacies will help you get a temporary supply, assuming that the left hand and the right hand at your drug company can resolve the problem.

 

 

 

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cow s(2)

By Paul Goldfinger, MD, FACC.  Editor @Blogfinger.net.

In a NY Times piece recently a young physician argued that experience in medicine is overrated and that smart young physicians, armed with technology, can do a better job in diagnosis and treatment than silver haired professors steeped in Hippocratic values.

In 2016, I posted a piece called “The Case of the Hypokalemic High Jumper.”  (link below)  It was a difficult situation where all the technology available could not produce a diagnosis, but a careful history taken at the bedside by a physician was all that was necessary.

The case of the hypokalemic high jumper

In the New Yorker cartoon above, an alert doctor took a good look and made the diagnosis.

In medical school, in the second year, we all took a course called “Physical Diagnosis.”  It taught us how to take a proper history—very detailed, but customized to suit the needs of an individual patient.  We also learned how to conduct a sensitive physical examination—how to feel a spleen, palpate a liver and listen to the heart and lungs—in fact how to accurately assess the whole body.  We were taught that such skills  have been used by physicians going  back to the Greeks  and that we could learn so much using those basic tools.

During my cardiology residency, we were trained to be meticulous in auscultating the heart  (ie listening with a stethoscope.) We used stethoscopes with 3 heads to help sort it all out.  We made recordings of heart sounds where we could measure intervals down to fractions of a second in order to figure out how narrow a heart valve might be.  It was a source of great pride to be able to use just our ears and minds to determine if someone needed heart surgery or not and then to help a medical student who couldn’t appreciate the subtleties of the cardiac examination.

But now, I am afraid that doctors are becoming too complacent in using technology to replace the traditional tools. These skills are still helpful in assembling all the pieces of a puzzle and then following the progress of the patient at the bedside or long term in the office.  I see doctors doing a poor job in taking a history, a process which has been replaced in large part by computer check lists.  Garbage in, garbage out.  And the same concern exists for the physical examination.

I was present when a patient went to a local ER with a painful, swollen knee. The Physician Assistant took a cursory history  (he had no idea that a real doctor was observing) and ordered an X Ray.  He did not properly examine the knee.   And he never bothered to review the patient’s medication list. He was functioning like a robot via an algorithm.  If he had done a proper history, he would have learned that the patient was on a blood thinner and might have a hemarthrosis  (bleeding into the knee.)  The problem was diagnosed with a proper history and physical exam by a careful physician and corrected by aspirating the joint with a needle and adjusting the medication.

Yes, the new technologies are remarkable, but each patient is different, and the physician must use all the tools available at his disposal including his eyes, head, ears and hands.  And, experience is perhaps the best tool of all.

RUFUS WAINWRIGHT   “Heartburn.”   This is a peculiar song, but it makes the point that doctors need to remember that psychological factors can mimic heart burn or something much more serious—like a derailed roller coaster.  A doctor must take a good history to pick up on this situation.

“Is this heartbreak or is this heartburn?
Can I be spared from being so dramatic?
Gotta learn the difference when I love ya
The difference when I love ya and that derailed roller-coaster”

 

 

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Submitted by the American Medical Association on January 2, 2018.  The CDC is the Centers for Disease Control and Prevention in Atlanta.

NBC Nightly News (12/30 ) reported on Saturday that “the CDC says this flu season is already shaping up to be a lot worse than last [season’s], with widespread flu activity now being reported in dozens of states.”

NBC Nightly News reported that flu is widespread in 36 states, according to the CDC.  This is more states than last year (24.)

Modern Healthcare (12/29) reported the CDC issued an alert warning health care professionals of an uptick in cases caused by the H3N2 strain of the flu virus, “which is usually associated with a higher number of hospital admissions and flu-related deaths.”

BLOGFINGER MEDICAL COMMENTARY:  By Paul Goldfinger, MD

Influenza is hitting the US very hard this season;  it is especially bad in the south, except for Florida where the snowbirds complain about 60 degree temperatures.

The CDC says that it will peak towards the end of January, and senior citizens are at the greatest risk of acquiring influenza and for getting very sick from it, including an increased mortality and hospitalization risk.  The currently most active strain, H3N2 is also the most deadly.

“If you haven’t gotten a flu shot yet,” Schaffner said, “run, don’t walk, and get yourself vaccinated. It can take up to 10 days for the vaccine’s full effects to kick in.”  (This quote is from an infectious disease specialist at Vanderbilt University School of Medicine.)

The symptoms of influenza are usually worse than with the common cold including high fever  (which may be absent,) hacking cough (which may be dry,) tightness in the chest with shortness of breath, shaking chills, marked fatigue and headache.  Complications include sinus and ear infections, pneumonia, and aggravation of asthma.

We used to gear up for the yearly peak of influenza around this time, when our hospital and ER would be swamped with patients.  It was the only time of year when we expected to have beds filled in the hallways. Stay out of the hospital if you possibly can.

Avoid crowds, avoid children or adults with respiratory infections, and wash hands often  (pick up some antibacterial liquid soap such as Dial.)   If you get sick, make sure you stay hydrated with electrolyte solutions such as Gatorade.  Chicken soup made with vegetables has medicinal value as long as a Jewish doctor suggests it.

And, if you think you have the flu, call your doctor to see if he wants to order an anti-viral medication such as Tamiflu, but do that as soon as symptoms appear.

Good luck staying out of trouble with this situation.

 

 

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The generator is under the skin. A wire is passed into a vein and into the right side of the heart (the tip is positioned in the right ventricle). This technique has stood the test of time.

Permanent pacemaker configuration.   The generator is under the skin. A wire is passed into a vein beneath the clavicle and into the right side of the heart (the tip is positioned in the right ventricle). In this example there is a second wire in the right atrium.

I saved this 1970's unit made by Cordis. The surgeon would place it into a

I saved this used 1970’s single lead unit made by Cordis in Miami.  The surgeon would place it into a “pocket” under the skin and attach it to an electrode in the heart.   Paul Goldfinger photo. ©

The opposite side of the unit shown.

The opposite side of the unit shown.  Cardiologists would go into the OR with the surgeon when a pacemaker was placed. Now, surgeons are usually no longer needed for this procedure. ©  Paul Goldfinger photo

A tiny modern version of a permanent pacemaker.

A tiny modern version of a permanent pacemaker.

Current model.

Current model.

By Paul Goldfinger, MD, FACC,  Dean at the Blogfinger  Off-shore School of Medicine .   Re-posted from Feb. 2016 on Blogfinger.net

My career spanned the remarkable history of permanent cardiac pacemakers. In the early 1970’s, those devices were as a big as a can of tuna fish. They had limited functions and a variety of technical problems. Today they are miniature electronic marvels.

The story began around 1930 when an Australian researcher found that the heart could be stimulated with a localized electrical shock delivered from a wire.

1949: The Medtronic Company, pioneers in pacemakers, was begun in a garage in Buffalo by an engineer and a physician.

1952: At the Boston Beth Israel Hospital, a patient was admitted with fainting spells due to drastic slowing of the heart. These are called Stokes-Adams attacks. This was the first case to be treated with a temporary pacemaker. A wire was attached to the external wall of his heart, while the pacemaker generator was outside his body.

1957: The first battery powered unit was developed, and, in 1958, the first permanent pacemaker was implanted in a dog, consisting of a generator under the skin and a wire attached to the outside wall of the heart.

1960: The first permanent pacemaker was implanted in a human. In 1961, the first in New Jersey was performed by heart surgeon Victor Parsonnet at Newark Beth Israel. Dr. Parsonnet is one of a core group of doctors world-wide to get credit for pioneering work in permanent pacemakers.

1973- 1980: The era when my own career began, the technology of permanent pacemakers evolved strikingly, with smaller and more complicated  “generators,” longer lasting batteries, and better electrode (wire) systems.  Medical electronics had been evolving thanks to the invention of the microprocessor.

When a patient only needed a temporary pacemaker, a cardiologist such as myself would pass a wire into the right ventricle through a vein in the arm or neck and attach it to an external pacemaker which hung from an IV pole at the bedside.  Eileen sometimes kids me by saying, “If you can put a wire into somebody’s heart, how come you can’t…….(fill in the blank)”

The permanent units could just only control slow heart rates at first, but later, more functions were developed and could be programmed (changing the settings) from without.

At first, pacemakers had to be routinely changed every two years because of battery life, but later the batteries were improved.

In the early 1970’s research with a nuclear powered pacemaker was performed by Dr. Parsonnet and his team at Newark’s Beth Israel Hospital . They were trying to increase the battery life.   That technology did not work out.

During this phase, techniques for monitoring the battery life and functions of a permanent pacemaker were developed. Eventually a patient could be followed by the use of a telephone, so hospitals throughout NJ had a setup where they could check their patients by phoning into NBIH for monitoring allowing doctors to predict when a pacemaker had to be changed and how well it was working. In-person visits to a pacemaker clinic were also required to check a variety of other functions .

In late 1970’s, at Dover (NJ) General Hospital and Medical Center, Jean Wiarda, RN ( a cardiac nurse) and myself,  with the cooperation of Medtronic, set up the first free-standing pacemaker clinic in north Jersey. After that, many other hospitals followed suit and broke away from the NBIH connection.  Later patients were able to phone in  their pacemaker signals from home  to the clinics. They also had to come for in-person evaluations intermittently depending on what we wanted to measure or program.

A major development, evolving in the 1970’s, was the transvenous lead for permanent pacemakers which eliminated the need to open the chest and sew an electrode into the heart muscle.   Instead, an electrode could be passed through a vein under the collar bone and into the right ventricular chamber, eliminating the need for heart surgery.

Now that continues to be standard, although the pacemaker generators are much smaller, and the electrodes have been refined, and sometimes more than one wire is used. Even though the generators are now tiny (you can’t even tell that someone has a unit,) they can perform all sorts of miraculous functions and are totally adjustable from without using a device called a programmer.

Surgeons used to install permanent transvenous pacemakers, but now these complex devices are placed by electrophysiologists, cardiologists who specialize in electrical diagnostics and therapeutics including implantable cardio-defibrillators.

The future of electrophysiology is huge, and progress is made every day in this field.

Around here, Jersey Shore Medical Center and Morristown Medical Center have first rate electrophysiology departments.

THE TIMETONES

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FROM THE AMA:    STAT reports the flu season “is off to an early start this year” and could “peak over the holidays,” a new CDC indicates. The piece says the “wildly unpredictable” flu viruses leave experts uncertain of precisely how extensive the season will be, but the CDC’s weekly flu reports offer updated predictions and data, with the most recent report showing “that Louisiana and Oklahoma already have widespread flu activity and some nearby states are heating up too.” According to CDC influenza epidemiologist Lynnette Brammer, who leads flu reporting, “If it continues to go up like it has the last couple of weeks, yeah, we could have a fair amount of activity right at Christmas.”

 

BLOGFINGER MEDICAL REPORT:  By Paul Goldfinger, MD, FACC

From the Nov.  29, 2017  NEW ENGLAND JOURNAL OF MEDICINE:     “Seasonal influenza epidemics cause 3 million to 5 million severe cases and 300,000 to 500,000 deaths globally each year, according to the World Health Organization (WHO). The United States alone sees 140,000 to 710,000 influenza-related hospitalizations and 12,000 to 56,000 deaths each year, with the highest burden of disease affecting the very young, the very old, and people with coexisting medical conditions.  (BF bold print)

“However imperfect, though, current influenza vaccines remain a valuable public health tool, and it is always better to get vaccinated than not to get vaccinated. In this regard, the CDC estimates that influenza vaccination averted 40,000 deaths in the United States between the 2005–2006 and 2013–2014 seasons.2 Yet we can do better.”

It is difficult and unpredictable to get the virus profile to be accurate, because the profiling is done early in the year, and virus mutations can appear, leaving your flu shot to have a reduced efficacy.  Usually flu shots are 40% to 60% effective, but this year, according to the New England Journal of Medicine,  “The preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%.”  They are referring to the Southern Hemisphere  experience earlier this year in Australia.  H3N2 is the main offender so far, although there may be others emerging now.  The transmission of the influenza virus has been accelerating sharply in the US at this time.

So, if you haven’t yet had a flu shot, rush out and get one.  Most drug stores offer it.  If you are  a member of a high risk group, such older folks  (over age 65) or those with chronic illnesses, try to avoid exposure in places with many people in close contact.  And stay away from anyone who has a “cold” or, especially, has flu-like symptoms including fever, cough, chills, muscle aches, congestion, runny nose, headaches, and marked fatigue.

If you have such symptoms, your doctor may prescribe an antiviral medication, such as Tamiflu,  if you call early in the course of your illness.

And don’t forget frequent hand washing.

 

 

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