Sunday, March 20, 2016

Best Practices and When Your Doctor Says No


The American College of Physicians and the Centers for Disease Control give guidelines (known as high value care advice) to physicians based on the best current scientific evidence. Physicians try to treat patients based on those guidelines even when patients want a different treatment. Here are three that create the most problems when physicians try to do the right thing.


  • (No antibiotics for acute bronchitis) Acute bronchial bronchitis can last up to six weeks with a    purulent or dry cough. It is one of the most common out-patient diagnoses we see. More than   15 excellent scientific studies show no benefit in treating with antibiotics and a trend toward       adverse complications when antibiotics were used.        
All Primary Care physicians and Emergency Department physicians experience the constant request for Z-Pac throughout the winter. "It helped my friend, family, kid." "It's the only thing that works for me." It is hard to see a suffering patient who wants to be helped and resist the request. That is why 70% of patients with acute bronchial bronchitis get an antibiotic.

  •  (No antibiotics for pharyngitis unless testing positive for Strept) Only 15% of acute sore throats are caused by bacterial infections. The remainder are viruses that do not respond to antibiotics.
  •   (No antibiotics for acute rhinosinusitis AKA: Sinusitis) More than 4.3 million adults are diagnosed with sinusitis annually and 80% receive antibiotics despite the fact that it is usually a self limited illness caused by a virus, allergy, or irritant that causes inflammation in the tissue in the nose and sinus cavity. A bacterial cause usually lasts longer than 10 days and is associated with fever.
Doctors are often put between a rock and a hard place if they follow evidence-based guidelines. We want to please them and help them and when we don't, patient satisfaction scores go down.  But some studies are showing that doctors who offer symptomatic relief and take the extra time to explain why antibiotics are not needed can still get good survey scores.

According to the Annals of Internal Medicine, reducing inappropriate antibiotic use will improve quality of care, decrease health care costs and preserve the effectiveness of antibiotics.
           

Saturday, March 5, 2016

Zika Pandemic - Early 2016


The Zika virus was first discovered in a rhesus monkey in 1947.  The Aedes species of mosquito transmits the Zika virus as well as dengue and yellow fever.  This mosquito is found in tropical and subtropical regions around the world. Since Brazil reported Zika virus in May, 2015, infections have occurred in at least 20 countries in Central and South America.  And now, in 2016, it has pandemic potential with outbreaks in the Americas, Africa, Pacific Islands and Southeast Asia.

It's important to know that  80% of Zika virus infection cause no symptoms at all.  The rest have just mild fever, rash and muscle/joint pain.  There is no effective treatment.   But we are seeing other serious effects like congenital neurologic malformations and microcephaly in Brazil and French Polynesia.  Brazil has had 4000 cases of suspected microcephaly in 2015, a 20 fold increase since 2010.  Evidence of the virus has been found in the placenta and amniotic fluid of mothers and in the brains of fetuses and newborns.  New research shows that the Zika virus affects developing cells in the brain's cortex.

The Zika virus can live in semen longer than blood and we believe it can be sexually transmitted from an infected man to a partner.  We don't know if women can transmit it and we don't know if it can be transmitted orally.  Pregnant women or women trying to get pregnant are advised not to have sex with  partners from endemic areas without protection.

At this time there are no reports of Zika being spread from animals.  At this time there are no reports of Zika transmission in the United States and the only Zika infection is from travelers from endemic areas.