Influenza A/H1N1 Update

Flu Cases Increase but there is Some Optimism - click blue links to original articles

"The worrisome things about this virus...is that it is new, so few people can be expected to have resistance to it, and that it is behaving unusually, flaring up and taking hold at a time when the flu season is normally just about over."

Google Flu Tracker with data compiled by Dr. Henry Niman, a biomedical researcher, moved here

(Update) As of May 16, more than 6,000 cases in the US - 5,000 confirmed; more than 7,000 in Mexico - 3771 confirmed

Swine flu goes person to pig

Pigs on a Canadian farm found with the new swine flu virus, infected by a man back from Mexico. Man and 200 pigs are recovering from mild cases.

Can it jump back? No one can say. If it did, it could mutate and be milder, or it could be stronger. Swine flu infects the respiratory tract, but Avian flu H5N1 infects blood, organs, and tissue. That increases the risk of humans getting infected which is why surveillance has been much stronger. "...the past three flu pandemics - the 1918 Spanish flu, the 1957-58 Asian flu and the Hong Kong flu of 1968-69 - were all linked to birds...."

Mexico changes reporting of H1N1

From now on they will only report confirmed cases. Previously gave suspected cases (think sudden and severe pneumonia). While they work on a backlog of samples, numbers will rise.... Until late on Thursday, the number of "suspected" deaths stood at 176 with more than 2,500 people having gotten ill with symptoms linked to the virus. They later scaled down the number of suspected deaths to 100..... As of Saturday, the new count looked very different: 443 confirmed infections and only 16 deaths.

You can find Mexico's up-to-date numbers here.

The Cochrane Library review on Tamiflu and Relenza

The generic name of the medication is oseltamivir and zanamivir. They need to be given within 48 hours of onset.

Not a miracle cure: “The time in which flu symptoms were alleviated was assessed by nine trials. The group treated with zanamivir were 24% more likely to have their flu symptoms alleviated than the placebo group, at a given time point. For oseltamivir the figure was 20%.” ”Overall, oseltamivir reduced the average time to alleviation of symptoms by 0.68 days. For zanamivir, the figure was 0.71 days.”

For prevention: “A 75mg daily dose of oseltamivir was 61% effective compared with a placebo, and 73% effective when the daily dose was 150mg, while Relenza was 62% effective.”

For prevention: "A 75 mg daily dose of oseltamivir was 61% effective compared with a placebo, and 73% effective when the daily dose was 150mg, while Relenza was 62% effective."

Swine flu born on US factory farms 1998 (click link)

On the surface: the HxNx Nomenclature for those interested in the science.

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Piggies

by the Beatles

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Swine flu now called H1N1 Influenza A - the hunt is on for pig zero. In U.S. hog farms in 1998

Update 5/1/09, 11:45 PM, title revised, controversy:

"CDC's chief virologist, Ruben Donis essentially confirmed the reading of the current swine flu strain made by New Scientist: that it evolved from a strain that cropped up in U.S. hog farms in 1998."

The same article notes two children got sick late March in California before the cases that began in Mexico early April. Ruben Donis talks about its genetic roots from 1998, here. "Both New Scientist and Donis emphasize that what we’re talking about is a swine flu—in direct contradiction of the pork industry’s party line...."

"We all pray this remains sensitive to antivirals. We all hope that vaccines will be developed. The virus doesn’t grow very well in eggs. We hope the virus will improve [the] ability to grow in eggs so we can produce [a] vaccine...."

More on the California origins here. There was no contact with swine, no travel to Mexico in a 10 year old boy ill with fever March 30 in San Diego County, and a 9 year old girl treated March 28 for cough and 104 degree fever.

Now in the US there are 6 confirmed hospitalizations. This CBS news video interview with Dr. Richard Besser, Acting Director of CDC, describes why doctors should not prescribe Tamiflu for everyone in the US. Doctors can contact their local department of health and sign up for ... email notification [for updates on management and best practice].

An interview with Brian Currie, MD, MPH, medical director of research at Montefiore Medical Center in New York City. He's an expert in pandemic preparedness.

I'm assuming people should not try to stock up on anti-virals like Tamiflu or Relenza--is that right?

It's too late, anyway, at least in the New York area. People have already bought up all of the Tamiflu and Relenza that were available in non-hospital settings. It's too bad, because it makes it hard to discharge patients if they can't fill a prescription for an antiviral.

That's why we want to manage our supplies; you really want to be able to give severely ill people these drugs. They make a big difference. People have to take these drugs in the right way at the right time to help themselves, isn't that correct? Yes. And there are side effects that go with Tamiflu—the most common one is gastrointestinal upset. What makes it a little more complicated is that we still have regular flu strains circulating. Those are resistant to Tamiflu, while the swine flu is susceptible to the drug. So when we treat, we have to give two drugs, one to cover swine flu, and something else in case it's human flu. Relenza would cover both, but that's very difficult to administer. It's a powder you have to inhale, not a pill. Some patients with asthma or respiratory disease are going to get bronchial spasm. Or people end up medicating their mouths instead of their lungs. Timing is a consideration, too. Isn't there a window of opportunity? They need to be given within 48 hours of onset. Do these drugs also help prevent illness—if, say, you're a family member of a patient? Yes. Tamiflu is about 70 percent effective. If you give it to ten people who have been exposed, it will prevent illness in seven of them. What signs and symptoms should send someone to the doctor, especially given that you want to get there within that 48-hour window? You'll have an abrupt onset of fever of 102 degrees or higher, you'll have cough, body aches, you may have some shortness of breath, and you can be flat on your back in bed within hours—that's how debilitating it is.... If you have diarrhea or vomiting or nausea, you probably have some other virus.

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California Department of Public Health Swine Flu website

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This is the CDC recommendation on use of face masks and respirators where H1N1 flu has been detected.

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Try here to purchase the N95 face masks or here

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Update 4/30/09, 11:00 PM, title again revised: Again, the Wall Street Journal Health Blog has the most detailed reporting of events hour by hour.

Nearly 300 schools have closed from every region around the country, triple from yesterday.

This morning brought a name change for the virus, announced by the World Health Organization. It will be called H1N1 Influenza A, to take the emphasis off of swine as it was causing needless slaughter of pigs. Egypt culled their entire population of healthy pigs.

Tracking the tangled origins of the virus raises several new issues, discussed in the New York Times here. "..there is not yet any genetic proof that this particular flu was ever in a pig."

Most geneticists believe the H1N1 influenza A virus has pieces of human, bird, North American swine and Eurasian swine flu.

"The next question, said Dr. Robert G. Webster, a virologist at St. Jude Children’s Research Hospital, is: How did this virus get in?"

"Now, scientists say, the hunt is on for what is jokingly being called Pig Zero." No one has swabbed a pig's snout. Ever.

"It presumably is in pigs somewhere, perhaps in Mexico.

The 1918 human H1N1 established itself in pigs by 1930. But, as Dr. Niman pointed out, it could be only in humans now - or even in a ferret."

Is there a hidden illegal trade? Is Mexico importing swine from Europe or Asia? Legal movement of lives pigs or even their semen is rare, expensive and requires quarantines. Frozen semen can transmit other diseases, but not the flu. It might be done for breeding, but not meat.

Symptoms in White House aide who travelled to Mexico with President Obama. He arrived April 13, became ill April 16, the next day he developed fever. On April 18, he returned home. As reported here, "The man visited his brother on April 19 and his nephew became ill. In the next two days, the aide's wife and son also became ill...." All have recovered and are being tested to verify if it is the same strain of H5N1 influenza. No one else in the US delegation to Mexico City got sick.

More details of this minor case here: his first symptom was a minor cough.

"When he got home, he chalked up the cough to Mexico's pollution and thought nothing of it the night after his return when he brought a present from Mexico to his brother's house and stayed for dinner.

Griswold's wife, Alison, a registered nurse, was the first to notice something wrong in the family. When she checked on her 7-year-old son at school April 21, something about him seemed off. He said he felt fine and he looked all right, Alison Griswold said. But the school nurse said he had a low fever, so Alison took him home and kept him there for two days until he recovered.

Then she started getting sick: a cough, a high fever and chills. Last Friday, Griswold and his wife went to a doctor, who wasn't overly concerned. On Sunday, they saw another doctor, who gave them a flu test that came back negative. On Tuesday, on advice from health officials, the couple and their youngest child got the more thorough nasal swab test

The results came in Wednesday morning: positive for Type A influenza, probably the swine flu.

The results came in Wednesday morning: positive for Type A influenza, probably the swine flu.

After the initial shock came dread. Like everyone else, they had been watching the news and had seen reports of panic and fear in Mexico and in the United States.

As reports of their test results reached the White House, officials began piecing together Griswold's brief connection to Obama. Aides began calling people who had traveled with the president and informed the president yesterday morning.

The White House press office began preparing to make a dramatic reversal. For days, Gibbs had insisted there had been no real danger of infection during Obama's Mexico visit. On Monday, Gibbs shot down repeated questions about health concerns, saying Obama "has not exhibited any symptoms; neither has anybody traveling with him."

Meanwhile, at home, Griswold and his wife tried to help their children get back into school. It was only at the advice of health officials that they kept their two unaffected children at school and sent the sick one back Wednesday, they said.

....Meanwhile, at home, Griswold and his wife tried to help their children get back into school. It was only at the advice of health officials that they kept their two unaffected children at school and sent the sick one back Wednesday, they said."

"Over the past two days, his daughter, who was not infected, has endured stares and mean jokes as rumors spread through her school about her family's role in some of the first swine flu cases in the region, Griswold said. Griswold probably infected his nephew, and now the parents, close friends, refuse to talk to him."

Update 4/30/09, 9:30 AM: San Diego's confirmed cases of Swine Flu are not clustered. They occur throughout the large county and none have been to Mexico, according to the NPR interview with Dr. Wooten, Infectious Disease Specialist at UCSD. CDC's acting director Richard Besser reports the US now has 109 confirmed cases; the median age is 16. Confirmed cases now exist in 11 states - South Carolina has just confirmed one. If a virus goes away, we will not know if it will return or if a return will be a more severe form. If your doctor suspects possible Swine flu, they will swab your nose, and send it to a local lab. If they are not able to determine the strain of virus, it will then be sent on to state or national labs for confirmation.

Update 4/29/09 at 11:45 PM, and Title revised: “The biggest question right now is this: How severe will the pandemic be? … It is possible that the full clinical spectrum of this disease goes from mild illness to severe disease.” That’s today's statement from the head of the WHO. It is still too early to tell. It may die off and stop. The longer this virus survives, the higher its chance of mutating into a more severe form. A pandemic doesn't necessarily have a high fatality rate, but the worldwide pandemic of 1918 that killed 50 million victims began relatively mild in the spring; a few months later it was deadly.

Yesterday, the CDC published the news that about 36,000 people in the US die in a typical year from flu-related causes. Today, I got the impression that some of my patients feel there is nothing to worry about as the swine flu has not killed anyone in the US. But this is just the start, and 2/3 of the deaths in Mexico occur in those under age 18. Yesterday we learned it began in late February or early March, but it could have been earlier as it went unrecognized until very recently.

Viruses rapidly mutate, and some become stronger as they evolve. There is no resistance to this virus because it is an entirely new virus in humans, which may make it more dangerous. No one can take for granted the reason there have been more deaths in Mexico is because mortality is higher in developing countries. We may not know how many cases there have been here or elsewhere until testing is confirmed, and so far the only testing lab in the US is at the CDC. There is a long delay for confirmation. But it is spreading rapidly. The first case in Europe appeared in Spain, in someone who had not been to Mexico. A pandemic is imminent because it is spreading globally.

Today, the WHO raised the current level of influenza pandemic alert from phase 4 to phase 5, its second highest level: "This means there is sustained human-to-human spread in at least two countries." As of this evening, in the US there are 91 confirmed cases in 10 states with one death. "Mexico has reported 26 confirmed human cases of infection including 7 deaths out of a total of 159 suspected deaths, nearly 2500 illnesses. The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (13), Germany (3), Israel (2), New Zealand (3), Spain (4) and the United Kingdom (5)."

There is no risk of infection from Swine Flu by eating well cooked pork.

Let me point out my initial comments, below, that ordinary masks are of no value except perhaps for the person who is sneezing or coughing to prevent them spreading infection. N95 masks are the ones needed for virus protection, and they are in short supply. They are expensive and probably need to be changed daily. One sneeze travels 90 mph and lands on many surfaces. The best protection is handwashing 20 seconds - as long as it takes to sing the Happy Birthday song, or at the least use a good alcohol based hand washing gel.

The Wall Street Journal Health Blog continues to be the best detailed site for daily updated news, as noted below. A local Carlsbad firm helped identify the virus. Ibis Bioscience's "rapid diagnostic system could have “revolutionary” consequences if it eventually wins government approval for commercial sale."

Posted 4/26/09 at 1:45 AM:

I received calls and emails a number of times today about Swine Flu, so I thought it best to post some information here now, even though I have only a moment to do a brief sketch. I will be updating this here as we go forward.

Google Earth is mapping the Swine flu here and quite a few new cases have popped up overnight, especially in Europe. Most require confirmation.

The Swine flu is a Type A influenza virus, H1N1, that originates in pigs, but is now passing person to person and no longer requires contact with swine. It started in March and appears to afflict those between the ages of 3 months to 60 years with more severe symptoms. Deaths in younger persons appear to be due to the body's strong immune system mounting a cytokine response, not due to the virus itself. Since it may be mild, it is difficult to tell the incidence; until then, the mortality rate cannot be determined. It is not clear why Mexican cases appear to have been more severe with higher mortality.

Treatment: It responds to Tamiflu and Relenza (prescription) for short term relief only, but is resistant to Symmetrel and Flumadine. Last year's flu vaccination is not likely to offer protection. It will take months for vaccine producers to develop a vaccine specific for the Swine flu.

Officials are assuming this is an airborne disease. N95 masks are on back order, but production has been increased. These are masks used in medical practice that offer more protection against viruses than those at the hardware store.

I particularly like the Q&A format in the Wall Street Journal blog here. And their Health Blog for updates is the best I've seen.

The CDC also has guidance for all of us, including physicians, with travel advice and what you can do to prevent the flu. The European Center for Disease Prevention and Control is here.

Cases in the US and Mexico are the same virus, but it has been more severe in Mexico with at least 149 deaths, 20 of which are confirmed cases. There are no deaths yet in the U.S., but that pattern is likely to evolve. It is already on several continents, therefore containment is no longer possible. Spain and Scotland are the first places to confirm outside of North America.

Confirmation is slow because the CDC is one of the rare laboratories that is able to test for this virus although they will be sending out test kits soon. Four experts discuss it here.

From the April 24, 2009, Wall Street Journal reference, above, emphasis mine:

Symptoms are similar to those of regular flu: fever, along with problems such as cough, sore throat, body aches, headaches, chills and fatigue. Some cases have also included reports of vomiting or diarrhea.

What should I do if I feel sick? People with ordinary flu symptoms do not need to seek emergency care, New York City officials said. But people with certain warning signs in addition to basic symptoms should seek urgent attention.

In children, those signs include difficulty breathing; bluish skin color; flu symptoms that begin to improve, then return with fever and worse cough; and fever with a rash.

In adults, warning signs include difficulty breathing, pain or pressure in the chest or abdomen, sudden dizziness, confusion, and severe or persistent vomiting.

[snip]

But most of the patients who contracted swine flu in the U.S. have recovered without taking the drugs. Both drugs have also been approved to reduce the risk of contracting the seasonal flu. But, unlike a vaccine, they do not provide long-lasting protection. So their preventive use is typically for short-term situations, such as for people who are at high risk of complications from the flu and who have a family member who has the flu. The drugs, which are included in the federal government’s pandemic stockpile, are only available with a doctor’s prescription.

Are there ways to reduce the spread of disease?

Cover your nose and mouth when you cough or sneeze. Wash your hands often. Avoid touching your eyes, nose or mouth. Avoid close contact with infected people.

People who have mild symptoms should stay home from school or work until 48 hours after the symptoms have passed, to avoid spreading disease, New York health officials said.

There were excellent tips on prevention here, (apologies to the author for condensing the article without indicating where it was cut):

A single sneeze propels 100,000 droplets into the air at around 90 mph, landing on door knobs, ATM keypads, elevator buttons, escalator railings, and grocery cart handles. In a subway station at rush hour, according to British researchers, as many as 10 percent of all commuters can come in contact with the spray and residue from just onesneeze (or sternutation). That means as many as 150 commuters can be sickened by one uncovered achoo.

...every sneeze should be covered -- preferably with the crook of an arm - and every hand should be washed ... and washed again.

In a subway station at rush hour, according to British researchers, as many as 10 percent of all commuters can come in contact with the spray and residue from just one sneeze (or sternutation). That means as many as 150 commuters can be sickened by one uncovered achoo.

1. Sanitize -- i.e. Wash Your Hands Frequently. It may sound obvious, but hand-washing with soap and water for around 20 seconds is the single best thing you can do (if you're going to go out into the world and interact with other human beings) [that's the amount of time it takes to sing the Happy Birthday song]. The CDC estimates that 80 percent of all infections are spread by hands. If you can't wash your hands regularly, try hand-sanitizers with 60 percent alcohol content.

2. Avoid -- i.e. Engage in "Social Distancing." That's the fancy term for reducing unnecessary social contact, staying away from crowds, and avoiding people if you're sick or if you're concerned that they may be infected. It may not be especially practical when you have to go to, say, work, but experts believe it's worth repeating: Isolation and avoidance reduce your chances of getting infected or infecting others.

If you need to go someplace crowded, the CDC says, try to spend as little time as possible and try to stay six feet away from potentially infected people. Wearing a surgical or dental facemask - cleared by the FDA as a medical device - "can help prevent some exposures," the CDC says, but they're not foolproof.

3. Be Alert -- i.e. Recognize the Symptoms and Get Help. Swine flu symptoms are similar to regular flu: Fever, body aches, sore throat, cough, runny nose, vomiting, diarrhea, and lethargy.

An Australian article compared this to some recent major flu outbreaks:

In 2003, Severe acute respiratory syndrome (SARS) spread to 30 countries, killing 774 people. Growth in the Asia Pacific Economic Cooperation countries was reduced by about one per cent overall but Hong Kong’s output dropped by 1.8 per cent.

The outbreak of avian flu in 2004, which began in Vietnam then moved to neighbouring countries, has led to hundreds of deaths. The flu, caused by the H5N1 virus, is still considered a pandemic threat by the World Health Organisation.

Check out the 5 Deadliest Pandemics in History for history buffs, from the The Peloponnesian War Pestilence to The Antonine Plague, The Plague of Justinian, The Black Death, and The Spanish Flu of 1918.

The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

Mayo Clinic Health Manager - Free online tool to manage your family’s health - Warnings

The Mayo Clinic has announced a Health Manager, hosted and powered by Microsoft Healthvault, to help you manage your own and your family’s health and medications.  It is a "security enhanced" online interactive personal guidance system that allows you to track and graphically monitor specific problems, and access Mayo Clinic advice about diagnoses and treatments.

You can enter your physician’s names and telephone numbers, organize immunizations, charts, chemistry studies, and tests then customize and print relevant information to take to your doctors.  In coming months, persons with Type 2 diabetes, hypertension or high cholesterol will find help managing those conditions, and the site will be updated regularly to reflect best practices in health care.

This allows you to become more pro-active in your care, print out material to take with you to your doctor, and get the most out of your doctor’s visits. 

Warnings about electronic health records:  Inaccuracies can have serious consequences and a list of medical conditions should have starting and ending dates on them, as this article points out. "For example, ... an inaccurate diagnosis of gastrointestinal bleeding on a heart attack patient's personal health record could stop an emergency room doctor from administering a life-saving drug." If a doctor knew that was 20 years ago, not 2 years ago, that may be a mortal difference. 

Yes, you type that in.  Be careful.  One small zero, one typographical error, one person's life.   

I would raise a word of caution that no personal information is that safe on the web. Even top secret military websites have been hacked.  Consider using code names, or at the least make certain that no medical record numbers are on any of those reports.  Use long passwords and change them often.   That would help.  Medical Identity Theft is a very real issue that may never be untangled if it were to occur. 

Here's more on that from today's Wall Street Journal; note comments below the article:  Are Electronic Health Records Worth the Risks?  

Risks for Patients ---Liability for Doctors:

More importantly, this excellent article by Dana Blankenhorn in ZDNet Healthcare points out the 2008 Riegel vs. Medtronic decision ... gave tech companies immunity from most state lawsuits, if their software is placed into a device.

....The Journal of the American Medical Association, which has its own problems with criticism, has now published an editorial decrying the immunity, which is based on a doctrine called “learned intermediaries.”  Present law assumes that faults lie with the user, writes Ross Koppel ... a sociologist at the University of Pennsylvania. “Health IT vendors claim that, because they cannot practice medicine, clinicians should be accountable for identifying errors resulting from faulty software or hardware,” he said in a press release. 

~~~“But errors or lack of clarity in HIT software can create serious, even deadly, risks to patients that clinicians cannot foresee.”~~~

In his article, Koppel and David Kreda, a Philadelphia software designer, offer examples of software bugs causing mistakes in drug administration, and failures to carry over warnings about drug allergies to the clinicians using them.  

All this hit like a thunderclap for Scot Silverstein of Drexel, the health IT skeptic profiled here last month, who blogs at Healthcare Renewal under the nom de blog MedinformaticsMD.

~~~ Along with your patients you are nonconsented beta testers and experimental subjects

of the health IT industry,

and potential victims of the computer industry’s arrogance and dysfunction.~~~

Silverstein believes that legal threats are necessary to end the “mission hostile user experience” he finds so often.

Dr. Koppel writes "Even when their products are implicated in harm to patients, manufacturers of healthcare information technology (HIT) currently enjoy wide contractual and legal protection that renders them virtually "liability-free."  His work on the benefits and the liabilities of HIT has been the subject of international focus.

In one example, a trauma team did manage to catch an error in a piece of faulty vendor software that miscalculated intracranial pressures. Had they not, patients would have been severely threatened and the hospital would have been responsible for the resulting harm. "From an equity standpoint," says Dr. Ross Koppel, "This is unacceptable."

Other examples of internal software mistakes include confusing kilograms and pounds used to derive medication doses based on a patient's weight, and software that erroneously remove warnings about fatal drug allergies. In both cases "learned intermediary" clauses hold that clinicians are responsible for noticing the mistake before prescribing.

Equally unfortunate and unacceptable are the provisions in most HIT contracts that prohibit healthcare organizations from openly disclosing any problems caused by vendor software, even to the other HIT licensees using the same products, e.g., clinicians, hospitals. Such stipulations defeat patient safety efforts and are contrary to the principles of evidence- based medicine, says Koppel.

The authors also identify circumstances where HIT vendors should not be held accountable for patient safety failures arising from their products' misbehavior, e.g., user misuse and medical circumstances not knowable in advance. "Legal and contractual changes must not reduce incentives to vendor innovation," said Koppel. "We must achieve a better balance among patient safety concerns, fairness to clinicians, vendor responsiveness, and vendor marketing." The authors suggest moving the HIT industry toward this balance may require several changes to the status quo, including:

• State and national organizations with responsibility for inspecting hospitals would have additional power to set rules affecting HIT contract terms.


• Professional medical organizations taking a stand that HIT contracts containing blanket "hold harmless/learned intermediary" clauses are inconsistent with professional practice. Vendors would then have to focus more strongly on patient safety concerns.


• Healthcare professionals and their associations lobbying Congress for changes in federal law that would recognize a range of HIT vendors' safety responsibilities--much as with auto manufacturers and seatbelt laws.


• Altering legal standards to facilitate rather than frustrate disclosure of HIT product shortcomings that have patient safety implications.

The American Recovery and Reinvestment Act of 2009 (ARRA) - What it means for doctors

The New England Journal of Medicine this month published a detailed article on Health Information Technology [HIT] pointing out the "significant barriers to their adoption and use: their substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information."  

Experts estimate the cost of a system for a medical office to be about $40,000 --- startling indeed.  That may explain why so few have invested.  And there will be sticks and carrots to get this going. Starting in 2011, doctors will receive financial incentives from Medicare for the "meaningful use"  of a "certified" system "that can exchange data with other parts of the health care system."  And if they do not have a system, reimbursement from Medicare and Medicaid will be reduced.  Obviously this does not apply to private insurance, nor does it apply to the growing numbers of doctors who opt out of Medicare because of low reimbursements that are not adequate to cover overhead. 

To get the most out of the fiscal incentive, an MD must have the system fully operational by 2011. The incentives are reduced every year until they end in 2016.

The law currently requires health care organizations to promptly notify patients when personal health data have been compromised.  But should tech companies be given immunity from lawsuits if their software causes problems in your health or if data is not secured, resulting in Medical Identity Theft?   

 

Enjoy this music:  Louis Armstrong  and don't miss the video.  It's magical.

What a Wonderful World

The bright blessed day, the dark sacred night.

§

 

"Heavy NSAID Use Linked to Higher Dementia Risk" - Exercise, Antidepressants Both Help Neurogenesis

NSAIDs are anti-inflammatory drugs used to treat pain, inflammation, or fever. The only NSAIDs that are NOT associated with increased risk of heart attack or arrhythmia are naproxen (Aleve) or aspirin. Taking high doses of aspirin has a greater risk of GI bleed than naproxen, which is why I usually recommend naproxen.

Background:

Several past studies have shown NSAIDs delay or prevent dementia, but there have been contradictory results. Last year Neurology published a study of 49,349 patients' usage ranging from ≤1 year to ≥7 years done at Boston University and Bedford VA. They showed long term use of NSAIDs protects against Alzheimers:

Compared with no NSAID use, the relative risk of Alzheimer's disease decreased from 0.98 for ≤1 year of use (95% CI 0.95 to 1.00) to 0.76 for >5 years of use (95% CI 0.68 to 0.85).

Among patients who specifically cited use of ibuprofen, the risk of Alzheimer's disease declined from 1.03 (95% CI 1.00 to 1.06) to 0.56 (95% CI 0.42 to 0.75).

Ibuprofen came out ahead in that study perhaps because it is the most commonly used.

They also sought to answer whether NSAIDs known to suppress Aβ1-42 amyloid would more likely protect . Aβ1-42 amyloid is a major component of plaques found in Alzheimer's Disease.

Aβ1-42 amyloid suppressors include ibuprofen, diclofenac, flurbiprofen --- but as for suppressing Alzheimer's, these were found to be no different than other NSAIDs, putting that theory to rest.

Risk of dementia and Alzheimer's Disease with prior exposure to NSAIDs in an elderly community-based cohort:

This new study by Breitner et al, from the University of Washington School of Medicine was published online April 22, 2009, before the print edition in Neurology.

Their outcome contradicts earlier protective studies possibly because they started with an older cohort, healthy adults 65 and older, which "could be enriched for cases [of Alzheimer's] that would otherwise have appeared earlier."

They prospectively followed 2,736 persons in a Seattle health plan. Before starting the study, they reviewed pharmacy records as much as 17 years earlier.

Findings:

12.8% of the study participants [were] heavy NSAID users at baseline. Heavy use was defined as taking 500 or more standard daily doses over a two-year period.

Another 3.9% of participants became heavy users during follow-up.

Ibuprofen, naproxen, indomethacin, and sulindac accounted for about 80% of all NSAIDs used.

Through follow-up, 476 participants developed dementia; for 356 of them, it was Alzheimer's disease.

After controlling for age, gender, education, APOE status, hypertension, diabetes, obesity, osteoarthritis, and physical activity, the risk of developing all-cause dementia was 66% higher among heavy users than among those with little or no NSAID use (HR 1.66, 95% CI 1.24 to 2.24).

The risk of developing Alzheimer's disease was 57% higher (HR 1.57, 95% CI 1.10 to 2.23).

Strengths of the study: the community-based sample, biennial assessment of dementia, rigorous exposure classification, and large numbers of dementia cases, outweigh the limitations.

Limitations: lack of generalizability to a younger patient population, the lack of exact dosing information, and the possibility of bias from unmeasured confounders.

Can we draw conclusions on one study alone? We know that exercise is protective against Alzheimer's Disease and pain may have prevented this older age group from being active. Though they did control for that, this research needs to be supported by further studies. What is helpful is to remain as active as you can. Keep and maintain every bit of function you can and get help for depression and anxiety as they may profoundly affect memory, morbidity and mortality. For a review of the literature on the morbidity and mortality of stress and mood, refer to my post on Cognitive Behavioral Therapy and the importance of a positive outlook.

The brain makes new neurons - neurogenesis. I will write more in the future on exercise, mood, stress, brain atrophy and memory loss. Exercise improves depression and anxiety, and exercise stimulates neurogenesis. It appears that the action of antidepressants also may be to stimulate neurogenesis. Chronic low back pain has been reported to cause brain atrophy. Chronic depression leads to brain atrophy and memory loss with atrophy occurring in the hippocampus, the area essential for memory. This important publication from Vancouver reviews the topic in great detail and proposes a hypothesis: Antidepressant effects of exercise: Evidence for an adult-neurogenesis hypothesis?

Further medication is being tested to reduce neuronal cell death that leads to Alzheimer's Disease, using a very simple compound that blocks free radicals and inflammation. More on this later.

The material on this site is for informational purposes only,

and is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

~

Controversy on Medication Coverage - "step therapy" (also known as "fail first")

Insurance Industry Opposes Physician's Choice of Medication for Pain Relief

The best or just the cheapest?

Before I define "step therapy," let me introduce Forgrace.org, a nonprofit organization "Dedicated to Ensuring the Ethical and Equal Treatment of All Women in Pain." Based in Los Angeles, the organization was formed in 2002 by John Garrett, Executive Director, and his partner Cynthia Toussaint, an accomplished ballerina who has suffered with CRPS (and later fibromyalgia) for 26 years. Thanks to their leadership advocating for health care reform in California, today they announce that

For Grace and HAAF's bill, AB 1144, was heard by the California Assembly Health Committee in Sacramento yesterday (April 21) and it passed overwhelmingly with a vote of 14-2. There was strong opposition from the health insurance industry - and this effort will be an uphill climb as we move the bill along to the Senate.

Also, today, ABC News national covered the issue of "step-therapy" (also known as "fail first") along with our bill, that if signed by Gov. Schwarzenegger, will abolish this unethical prescription practice that negatively impacts women in pain. Ms. Toussaint pitched this story, consulted and interviewed for it.

Because of its importance to every single one of my patients whose lives hang by the constant threat of an indifferent refusal by insurance carriers to continue providing medication that they require, I am posting almost the entire ABC News article titled "Patients Irate With Insurers' 'Fail First' Policy" by Dan Childs

What Is Step Therapy?

The basic idea behind step therapy is to start with the most cost-effective and safest treatment, progressing to more costly or risky therapy only if the current treatment is not effective. In theory, proponents say, the strategy both minimizes risks to the patient and keeps overall costs under control.

Robert Zirkelbach, spokesman for America's Health Insurance Plans, said that when it comes to the bigger picture, step therapy is a key element in making the country's health care system more efficient by creating a standard system of care from state to state. He said that this saves costs, and it also ensures that patients get access to therapies that have been proved to be medically effective.

"We see individuals with the exact same illnesses get drastically different treatment depending on where they live," he said. "Right now there is no correlation between the money being spent and the health outcomes being advanced. Our goal is to help guide the patient."

Dr. Forest Tennant, head of the Veract Intractable Pain Clinic and editor of the trade magazine Practical Pain Management, is also Cook's doctor. He agreed that in theory, step therapy is not a bad strategy. And he added that doctors have traditionally employed a form of step therapy, in which they would gradually increase the dose of a given medication for a patient who was not responding until they were able to achieve the desired effect.

Doctors Employ Different 'Step Therapy'

And even when it comes to designing a course of treatment, Tennant agreed that a cheaper approach is preferable, as long as it works for the patient.

"Given the cost of some of the medications I prescribe, I also want the patient to try the cheaper medication first."

But he said that the step therapy used by the health insurance industry is different in that it may actually place a preferred therapy out of reach of a patient. Particularly vulnerable may be pain patients like Cook and Toussaint, who have experienced success with a given medication but are switched to a different drug by an insurer.

"What we have today is a situation where a patient is knocked around in the system, usually after they've already tried something that works for them but which they can't have," he said. "All of a sudden, the drug that they have been taking for quite some time is pulled away from them -- because it is more expensive, usually.

The Best -- or Just the Cheapest?

According to data collected in 2006 by the health care analytics company Verispan, the drugs for which step therapy is most commonly used are anti-ulcer medications, with 58 percent of health insurance plans using step therapy for this class. The data also reveal that antidepressants are the fourth most common drugs subject to step therapy, with 45 percent of plans subjecting these to step therapy. Twenty-six percent of plans use step therapy for pain drugs, according to Verispan, and other drugs including heart medications and antipsychotics are also on the list.

Zirkelbach argued that in most cases, patients are allowed to switch drugs if the recommended option is not working for them, and if the drug that the patient is switching to is supported by medical evidence.

"If there is a good medical reason to switch to drug A versus drug B, health plans typically allow that to happen," he said.

But he noted that how long a patient is required to stay on a given medication before making a switch varies from case to case. Doctors who prescribe a drug that is unapproved by the insurance company risk receiving what Tennant calls a "tantrum letter" from insurance companies.

"The insurance companies hire auditing firms, and they demand to know why I prescribe [patients] certain drugs," he said.

The net effect, Tennant said, is a grave imposition on the doctor-patient relationship.

"I have to say [to patients], 'I can't tell you what you should take. I can only get you to get what your insurance can pay for, and I'll design a regimen,'" he said. "For the expensive medicine, the doctor no longer chooses what he wants."

And according to a Thomson Reuters study published in the February issue of The American Journal of Managed Care, step therapy may actually be more expensive for insurance companies, at least when it comes to patients receiving medication for high blood pressure.

Step Therapy May Not Be Cheaper

In the study, which was sponsored by Pfizer, researchers looked at insurance claims for 11,851 people with employer-sponsored health coverage that incorporated a step therapy protocol for high blood pressure drugs. These patients' claims were compared with those of 30,882 patients on similar medication who did not participate in a step therapy program.

What the researchers found was that the group of patients treated for hypertension under the step therapy program had 3.1 percent lower drug costs. But these savings appear to have been wiped out by the apparent increase in hospital admissions and emergency room visits. Over two years, the step therapy patients incurred $99 more in healthcare costs per quarter, on average, than the control group.

Hope for Step Therapy?

If indeed California passes anti-step therapy legislation, it would not be the first to do so. New Jersey already prohibits such plans. And even the Centers for Medicare and Medicaid Services may be considering regulations to limit step therapy by health plans available to Medicare patients.

But Robert Taketomo, president and CEO of the Glendale, Calif.-based managed care contracting services organization Ventegra, warned that if such legislation passed in the state, patients may find that other parts of their coverage will be cut back to compensate.

"As long as healthcare is a benefit, and not a right, then measures such as step therapy are important means of preserving pharmacy benefits," he said. "If step therapy were to be prohibited through legislative means, there are other means through which a payor -- whether they be government, health insurer or employer -- could limit their cost exposure in pharmacy.

"These could include removal from formulary, increases in copayment, addition of deductibles (and increasing them), or 'carving out' pharmacy altogether and just cover medical expenses."

Tennant said he believes the true solution to the problem does not lie with new laws.

"There has to be some goodwill meeting of the minds for the people who practice medicine, those who need the help, and the people who are paying for it," he said. "Most of the [insurance companies] are trying to develop formularies comprehensive enough to get the job done without compromising patient care too much."

But Cook said that as long as her insurance adheres to a step therapy policy, she and other pain patients will worry about her medication one day becoming unaffordable.

"We all know that our lives could change at a moment's notice if the insurance companies say, 'Change,'" she said.

To view some of Ms. Toussaint's presentation to the media, including her "fail first" experiences... on the second page of their "Videos" go here.

Her focus has now shifted to bringing a single-payer, universal health care plan to all in California which will provide a model for the rest of the country.

Being Positive - Cognitive Behavioral Therapy

The benefits of being positive

I don't know how the Great Recession may be affecting your mood, but for those with chronic pain, it is often difficult to nurture and maintain a positive attitude. Especially at times when we need the most help, we may be most reluctant to appreciate the benefits of Cognitive Behavioral Therapy, but that's how we get help to reorder our thoughts in positive ways that are healing. London's syndication, The Independent, reviews recent research that tells us how much our attitude is harming ourselves. Don't forget, it harms everyone you love and constricts their lives too. But the right frame of mind can lower your pain and other health risks.

PAIN

People showing dispositional optimism may be better able to cope with pain and need less medication. A study at Michigan State University on cancer patients shows that those who were more optimistic tended to report less severe pain. A study at the University of Alabama showed that patients who were optimistic used less medication for pain relief. "More optimistic adolescents are better able to match their medication use to their pain severity. Future research should examine how other psycho-social factors might influence pain medication use in adolescents and adults, and clinicians should take into account psychosocial factors when working with pain populations."

CANCER

Women who are happy and optimistic may have a lower risk of developing breast cancer. The research also show that adverse life events, such as loss of a loved one or divorce , can increase the risk. Results from the study at Ben Gurion University in Israel show that exposure to more than one adverse life event was associated with a 60 per cent increased risk of disease, while happy and optimistic women were 25 per cent less likely to have the disease. "A general feeling of happiness and optimism seems to play a protective role," say the researchers. "The relationship between happiness and health should be examined in future studies and possible relevant preventive initiatives should be developed," say the researchers.

MORTALITY

A review of research into the association between positive wellbeing and mortality shows a signifciant link. The University College London analysis of 35 studies showed that positive psychological wellbeing was associated with an 18 per cent reduced mortality in healthy people and a 24 per cent lower risk in sick people. "Positive feelings - emotional well-being, positive mood, joy, happiness, vigour, energy - and life satisfaction, hopefulness, optimism, sense of humour, were associated with reduced mortality. Results suggest that positive psychological wellbeing has a favourable effect on survival in both healthy and diseased populations.

HEART DISEASE

The positive-minded have a 55 per cent lower risk of dying from heart disease, according to the results of a study which followed 500 men aged 54 to 84 for 15 years. "Our results demonstrate a strong and consistent association between dispositional optimism and lower risk of cardiovascular mortality," says the researchers from The Netherlands Institute of Mental Health, Delft. Just how low optimism may lead to cardiovascular death, is, say the authors, an intriguing, but unanswered question. One possible mechanism, they say, is that optimism is related to better coping behaviour. Another study at the University of Pittsburgh, and based on 200 women diagnosed with thickening of the arteries, showed that over a 15-year period, the disease progressed more slowly in those women classed as optimists. Other research has shown that optimists have a lower risk of rehospitalisation after coronary artery bypass graft surgery.

The article also covers the field of research as it applies to blood pressure, longevity, infections, even the common cold........

Practice makes perfect. Take time out to give yourself some love. Doctors too.

And read Diana's blog to see how the addition of 3 kittens have added so much to her family's mood. Even if you can't have a pet, you can still enjoy a friend's.

Desert Fairy Duster

This Medical Library may be helpful to you, allowing you to search for the explanation of Medical Conditions, Medications, Procedures, Tests, and general questions. Most of those are self explanatory with the exception of the last category, general questions, were you will find:

Advance Directives & Do Not Resuscitate Orders Handout

[Advanced Directives by State - End of Life Choices: CPR & DNR - Tool Kit for Health Care Advanced Planning - Alternative & Complementary Therapies]

Brain & Nervous System

Caregiving a parent with dementia

Caregiving a person with Multiple Sclerosis

Clinical Research Protocols

First Aid including CPR

First Aid for Seizures

Smoking Cessation

Overall this is a useful site and I am happy to make it available in one place though I may not agree fully with everything it says.

It saves time with topics linking you to such places as Merck Manual, Medline Plus, government sites, Medical Centers and NIH where they are recruiting for research protocols, American College of Emergency Physicians, National Hospice and Palliative Care Organization, Family Caregiver Alliance, American Bar Association Commission on Law & Aging, National Center for Alternative and Complementary Medicine, and many many others. In sum, good people. Useful.

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This service should not be used in place of a visit, call, consultation with or the advice of your healthcare provider.

Communicate promptly with your provider with any health related questions or concerns.

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