Growing Concern in Health Care Workers over Measles Outbreaks

The outbreaks of measles largely in the Northeast and Northwest are a glimpse to a larger problem:  the breakdown in vaccination programs.  Worldwide, there has been a significant increase in caseload of measles.  Countries with the highest rates of measles and the most challenges to vaccination infrastructure include the Philippines, Ukraine, India and the African continent.  Imported measles has fueled outbreaks in pockets of the United States and Europe where vaccination has either been substandard or has been declined.  The outbreaks in New York and Washington were started after unvaccinated travelers to measles-prevalent countries returned home unknowingly with measles.  Their circle of friends and public spheres of contact were also locations where there were unvaccinated children.  Recently, a similar situation occurred in Salem, Oregon, which has just confirmed its second measles case. 

Measles outbreaks has served as a “canary in the coal mine” for vaccination programs.  Should we have reason to be concerned?  The Doctors Company asked me to write a summary of the results of a survey held on their site.  “How concerned are you as a healthcare worker about the recent U.S. measles outbreak?”  A majority of the 9,459 respondents (43%) answered “very concerned” .

Below is the link to the summary on the Doctors Company site:

www.thedoctors.com/articles/concern-about-US-measles-outbreak/

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Increase in flu cases over the last few weeks nationwide: peak flu season

The link to an interview of me and Sarah from Channel 12 Portland – article and video – on the uptick of influenza cases locally in Portland. Yes – I said it — it’s fist-bumping season!

Regionally and nationally, we are approaching peak flu season. This current surge in caseload has come a little later than the last few years, when it was at around the beginning of February. As a result of this, the clinics and hospitals have seen an increase in caseload as well.

What can be a mild illness in some can be a severe, life-threatening illness in others. The highest risk groups for hospitalization and death are those older than 65 years of age. Persons with underlying health issues, including cardiovascular disease, metabolic disorders (diabetes mellitus), chronic lung conditions and other immunocompromising risks *including advanced age are at the greatest risk of a more serious outcome. It is for these reasons that this population should be encouraged to receive the flu vaccination – even now if one still hasn’t received it. Also crucial is therapy with oseltamivir (or the new agent baloxavir) which can reduce the severity of symptoms, ideally if taken within 48 hours of onset of symptoms.

Nationally, for this influenza season, the CDC estimates that about 20 million have already had influenza-like illness (ILI), there have been about 10 million medical visits regarding ILI, 250,000 flu hospitalization and possibly as many as 20,000 deaths (estimate 16,400-26,700) are attributable to influenza.

It is almost unbelievable the sheer magnitude of those infected, unlike the measles outbreaks we are seeing in the US. This caseload makes a fairly low attributable mortality rate (1/1000) an increasingly important target to try to prevent. Influenza attributable deaths refers to the number of people who have died as a direct consequence of influenza (8-15% are from respiratory failure from influenza pneumonitis) or a result of having the diagnosis of influenza, such as a secondary pneumonia with respiratory failure or cardiac consequence.

Of the caseload nationally, there has been an increase in the amount of H3N2-related influenza. There is nothing characteristic of this virus that makes it more virulent than the most common influenza A virus H1N1. Of the viruses analyzed from a sample thusfar this year, there is much more genetic diversity seen in the H3N2 circulating viruses than the H1N1 (which is largely the same clade). Tests of anti-sera similar to that of the vaccine showed 62% efficacy in neutralizing the H3N2 strains sampled compared to 38% inactive even at high doses. This means that the genetic diversity may be contributing to a decrease in the vaccine’s effectiveness for H3N2.

Why does the flu have a seasonal pattern away from the tropics, which are usually year round in risk? This has always been a question that has stimulated interest and research. There have been multiple factors posited including an increase in transmissability in colder (often drier) weather, changes in mucosal membranes of the nose of respiratory tract that increase the ability for the virus to cause infection, other immune effects of colder temperature, and the increase of indoor cloistering (more people indoor spreading germs). Some studies raise the question as to whether global warming with milder seasons cold increase the likelihood of a sharper curve early into the next flu season.

Infographics | CDC

Take 3 actions to fight the flu infographic
Photo from the CDC website “Take 3” actions to Fight the flu

Recommendations:

  1. It is not too late to get the flu vaccination if you haven’t already
  2. Practice prevention habits — including handwashing, social distancing (if you are sick) from others, getting plenty of sleep and eating a well-balanced diet, avoiding smoking or excessive alcohol.
  3. If you do have flu-like symptoms, get seen in the clinic – immediate care or ER (if you are having shortness of breath or any signs of complications and have an underlying risk factor that puts you at risk for more severe disease). You can then be given treatment with oseltamivir and additional care, if needed.
  4. For heaven’s sake, if you have a cough or sneeze, please do it in your sleeve or use a tissue and wash your hands. The visual of coughing and sneezing in the same hand that touches a doorknob or a shakes someone’s hand afterwards is almost unbearable. But I digress..

The CDC has an excellent update of the flu season and tips including “Take 3” actions to fight the flu.

The Last Diet I ever had to go on: A personal account of my journey toward wellness

The following is an excerpt of my personal journey to overcoming obesity on the path to finding wellness.  You may find some similarities in your journey:

Sometimes when I share with people regarding my health journey, they have a hard time believing that I was once straddling between being overweight and obese for a good part of my life. Most people, looking at me and my current state of health, think that I have always been in a healthy weight range. In that same vain, when I was a child, I thought that no matter what I tried, I would always be fat.

Or as Kelly, a friend in grade school, once told me after someone called me “fat”, “You’re not fat. You’re pleasantly plump,” commenting on my pudgy build in fourth grade. I really appreciated that euphimism, though it still pierced me like a dagger. Why would it though? It was afterall true.  The shame and low-self esteem grew.

At around the fourth grade – I had accumulated enough adipose tissue around my waist to fit in the overweight category. Before that time, I never had to think much about it. I remember my kindergarten photo with a Fonzi shirt and my hair slicked back. Where did this adorable child go? The first accumulation of weight came on the sides as “love handles”. Then, I started noticing more on my face, chin, chest, arms, and legs.

As a child, meal time other than dinner was usually casual.  Breakfast was a healthy bowl of raisin bran or cheerios with milk – or maybe not so healthy.  Lunch was often sandwiches or leftover pasta from the day before.  We were often left to create our own meals – and as growing teenage boys, we sure could eat!  My mother or father prepared dinner when they got home from work, and we all had to sit down to dinner together every day. The typical foods for dinner were the staples during the seventies and eighties: spaghetti, “poor man’s lasagna” – a mixture of macaroni, tomato soup, ground beef and chedder cheese slices, sub sandwiches. One of my father’s classic statements when he was preparing pasta was “if I could have pasta for breakfast, lunch and dinner, I would“. He often tried just that. Sometimes, when we were running late, my parents would bring home McDonalds or order pizza. 

Our whole family has had problems with weight.  My grandma on my mother’s side died at the age of 62 when I was only 7.  She had kidney failure requiring dialysis and poorly-controlled diabetes.  Imagine having diabetes in the 1970’s, giving yourself insulin without even checking your sugar.   My mother and father were like most of the parents of the time, not well informed about healthy eating.  I had no nutritional knowledge growing up.  My information was what a child could get watching cartoons and School House Rock.  I remember learning about the food pyramid around the fifth grade.  I thought, how could I have become overweight?  I was eating mostly the base of the pyramid – plenty of bread, pasta, and cereal.  That was healthy, right?  I remember thinking even back then that something didn’t seem right about what was considered healthy eating.

When my father went shopping, he liked to bring home fresh fruits and vegetables, and from the local import store, Italian meats, cheeses and olives and lots of bread. He usually made a salad with iceberg lettuce, tomatoes, cucumbers, and celery with olives and pepperoni with an olive oil dressing – ideally every day. I detested celery and tomatoes at that time, so didn’t explore the salad too much and probably didn’t have salad more than once a week.  Little did I know at the time that this was a missing ingredient from my diet.

I remember the wonderful holidays as a child and my first “sweetheart” – chocolate. My mother gave us loads of chocolate and candy for Christmas and Easter, stuffing the stockings and the baskets full.  During the holidays, we would make chocolate specialties by melting the disks of chocolate — making haystacks, chocolate with cherries and other delectable deserts. There were times when I craved chocolate and didn’t want to eat anything else.  I would make “chocolate runs”, walking or riding my bike a mile to the nearest store.  You could probably guess that my favorite book and movie as a child was Roald Dahl’s Willie Wonka and the Chocolate Factory.

As a teenager, I was enrolled in the gym and would go very often to exercise. Back then, the common knowledge was that if you got overweight, it was because you had “bad genes”, you were not disciplined enough, and you ate too many calories compared to what you expended.  So you needed to cut the food and to exercise more.    I tried all too many times various diets — juices, grapefruit, sometimes skipping meals and finding that my hunger drive was taking me to eat from the cabinets – grabbing the worst food options from the boxes, like pretzels, cookies, chips, and cereal.  My mother was also diagnosed with diabetes when I was a teenager – she was in her early forties.

As I grew taller during puberty, I did grow into my weight a little and was in the middle range of the overweight category. I joined sports like basketball, wrestling and soccer, as a way to optimize my weight, but just resorted to the foods that I grew accustomed to eating – fast foods like burgers, gyros, tacos, pizza and subs. I quit many of the teams after the first month of joining, because of the demand.  

Without as much emphasis on sports, I put my efforts on being a good student and being involved in multiple extra-curricular activities. My father rewarded our scholarship very well with $5 for an A, $4 for a B,etc.  I mostly earned A’s.  I found exceeding in school was something that would give me approval and a feeling of accomplishment.

Just before entering college, I had to have jaw surgery, recommended by my orthodontist on account of a significant overbite. I was told that if I did not have surgery, that I could later be at risk for sleep problems, like sleep apnea. My mother was able to arrange a similar surgery for her malocclusion at around the same time. We joked about the fact that our jaws would be wired shut, so there would be no way we couldn’t both lose weight. I did end up losing about 20 pounds, but during my college years my weight increased to approximately 192 lbs with a height of 5ft 10inches, which calculated to a BMI of 27.5.  

In medical school, my weight was at a steady state, though I longed to get healthier. I continued my regular exercise, though I struggled to maintain good sleep habits on account of the demands of medical school. I continued to gain weight slowly through medical school and residency, though had a few periods of weight loss, which were associated with more rigorous general fitness.

It was at a time, while preparing for boards (rigorous tests of several hours that designate a physician as “board certified”) that my activity level dropped, my stress level rose and my eating habits hit rock bottom. My body was fueled by pizza and Chinese food brought by well-meaning pharmaceutical representatives and the frequent pharmaceutical dinner programs – I rationalized that it would save me money and provide socializing time. Unfortunately, by the end of my training, I was well in the range of what is considered obese. My weight increased to 225 lbs; a BMI of 32.5. I regularly had night-terrors and poor sleeping habits, which reflecting on it now, were likely related to some degree of obstructive sleep apnea.

I ate whatever I could, and admit to resorting to pasta and pizza regularly and not eating much natural food. In preparation for getting married, I decided to force a diet change. What did I have to lose … other than maybe weight? I considered my options, knowing that prior attempts were unsuccessful. My life was more stable with a more predictable schedule. My diet was mostly centered on South Beach / Atkins premise – eating more fat and protein and less carbohydrates. I organized my plans, and ensured that I prepared my own lunches and avoided fast foods and complex carbohydrates, including pizza, pasta and bread. There were times I had to pinch my nose shut while I forced spinach or sardines down. For desert, I would have ricotta cheese with cocoa and almonds and sucralose, or desert teas during the evening, which were enough to replace my nighttime cravings. I practiced saying “no” to desserts, which were often brought into my work setting — “no” to cookies, cakes and pies, while I nibbled on beef jerky and almonds.  I found myself gaining momentum, confidence — and even discipline — making these first steps.  About three weeks into the diet, I felt different. I had less cravings, I didn’t have to eat as much food, as long as I provided myself three meals a day and a few snacks. Over the course of about 8 months, I lost about 40 pounds, with a drop from a tight 38 to a comfortable 34 pant size. I had to have my wedding ring resized after I dropped the weight, because my ring slipped off my finger so easily that I lost it for a moment. 

The cravings that I had for the usual carbohydrate-rich foods passed after the first few weeks.  I found myself just as content with saying “no” to short-term sugar fixes over the long-term goal of better health.   I visualized what my body was doing when I had consumed higher carbohydrate foods.  I reminded myself that it wasn’t about taking foods out of my “bucket” of usual foods, but about putting new food options into it.  Unlike other diets, this was a journey I made one step at a time, one day at a time, one meal at a time. This was the last diet I ever had to go on.  

Continuing on this same trajectory through the years, I have lost a total of 60 pounds from my maximum weight and have been able to maintain the weight loss for the last 16 years.  I am empowered now knowing that, if I ever were to slip and start gaining weight, I can re-evaluate my daily carbohydrate intake and adjust accordingly.  I eat a high vegetable, moderate fat/olive oil and protein diet and low carbohydrate diet — amounting to the most natural form of food and have never had to count a calorie

Lessons that I learned:

  1. First work on addressing the stressors that let our guard down to consuming rapid-fire simple or complex carbohydrate foods.  This includes adding exercise, walking, meditation and some breaks in the day.
  2. Plan your meals, including packing a lunch to “protect” you from cravings at work – either the vending machine or well-meaning work partners bringing in cookies and cakes.  Say “no thank you” and feel your discipline getting stronger by doing so.
  3. Discipline comes with practice and strengthens as you go forward.  It is a skill that you develop, one small step at a time.
  4. It is OK to fall off the wagon, but get right back on.  Nowadays, your steady path doesn’t have to be affected by vacations, holidays, birthdays and eating out – order the freshest options and small plates and enjoy.  Consume a small amount of dessert, if you can.  Know yourself.
  5. Being overweight or obese is not a character flaw.  It is a dietary disequlibrium that takes practice and self-nurturing to adjust one step at a time.  It is not a past tense or future tense thing, it is taking control over the now.

I hope that you enjoyed reading this blog.  Please share it and refer to the Overcoming Obesity section for more related topics.  Dr. Christopher Cirino

The Calorie Challenge: Letting go of it on your Health Journey

Video Link “The Calorie Challenge”

A calorie is the most common term that people refer to when they are describing the content of food. Yet, it doesn’t provide much detail about food. Much less does it really serve as a useful tool to those who are working toward a healthier weight. In this post, I will describe the term calorie, how digestion involves multiple mechanisms, and how the calorie should be considered an outdated term.

What is a calorie? It is the amount of heat (in Joules) it takes to raise one 1kg of water 1 degree celsius *(Calorie). From the chemistry lab to the food that we purchase in the grocery stores, It was popularized in 1918 by a physician from California, Dr. Lulu Peters. It became the measuring stick of a daily diet, and the American Diabetes Association recommends approximately 2000 calories per day. The very common dogma growing up and still promoted is that weight gain occurs from eating an excess amount of calories than what is expended. There is no further information to what constitutes that unit of energy – is a calorie a calorie?


Is this the time to ditch calories?

As a child growing up, I had challenges with my weight. It accumulated around my waist and then my it began to show on my face (I will include this in a later blog). I looked at this “calories in, calories out” model when I approached getting healthier as a teenager. I found myself going through a yo-yo course of eating less calories, hoping that I would lose weight and rebounding after eating a higher calorie count. I found myself only gaining more weight.

In fact, what I stumbled upon was a disconnect with the concept of calories in and calories out and what actually happens in the body. The term of a calorie may be one better left for the Bunsen burner of the chemistry lab than for food labels. The body handles each constituent differently, whether it is a carbohydrate, a protein or a fat. Unlike a certain amount of heat to break down the food, our bodies utilize multiple methods to digest, absorb and metabolize the food that becomes the building blocks of our body. What is broken down is stored in various forms to used in between meals or when an increase of energy is required, such as in exercise. The following will be a description of how our body uses the food we eat.

Digestion, Absorption and Metabolism in the Body: A brief, detailed overview

Starting with food entering the mouth, chewing it mechanically breaks down the food and exposes it to our saliva which coats the food for swallowing and starts breaking the starches (amylase in the saliva). When we swallow the food bolus (amount), the esophagus moves the food through contractions into our stomach.

Inside the stomach, the food is churned mechanically and also exposed to protons (acid) that help to break down the food further. There are proteins (enzymes known as proteases) in the stomach – trypsin and pepsin – which get a head start digesting the proteins into the amino acid components. In the duodenum, the first segment of the small intestines, literally translated as 12 finger breadths, the digesting food is met with multiple substances from the gallbladder, known as bile, which breaks down fat and cholesterol, and the pancreas which breaks down fats (lipase) proteins (trypsin and chymotrypsin) and carbohydrates (amylase) — and still others (elastace, ribonuclease, etc).

These breakdown products can then begin to enter the small intestines and make their way into the venous system (portal system) of the liver to become metabolized and detoxified by the liver tissue. This is the initial setting of glucose, protein and fat/cholesterol metabolism. A hormone secreted in the pancreas – insulin – helps to keep sugar at a balance in the bloodstream. Excess sugar seen in diabetes can become harmful in the vascular system. The pancreas adjusts the amount of insulin needed and secretes more insulin when more glucose is absorbed. Fatty acids which are derived from fats that we eat are converted with glucose in the liver into triacylglycerides (and transported in chylomicrons) from the blood into adipose tissues.

Insulin metabolism shifts the glucose into cells of muscle tissue, the brain and organs and shifts glucose in the form of triacylglycerol to complex in fat tissue (adipose tissue) and increase fat stores. The level of glucose in the blood is closely monitored by several hormones, insulin, glucagon and somatostatin, which keep the glucose at a basal (steady) requirement – in a non-eating state. The liver stores excess sugar by means of insulin into glycogen, which can buffer the blood glucose levels for up to 12 hours of fasting state. After these stores are expended, the adipose (fat) tissues of our organs, white adipose tissue (WAT) start being utilized by converting the triacylglycerates back into free fatty acids which are converted into ketone bodies in the liver — betahydroxybutyrate, acetoacetate, etc.

The body can use ketone bodies to derive energy. In some early ultra-low carbohydrate starvation studies, samples of blood taken from the carotid artery (the artery which goes circulates blood to the brain) found betahydroxybutyrate, suggesting that the brain can survive on ketone bodies in starvation states as well as glucose in surplus states.

There are also feedback systems for hunger. An empty stomach produces a hormone ghrelin which functions in the brain to trigger hunger and appetite. When the stomach expands, the ghrelin levels drop. Adipose tissue produces a hormone leptin which triggers satiety. With increasing obesity, ghrelin continues to function normally, but there is a state of leptin resistance. Ghrelin may have other effects on the brain, including mood, memory, and growth of new nerve cells that are beginning to be more understood.

What leads to obesity is more of a intake disequilibrium rather than a calorie equation. When sugars (complex carbohydrates are broken down to glucose in the gut) are more prevalent in the diet, the body metabolizes the absorbed glucose surplus leading to more being shifted into adipose tissue. Weight gain “simply” is a result of this imbalance of intake. I put quotes on “simply”, because if it were this simple, everyone would be able to normalize their weight. The added challenges include behavioral loops, taste memory and emotional eating as the glucose actuates (and even our gut microbiome! – stay tuned for a future blog on this) neurotransmitters in our brain that control our mood and memory.

Taking the above information and boiling it down (no pun intended), the message is that calorie counting, while it may be a tool to which we are all accustomed, doesn’t really help much to understand the more important concept of what we eat and how the body metabolizes that in a way that can lead to weight gain or weight loss. How many calories we eat, although a surrogate marker for how much we eat, doesn’t describe the individual components of fat, carbohydrates and protein along with fiber. There is more going on in our body than “burning food”. Furthermore, calorie counting for your exercise program is also fraught with problems because they generalize estimated calorie loss and they don’t take into account calories burned through respiration and resting metabolic rate (RMR). The concept of calorie misses the mark when it comes to describe the metabolism of food and the acquisition of energy in the resting and exercising body. It is as if we were using an archaic measurement and still applying it to things out of habit, rather than using other, more accurate tools.

Below are a few suggestions for working toward a healthy diet:

  1. Eat mostly plant products such as green,leafy vegetables and vegetable products such as legumes and to a lesser extent fruit. Green, leafy vegetables should be at the base of the food pyramid. It is replete in water, undigestible fiber and vitamins and minerals, which gives each vegetable its own color, aroma, texture and taste. Start every meal with the vegetable first – since this can be more fulling.
  2. Favor the original product over the processed product, e.g. steel-cut oats over granola, peanuts over peanut butter, etc. If it is boxed and capable of long storage, save that for your earthquake-ready food kit (for all of those who live in the NW or other earthquake prone areas) rather than the first go-to food in your pantry.
  3. Avoid liquid sugars, favoring water as the only source of hydration. These liquids include juice, soda and milk. Favor the original source, e.g. orange instead of orange juice.
  4. Ditch the calorie counting — I say this understanding that many people have been doing this for a long time and feel like it offers some control. Unfortunately, it tells us little about of how wholesome a food is. We also tend to underestimate the calories in the food we eat. It might give us a false security that a certain number is going to be a target for possible weight loss, and often leads to the up and down cycles of intake. If you would like to count something, you could try carbohydrate counting. But – just as a calorie is not a calorie, a carb is not a carb. A good rule to follow is to eat real food. Also, ditch the calorie counting for exercise. Our body, while it generates heat, doesn’t burn calories in the strict sense – it utilizes tissue glucose to make the needed adenosine tri-phosphate (ATP) at the cellular level for the increased activity. When this occurs, there is some magical calorie deficit — there is just hunger. Don’t ditch the exercise though — do that every day!

I hope you enjoyed reading this post. Remember little changes over time can lead to big results. It really is not a sacrifice at all to lose weight — it is a discipline that strengthens over time – even in someone who failed every diet before the last diet I every needed to go on. I sometimes hear patients exclaim, “but doctor, these (sweets) are the last pleasures that I have!” I recount to them that when I was younger I rarely used to eat salad, but after finding a way to make it taste better to me (I use a little olive oil and salt), I now eat three plates of salads every day. Well, after doing this for nearly 15 years, I have come to find pleasure in the variety of natural foods and their preparation. They are truly multi-dimensional foods.

Stay tuned for a future blog that details my personal journey toward finding health.

“If it doesn’t challenge you, it doesn’t change you” Fred DeVito

For additional reading on the topic of calorie, I would recommend Dr. Zoe Harcombe’s book The Obesity Epidemic and Gary Taubes’ book Why we get Fat and what to do about it.

Update on Flu Season 2018-2019: A mild season but never mild enough

We are finishing up on week 7 of the new year and about halfway into the 2018-2019 flu season. This season has been mild on account of less influenza case burden.  The 2017-2018 season was more severe than the current season. By the end of that April 2018, more than 34 million people had the flu, about 1 million were hospitalized, and approximately 54,000 people died.   However a mild case load doesn’t mean that the disease is any milder. The Center for Disease Control (CDC) estimates that from October 1, 2018 through to February 9, 2019 there have been an estimated 15-18 million cases of flu illnesses in the United States, 7-8 million have been seen in the clinic, an estimated 200,000 people required hospitalization, and around 11,600 to 19,100 people died from the flu.  These deaths are usually from a secondary bacterial infection, complications of respiratory distress, or a cardiovascular complication attributable to influenza.

As a general estimate, around 5-15% of the total US population gets the flu yearly. The hospitalization rate is 1 in 100 (1%) and the death rate is 1 in 1000 (0.1%). The highest risk of mortality is seen in the 65 and older age group, but almost 60% of reported hospitalization are ages of 18-64 years. Sure, most people will get a mild case of influenza and many people will get a classic case – with rapid onset of tiredness, body aches, chills and fever with cough, fewer will need to be hospitalized and a small percentage will die. Given the sheer magnitude of those affected, this means a lot of people. Influenza is not a mild illness.

With the attack rate of influenza approaching 20% and disease now widespread, we are approaching the peak of the flu season and greatest risk to acquire the infection. The good news is that if you have received the vaccine, you have a good chance that you will be either protected from the disease or get a milder case. This year’s vaccines were a good match with the selected viruses for the vaccine being the current active viruses (H1N1 pdm 09 (75-80%), H3N2 (20-25%)). The CDC estimates that the vaccine efficacy this year is 47%, approximating 61% in ages 7 months to 18 years, and probably lower in the over 50 age group.

https://www.cdc.gov/flu/index.htm

In general, the vaccinations consist of two type of influenza viruses. Type A viruses are named after cell membrane (the outer layer of a virus) components – called hemagglutinin (H) and neuraminidase (N). The vaccine consists of 2 type A viruses H1N1 pandemic 2009 and H3N2. The type B viruses are named after two lineages B/Yamagata and B/Victoria. These are typically the strains that are included in a typical quadrivalent vaccination (4) or trivalent (minus Yamagata). Unfortunately, unlike the measles or other childhood viruses, there is more virus differentiation — changes known as antigenic drift, when gradual, or antigenic shift, when sudden. A new vaccine has to be decided upon each year. An extensive vetting occurs involving input from multiple centers, where the most common strains are selected. Occasionally, the vaccinations do not match the years prominent strains. This year, the majority of cases have been caused by the H1N1 pdm 09. Why not 100% effective — there are enough differences from the vaccine strains and the seasonal strains (yes – it changes/re-assorts that fast) that make an immune response from the vaccination not as effective.

Below are some general questions and answers regarding influenza:

  1. Is it too late to get the vaccine if I missed earlier?  No. It is not too late to get vaccinated. The flu season usually tapers off after April. Getting a flu vaccination now would provide some protection for the remaining 2+ months. If you don’t want to make an appointment with your doctor, you can get it at many pharmacies. I would recommend the recombinant vaccination (quadrivalent) and the high-dose if you are older than 64.
  2. How is the flu spread? What are the signs and symptoms of the flu and how do these differ from the common cold.

The influenza virus can be transmitted fairly easily in both coarse/large and fine respiratory droplets – the greater density of virus is on the smaller droplets. You can breathe these droplets in or put them in your mouth. There are several ways to put these in your mouth: Surface they can land on a surface and you can touch it and then put your fingers in your mouth or touch the food you then eat; Person-to-person a person could cover their cough and sneeze and shake your hands and… and Fomite, a person can contaminate an inanimate object, such as a doorknob, keys and a cell phone, and you can touch it and…

Unlike the cold, most people with the flu will get symptoms fairly abruptly. These will be fatigue and muscle aches. Cough is the most common symptom in all presentations, as influenza causes a lung infection known as pn. Those with advanced age will often have some confusion, along with a non-focal fever and cough. Anyone coming in with any exacerbation of chronic disease, e.g. lung disease or heart disease, should be screened for influenza during the season, given its association as an illness trigger.

3. How can I protect myself from getting the flu?

  • The influenza vaccine
  • Hand-washing : think about doing this more often during this time of the year -particularly when you touch a public surface or object (e.g. pen, doorknob). It might be a good time to get used to the fist-bump or bowing or maybe just remembering to use alcohol rub if you shake someone’s hand – and wash your hands before eating.
  • Quit smoking :  Smokers have a greater risk of more severe sequellae. It may be a good time to consider quitting or seriously reducing.
  • Limit alcohol : For multiple reasons, excessive alcohol intake can affect the immune system and increase the risk of aspiration which is likely a risk factor to secondary bacterial infections in influenza. My recommendation would to limit alcohol to no more than 1 or 2 drinks a day or less.
  • Eat a healthy diet, maintain a healthy weight  Eating a variety of vegetables rife with minerals and vitamins is a great way to bolster the body’s immune system. Various vitamins such as vitamin A, D and to a lesser extent C and E have been shown to affect the immune system in deficiency states. (complexity alert) For instance Vitamin A deficiency was found in mice to impair respiratory epithelium (layer) regeneration and antibody response to influenza A (link). Vitamin D has been touted to be beneficial from a meta-analysis to reduce risk of infection, but there is some conflicting evidence from other studies (link) . Nevertheless there is some biologic plausibility that Vitamin D plays a role in both adaptive (T- and B-cell) and innate (Natural killer, macrophages,etc) immunity (link). A prospective controlled study of 463 students 18 to 30 years old showed a benefit in the use of mega-doses of vitamin C, with a reduction in symptoms and severity (85% reduction) if taken before or after the appearance of cold or flu symptoms. A study on vitamin E in mice showed a reduction in influenza viral titer (amount), possibly linked to enhanced T helper 1 (TH1) cytokines.
  • Get plenty of sleep:   I will explore the topic of sleep and immunity on another post. Suffice it to stay, the many effector signals are involved in keeping our immune system robust and sleep is an important piece of the puzzle of why some people get more severe infections than other.
  • Exercises and keep a stress-free lifestyle

Obesity has come out as a new risk factor since the 2009 H1N1 pandemic flu season. One study looking at the cases of influenza showed an increase risk of hospitalization for a respiratory illness. In a person with class I obesity (BMI 30-35) the odds ratio was 1.45 and class II (BMI 35-40) and III (BMI 40-45) obesity, the odds ratio was 2.12 — for pneumonia and influenza. This fits similarly the association of more severe presentation of influenza and chronic diseases including diabetes, lung and heart disease and advanced age (impaired immunity).

4. Do omega-3 fish oils help influenza?   NO, I was asked this question recently. From my review online, fish oils may impair immune reactivity from the influenza virus (lower IgG and IgA levels) but may not have clinical impact. In one study in 1999, fish oils had anti-inflammatory properties and led to less viral clearance and some increase symptoms in mice but did not change the outcome. The possiblity of worsening the severity of influenza was suggested in another mice study

At this point, I am going with the likelihood that fish oils do not enhance one’s recovery from influenza.

5.  Are there any treatment options available for influenza?  YES.  Oseltamivir and Baloxavir.  Oseltamivir (Tamiflu) is given twice daily over five days and is a neuraminidase inhibitor, which blocks an important step of viral progeny (new virions) leaving an infected cell to go on to infect other cells.  Baloxavir is a single-dose option recently approved for this flu season (Oct 2018) and has a novel mechanism – a endonuclease inhibitor, which blocks a step needed in viral replication (“making copies”).  The important thing about these medications is that they have to be taken within 24-48 hours of the onset of flu symptoms to experience the maximal benefits, which amount to a reduction of severity and duration by a few days.

Not everyone requires this therapy, particularly in those with mild disease.  I would recommend that anyone with an age over 60 or BMI >30 and/or with conditions such as diabetes, cirrhosis, cardiovascular or pulmonary diseases consider taking this medication to reduce the risk of severity and duration.  Patient with lymphoma and leukemia or solid organ cancer are also at higher risk of complications.  In all of these patients, I would suggest if they present with disease within 24-72 hours or are hospitalized even after this period, that they receive the therapy.

Conclusion

I hope that you have an uneventful flu season – and if you get it this year, I hope it is as mild for you as the common cold. There are things you can do to ensure that it is. Though, remember influenza can be a significant disease. Please refer to my prior blogs on “Respiratory infections” and “10 ways to stay clear from infectious diseases”. Thank you for reading this and please share!

Your Health Forum by Dr. Cirino, LLC

A Forum (Latin “public place outdoors”) is a place or medium where ideas and views on a particular issue can be exchanged. Likewise, this page has been arranged for the purpose of sharing ideas as they relate to health and wellness, with a solid foundation of evidence-based recommendations.

I have been a physician for more than 20 years, and I realized that in the clinical setting, physicians and patients are often unable to broach the most important issues to health – behavior. It is likely that three-quarters of conditions seen in the clinical setting are linked to behaviors. If behavior can be explored and adjusted, it will likely result in more sustainable benefits on a person’s health — often much more than any medication could provide.

For this reason, I created this page. It will feature important topics for general health, the latest research evidence and links to additional reading (other blog sites, journals and books), and my published literature and resources. All members are welcome to bring up topics of interest, current health news or general questions as they relate to health. I can provide a review on the topic and we can explore it further.

At fist, I will provide a groundwork of writing on health and wellness “Finding Wellness“, Overcoming obesity challenges “Achieving Weight Loss“, Infectious Diseases Topics and other interesting topics that aren’t otherwise classified Miscellaneous Medical Topics. Additional information including outlines following acute hospital management of several medical conditions, publications and vlogs will follow. I can also be found on FACEBOOK, Instagram and Twitter at @yourhealthforum. If you are local, I invite you to attend a “Walk with a Doc – PDX” weekly walk or a monthly (for now) Your Health Forum Health Symposium, which you can find on MEETUP under the same title.

The content of this information is for educational purposes only. I strive to convey helpful tips to improve your health and ready you with some of the basis of decision-making in the clinical setting. This blog site is not intended to replace your primary care physician or specialist and you should seek consultation with him/her directly for more specific recommendations tailored to your medical history. I invite you to use this as supplement to your direction of finding health and wellness and warmly welcome you to this blog.

Cognitive Dysfunction Tied to Chronic Inflammation

More than 5 million US Americans are affected by Alzheimer’s dementia, and it has been attributable as the fifth leading cause of death in those aged 65 and older.  We often look at Alzheimer’s dementia as an isolated consequence of aging for some unfortunate people and varying developments of cognitive decline as a normal condition associate with aging.  These conditions may be consequences to chronic health conditions, such as obesity, and potentially may be mitigated by optimizing health

A recent study  in Neurology showed a steeper decline in cognitive function was associated with the presence of higher levels of chronic inflammation in middle age, as seen in chronic health conditions.  A nice editorial on cognition and chronic disease is provided in this link.     

What is causing this chronic inflammation? It is becoming increasingly clear that chronic inflammation is attributable to diet and the obesity state.   A high carbohydrate diet leads to hypertriglyceridemia, a high insulin state (insulin is a pro-inflammatory hormone) and obesity (associated with inflammatory white adipose tissue) — these are associated with fatty liver, diabetes, gout and cardiovascular disease. It isn’t a coicindence that the increase in the prevalence of obesity has been met with increases in diabetes, stroke and cardiovascular disease.  Similarly, I would predict the prevalence of sleep apnea and cognitive dysfunction have increased. The process of memory loss and Alzheimer dementia occurs over a long period of time and may be largely a preventable disease.

A link to obesity as a chronic inflammatory condition:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4594154/

My suggestions to protect yourself from cognitive dysfunction (memory loss):

  1. Eat largely real, unprocessed foods, mostly vegetables.
  2. Keep active daily. Healthy perfusion to the brain is more protective of dementia than word games, puzzles etc.
  3. Work toward a low stress lifestyle and prep the body for stress with meditation, exercise and mindfulness practices each day.

Determine your health risk NOW, by assessing your BMI, waist circumference, begin walking each day and adjust your diet by eliminating excess sugars and alcohol from the diet. Optimal health is a life-long and long-life strategy!

Trauma and Chronic Disease

What has a higher impact on our Health? Using medications or having the basic needs?

Our healthcare system is broken. Our nation is in “sickcare” mode. The typical entry point into medical care is in the ER or the urgent care clinic, when something is wrong. The clinician’s office visit allows only enough time to go through medications and cursorily address complaints. Oftentimes, the very source of a health problem is put aside for later – which never comes – or thrown out, rather than being addressed directly.

When I was training, one of my attendings didn’t want to hear anything about social history when we presented the patients. On one side, it seemed superfluous to the problem, but, on the other hand, our social factors and behaviors completely interact with our health. Within these information lies often the source of the risk factors to an illness.

If you wanted to know how much a person is at risk for health issues, you need only broach the topic of childhood trauma – which undermines the basic needs of safety and shelter:

When 17,000 members from an HMO in SoCal were asked to fill out a survey on trauma or adverse childhood experiences (ACEs), two-thirds of participants reported at least one ACE; one in five reported three or more Aces. A dose-response of ACEs was seen with regards to health outcomes – depression, alcohol abuse, COPD, liver disease, risk of partner violence, heart disease.

A nice website link for details of the ACE and how the study relates to chronic diseases.

Likely, what is at play are changes in our brains in the setting of trauma that predispose us to future unhealthy behaviors. The changes likely have to do neurotransmitter or endocrine signaling, e.g. cortisol produced in adrenal gland regulated by hypothalamus-pituitary-adrenal axis. This is a signal for “fight or flight”. I have written a few earlier blogs that can go into more detail about this. Trauma primes the brain for behavioral loops, including an increase sensitivity for cocaine and an “addictive personality”. Developing obesity has been strongly correlated with trauma as well.

What are we to do? 
We are not doomed like Sisyphus to repeat the behaviors that lead to the same harmful consequences. We are not victims but survivors. The brain can modify its function to lead to new behaviors. The brain can change and reorganize its connections from the inside – the concept of neuroplasticity – without the need for lifelong medications or therapy. Stemming from this is mindfulness and living in the “now” rather than being anchored down by our past experiences.

Basic needs like shelter, safety, food, water and clothing are the strongest health determinants. We must ensure that we and our sphere of influence, loved ones, friends and family are getting those needs met .. Starting with ourselves first.

In the hospital, we often must face with the dilemma of providing medical care to a person without a social support web or resilience / coping skills. A person who is homeless is admitted for an abscess in the setting of intramuscular injections “muscling” and is found to have a chronic health problem, like diabetes or hypertension. We are eager to treat the diabetes or the hypertension with any of the treatment options available and check that off the list. The likelihood of her filling the prescription – zero. How do we address the most difficult situation about her healthcare, no shelter, no social support and no resilience mechanism (beaten down from drug abuse and prior trauma)? The basic needs are like the base of a house of cards — without a stable base, all the cards fall.

When those basic needs are addressed and a person is in a stable social system free of abuse and trauma, a person can then press onward on the path toward wellness. Our fear of safety diminishes and we can then focus on development — rather than flight or flight. We can then develop a bridge to others through love, gratitude and creativity.

I leave you with this message on Wednesday:
Let the light of your creativity shine for all to see, breaking free from any shame, guilt or trauma that you suffered. It may just be the first step to finding wellness in your life.

Reading:
Relationship of Childhood Abuse and Household Dysfunction to Many Leading Causes of Death. Am Journ Prev Med. 1998. 14:245-258.

MRSA Infection: Questions and Answers

Addressing MRSA and how to protect yourself from an infection

MRSA:  Bacteria and the human state

The state of being human is anything but static.  Humans are home to many bacteria, viruses and fungi.  By an order of magnitude, there are more non-human cells than human cells on the surfaces and within the orifices of the body (10 to 14th compared to 10 to 13th).  Bacteria colonize any surface that is in contact with the environment, such as the skin, mouth, upper respiratory tract, gastrointestinal system, urinary tract, vagina.  Each surface has a predilection for different microbes on the basis of multiple factors, including pH, temperature, protein sources, oxygen content and moisture/salinity.  Staphylococcus aureus is one species that colonizes the surface of the skin of the groin, perineum (area between genitals and anus), axillae (armpits) and the nasopharynx (nose and throat) – its primary habitat.  As many as 25% or more of the population is colonized with S. aureus in the nose.  Much less are colonized with MRSA (2-4%).  A discussion of the complex relationship with S. aureus and humans in colonization and infection follows.

Compared to oral and intestinal surfaces, bacterial colonization on the surface of the skin is sparse.  Of the 1.2 kg of total body weight amounting from bacteria, the weight of bacteria of skin is approximately 0.2 kilograms; the intestines comprise the bulk of the weight (1 kg). Bacteria reside on the surface of the skin generally as commensalists or “neutralists”, a relationship with the human host that is neither beneficial nor detrimental.  Bacteria utilize various elements on the surface such as carbon, oxygen, nitrogen, potassium, magnesium, iron and calcium in order to allow for growth.   However, given the right circumstances, such as trauma, skin abrasion or excessive dryness of the skin (xerosis), there is a transition from greater colonization to infection. 

The most common bacteria associated with skin infections are Streptococcus and Staphylococcus.  Streptococcus commonly cause impetigo (a superficial infection), wound infections frm injury or after surgery and cellulitis, an ascending infection associated with fever, rash and pain and swelling of the site.  Staphylococcus aureus are predominantly associated with wound infections, folliculitis, furuncles, carbuncles (skin abscesses or “boils”), but can become deeper, more serious infections, if left unchecked.  With both Staph and Strep, these deeper infections may require significant surgical intervention, such as necrotizing fasciitis (deep fascial infection) or a muscle abscess (pyomyositis).  An untreated Staphylococcus aureus infection can predispose to abscesses in the epidural space or even heart valve infections (endocarditis). Post-viral respiratory infections can sometimes be complicated by Staphylococcus aureus which can sometimes be necrotizing and life-threatening.

Staphylococcus aureus is easy to see on Gram staining. They stain Gram positive (purple) and appear as grape-like clusters in the microscope. They grow readily on culture media, including blood cultures. Newer methods of testing including a nasal swab for PCR are useful for detecting colonization of Staph aureus in the nares and differentiating between MRSA and MSSA. This has clinical implications for treatment and pre-operative preparation.

Methicillin-resistant Staphylococcus aureus (MRSA).  This form of Staphylococcus aureus defined by its resistance to methicillin (including others such as oxacillin; cefazolin), an iteration of penicillin produced in the 1959.  It provided a short period of coverage against penicillin-resistant Staph, associated with production of an enzyme beta-lactamase, which was capable of breaking down the penicillin structure (beta-lactam ring), neutralizing its activity.  Unfortunately, not long after its use, Staph bacteria capable of growing in its setting appeared, initially in the hospital setting.  In the 80’s and 90’s, a growing percentage of community-associated infections from MRSA appeared.  Various proteins expressed by MRSA, such as the Panton Valentin Leukocidin (PVL) and others are associated with outbreaks and, to some extent, a greater virulence (more severity) of infection.  Co-association with colonization of MRSA and MSSA can be attributable to a risk of infections after surgery. 

An approach to treatment of MRSA in a person presenting with an infection is three-fold.

  1)  Address the infection – for instance, perform an incision and drainage of a boil, if present; or sometimes, allow it to mature and resolve spontaneously.  Some data support that antibiotics have a limited role after an incision and drainage of a small <2cm abscess.  Though with larger abscesses, there has been found a lower failure rate than with a proper incision and drainage.  Antibiotic consideration include trimethroprim-sulfamethoxazole (bactrim), doxycycline and possibly clindamycin (some resistant isolates). 

2) Address the colonization state – Again, the usual colonization site is the nose and skin and  can be addressed after the infection is treated.  For decolonization, I prescribe a surgical cleanser, such as Hibiclens, which can be applied 2 to 3 times weekly – lather on the skin and rinse off.  For the nasal carriage, an antibiotic ointment such as bactroban (nasal bactroban) can be used – apply a cotton swab with the ointment in each naris twice daily for 1 week.  I usually begin this protocol 2 weeks after the acute infection is treated.

3) Address the risk factor – For a state of colonization to transform to a state of infection, there is often a risk factor that can be identified.  Some are more obvious than others.  Occasionally, upon examining a patient, I can tell the risk factor.  For instance, some men (swimmers, other athletes) are shavers; some women shave closer to the groin or mons pubis.  Using a dull razor, not using a cream or moisturizer to shave, or not treating the razor with alcohol prior to use can lead to a break in the skin and allow the bacteria to cause an infection.  Sometimes, a new sexual partner of a patient was colonized with Staph and increases the risk of transmission, enough to lead to folliculitis and abscesses.  On the examination, I will often observe a patient scratching themselves where they have dry skin or folliculitis and even attempt to express a lesion in front of me.  People who are chronic sitters, e.g. truck drivers, writers, bloggers (one of many reasons I have a standing desk…) are also prone to folliculitis on the buttock, which can then cause an abscess.  Below. I have listed several ways to reduce the risk of Staph aureus infection.

MRSA: Question and Answer

What is MRSA?
 
Methicillin-resistant Staphylococcus aureus.  This is a ubiquitous bacterium resides on the skin and naso-oropharynx of humans and other animals.  The ecological niche of Staphylococcus aureus is the nares (nose).  Others areas of the skin populated by this bacterium include the axillae (armpits), groin, perineal area (area between genitals and anus).  Contamination of fomites (inanimate objects such as keys, computers, phones etc) can represent a source of transmission to other people.  Although colonization generally precedes infection, outbreaks have been described where colonization was not evident.

I had a Spider bite that got infected with MRSA.  Is this possible?
 

Typically, when someone is in the process of developing an infection with Staphylococcus aureus, the area may feel a sharp pain.  Although the sensation is similar to an insect of spider bite, it is almost never the case.  Certainly, in various geographic locations, the bite of a brown recluse or hobo spider, to name a few, can result in a erythematous lesion with central necrosis (dark center). This aside, an abscess that cultures Staphylococcus aureus in the wound suggests that this alone was the likely cause of the process.

In one study by Moran er al, a report of a spider bite had an adjusted odds ratio of 3 (that means that those with this history were 3x more likely than those without to have an MRSA infection.

What are some epidemiologic associations of MRSA infection?

  1. Locations: Prisons, athlete groups/gyms, astroturf, hospitalization, military, reservations
  2. Behaviors:  Men who have sex with men (MSM), Elicit drug use (meth/heroin), shavers
  3. Conditions:  HIV, Hepatitis C, Diabetes mellitus and cirrhosis, Jobs syndrome, Paraplegia
  4. Medications:  Recent antibiotic exposure, Steroid use (prednisone) or other immunosuppressants, possible association with nonsteroidal agents (NSAIDS)
  5. Devices: Hemodialysis catheters, Peripherally inserted central catheters (PICC), foleys, PEG tubes, etc

What are risk factors for MRSA infection?

This question is one with a difficult answer.
Miller and Binh an Diep CID 2008 had a nice way of representing risk factors in three areas:
 
Risk factors of behaviors and exposures:  skin-to-fomite contact (shaving, tattoos, rug burns,etc), skin-to-skin contact, antibiotic exposure

Host defenses:  Skin integrity, Antimicrobial peptides (an area that is in its infancy but essentially looking at proteins that are secreted by our skin which neutralize bacteria,etc, medications that affect the immunity such as biologicals e.g. tnf-a antagonists (etanercept,etc), chemotherapy, steroids, etc.  Immunodeficiency states. 

Pathogen factors:  Virulence factors, strain type, etc.


How do I prevent myself from getting MRSA?
 
Approximately 10-25% of the population is colonized with Staphylococcus aureus – sensitive or MSSA, while 3% of the population is colonized with MRSA.  Suggestions for avoiding colonization are somewhat similar for those suggestions for avoiding infection:

1.  Good hand washing, regular (but not excessive) showering and laundering – increased rates of MRSA in poor hygiene practices. Wash hands after touching or picking nose.
2.  Use sharp razors for shaving (to avoid blunt trauma) but avoid cutting trauma.  Apply alcohol to the razor before/after use.  Do not share razors.  Use a moisturizer for skin after shaving.
3.  If you have dermatitis such as eczema, psoriasis or others, make sure that it is treated.  You have a higher rate of colonization with Staph…
4.  Use antibiotics judiciously – you play an important role in limited antibiotic use!
5.  If you develop a pimple, DON’T attempt to express it.  When the process is deeper, the attempt may fail and lead to more inflammation which means more abscess.  The majority of people I see that require an incision and drainage have admitted to having attempted too vigorously to express a furuncle.
6.  Use NSAIDS and Steroids judiciously.
7.  Keep your skin well lubricated with humectants, as drying can promote breaks in the skin and dermatitis/eczema.  Plan on applying skin creams after you have dried yourself from your shower/bath.
8.  Move your body around.  Sitting on your butt, kneeling, or leaning on your elbows too long promotes skin changes that can lead to breaks in the skin in these areas.  It is this reason that I see a lot of MRSA abscesses in paraplegics/quadriplegics or others that have limited motion.
9. Get plenty of quality sleep and exercise (don’t underestimate the role of these factors on the immune system)

After decolonization, there is a fairly high likelihood that a person previously colonized will become recolonized. This does not mean that you will get another abscess. With a greater awareness of cause and prevention measures, it is with hopes that Staph aureus will not cause recurrent problems.

Thanks for reading This! Dr. Cirino

Further reading (below are a few references and links):

Boeker S et. al. Methicillin-resistant Staphylococcus aureus: risk factors associated with community-onset infections in Denmark – Clinical Microbiology and Infection. 2008. Clin Micro and Infection. Danish Community-MRSA group.

Moran er al. N Engl J Med 2006; 355:666-674   (Epidemiology)
https://www.ncbi.nlm.nih.gov/pubmed/27668900

https://www.ncbi.nlm.nih.gov/pubmed/18510460


Please feel free to post any questions or comments.

Polypharmacy: Navigating Risk and Benefit in a pill-taking society

Key points: Medications are metabolized in the body to produce an intended effect along with secondary effects. With an increase of medications taken, there is an increased risk of drug to drug interactions and potentially serious harm. Multiple medications, or polypharmacy, are often seen in an older age cohort, individuals with significant mental health issues and those that have obesity-related conditions. Finding a safe level of risk and benefit often avoids harmful side effects and health risks.

The new patient visit, and subsequent visits, to a primary care physician is often an ideal time to discuss medications. As the clinician is becoming acquainted with a patient, they may begin to discuss the reasons and necessity for each medication. A patient with a chronic condition, such as diabetes or hypertension, will often already be taking 2 to 3 medications.  I start getting more concerned for harm when I see a patient on more than 4 or 5 medications. 

Not surprisingly, however, is that the proportion of patients with polypharmacy has grown with the aging society.  In one longitudinal survey of persons ages 62 to 85 published in the JAMA internal medicine, more than a third of patients were taking at least five prescriptions.  In this older cohort, chronic conditions, such as hypertension, diabetes and vascular disease were common. Their bodies metabolize medications differently, on account of an aging kidney, liver and differences in subcutaneous tissue and protein levels. It is for this reason, that the elderly population is at a higher risk for harm.

Multiple medications could increase the risk for adverse drug reactions (ADRs) and drug-to-drug interactions, some of which can have serious health implications, including increase risk of falls, decline in functional status and delirium. It is estimated that as many as 10% of emergency room visits are attributable to an ADR and a patient who is taking more than 4 medications have a near 90% risk of experiencing an ADR.  There can even be significant cost issues, as a retiree is cutting into their savings to cover the medication expenses.  This has become increasingly more costly, as insurance companies are reducing their expenses by not covering newer agents.

Reasons for polypharmacy include 1) having multiple providers, 2) taking additional over-the-counter agents which are sometimes construed as harmless, 3) a new health problem or treatment for a temporary process, e.g. antibiotics in the setting of a new infection. Often underlying polypharmacy is an unaddressed health behavior that contributes to the maintenance of a dis-ease state, e.g. ongoing smoking, alcohol use and emotional eating. (see Behavior and Health and Behavior and Eating posts)

Polypharmacy can occur when a patient sees more than one provider – maybe a cardiologist, an endocrinologist or a psychiatrist – who may not thoroughly review non-specialty-related medications. Sometimes, the specialist will use two medications for complimentary effect, e.g. treating high blood pressure. There may not be communication between providers if a medication addition or change is decided upon.  A person with a significant mental health condition is particularly at risk, because they are often placed on more than one medication.  Some of these medications, for instance anti-epileptics or medications for bipolar disorder can increase the risk of developing metabolic syndrome including diabetes. A patient with chronic pain may be treated on multiple medications, such as tramadol, cymbalta or hydrocodone which have numerous drug interactions. 

Patients may add to their prescribed medication regimen with over-the-counter agents or herbals that are otherwise thought of as harmless given that they do not require a prescription. Medications like “sleep aides” often contain diphenhydramine (benadryl) which can contribute to multiple drug interactions, confusion and urinary retention. Cimetidine (pepcid) can be associated with confusion or delirium in the elderly. A list of potentially harmful to the medications The Beer’s List is included and contains several over the counter agents. A few links are included at the end of the post.

Consequences of Polypharmacy*

  1. Increased Cost for healthcare – imagine that a retired person receiving a minimum income is asked to take a brand medication at top dollar (pharmaceutical companies will provide coupons but these will not be applicable to medicare). The average cost of these is approaching $5,800 a year. Imagine having to pay for even a portion of this on a social security income.
  2. Adverse Drug Reactions and Drug-to-Drug Interactions
  3. Problems with adherence – This is understood when someone is taking more than one medication and more than one time interval daily.
  4. Cognitive Impairment and Delirium – It doesn’t take a lot of a medication that has soporific or CNS side effects (sleep-inducing) to effect an elderly person who ends up with higher doses of drug distributed in the blood because of changes in pharmacokinetics (the way a drug is metabolized by the body)
  5. Falls – There is a greater likelihood from falling because of drowsiness or dizziness.
  6. Functional Status
  7. Urinary Incontinence – some medications can lead to urinary retention (benadryl, opiates, some dementia medications) or increased urination (diuretics).
  8. Nutritional Impact – some medications can increase risk of vitamin deficiencies, e.g. proton pump inhibitors, such as omeprazole, can lead to vitamin b12 deficiency and is linked to increased risk of osteoporosis.

*Maher et al. Clinical Consequences of Polypharmacy in Elderly. 2014. Expert Opin Drug Saf. Jan 13 (1): 10.1517.

Questions to Review when considering Polypharmacy

The following questions are useful in approaching polypharmacy for both patient and clinician alike. The paragraphs that follow will provide greater detail.

  1. Does patient need the prescribed medication?
  2. Number needed to treat? Number needed to harm?
  3. Are there any redundancies in the medications?
  4. Are there any drug-to-drug interactions?
  5. Does the medication need to be taken every day e.g. sleep medications, pain medications and is there a safer alternative?
  6. Is there an underlying behavior that is causing problem that is being medicated?
  7. Are there any preventive options?

Besides asking the obvious question, whether a patient really needs to take every medication, there is also the question of what is really the benefit of the medication. The number needed to treat (NNTT) and number needed to harm (NNTH) are useful tools to determine the benefits and risks of a medication. The higher the number is the less beneficial a medication. A detailed list is available with the link – http://www.thennt.com/home-nnt/ Unfortunately, most medications are not very effective in their intended activity and are often more likely to cause side effects. For instance, the HMG-CoA reductase inhibitors for the treatment of hypercholesterolemia (high cholesterol) which many cardiologists would joke ” we need to put them in the water” during my training are more likely to harm than to help: NNTT 1 in 104 (preventing cardiac disease) and 1 in 154 (preventing stroke) and NNTH 1 in 10 (muscle damage) and 1 in 50 (diabetes association*). And that is after taking them for 5 years!! The data doesn’t look much better after taking them for a heart attack. I would suggest that patients check their medications with the link.

During the first and subsequent office visits, it is often possible to begin whittling down the medication lists to the most effective and least harmful number of medications.  I often will have patients bring all of their medications in a bag to the clinic.  As I run through the medications, I ensure that every medication has a justifiable indication, there is no obvious redundancy and include the prescriber and specialty, and the dose. I then run a check of drug-to-drug interactions on Epocrates (which has an online format as well).  If there are any redundant medications or those with no clear indication, e.g. the use of a “statin” in an advanced elderly patient, I will collect the medications and dispose of them or discuss with the patient regarding titration off or to a lower dose. Most patients are relieved (and a little surprised!) with these reductions and sometimes report an improvement in their health, as significant and subtle medication side effects dissipate after the medication is stopped.     

“Doctor, can I get a dose of #### for a yeast infection…”
It is also important that a physician review medications prior to considering a new prescription.  The addition of antibiotics to a patient medication list, although usually for a short course, has implications as well.  From what a seemingly innocuous course of an antibiotic could arise multiple drug-to-drug interactions and ADRs.  For example, many patients will request fluconazole because the topical creams can be inconveniencing and have mixed results.  The treatment is usually a one-time tablet of 150mg.  There are more than 600 reported drug-to-drug interactions with fluconazole, one-fifth of which can be severe or life threatening (though rare).  The metabolism of fluconazole in the liver may impact that of other medications used in chronic diseases, such as statins or cardiac medications, increasing levels of metabolites of these medications in the bloodstream.  Patients who take hydrocodone or oxycodone may have an increase in levels of metabolite in their system after taking fluconazole, increasing risk of harm. The anticoagulant Coumadin levels increase when fluconazole is taken, which increases the risk of bleeding.  When fluconazole is simultaneously prescribed with another cardiac medication amiodarone, there is an increased risk of Q-T prolongation, which is capable of increasing the risk of the life-threatening condition ventricular fibrillation.  Although a few doses of fluconazole is not as likely to cause problems, the risk requires a consideration of whether this medication is safe or an alternate regimen or route (e.g. topical) should be considered. 

Sometimes a medication doesn’t need to be taken on a regular basis and can be taken only as needed. I have had many patients who request taking Ambien (zolpidem) or other agents (e.g. oxycodone, hydrocodone, tizanidine, alprazolam, etc) on a daily basis for sleep or arthritic pain or anxiety issues. As disabling these conditions can be, these are conditions that should not be just blindly treated. It is generally more pro-active to regard these conditions as requiring investigation and therapeutic and lifestyle considerations. For instance, a sleep study may uncover restless leg syndrome or significant sleep apnea. A thorough history and physical may uncover a behavior that is leading to increased neck pain, a condition in which physical and occupational therapy would be more useful. A referral to a counselor can help a person develop better coping skills. Unfortunately, by the time a patient comes to see a new physician, they are often already on the medication every day and have developed a dependence on that medication. A physician’s well-meaning attempts at reducing the medications will be met with resistance and some patients may take their business elsewhere. On the other hand, by taking medications intermittently and only with severe symptoms, dependence and significant side effects can be avoided.

It is not unusual for me to see a patient who is taking a statin medication for known heart disease e.g. they suffered a heart attack, and is still smoking. On one side, I might as well tell them to stop taking the statin, because the smoking trumps any medication. That is often the case with behavior. Why piddle around with medications when someone is still doing a harmful behavior? Well – one obvious answer – BEHAVIOR CHANGE IS NOT EASY! and certainly ADDRESSING BEHAVIOR CHANGE IN THE CLINIC is almost USELESS. That is my objective with Your Health Forum – take behavior change out of the clinic and partner physician with the patient! It is incredible how much more effective a successful behavior change, such as quitting smoking and eating natural food rather than processed food, can have on one’s health.

A weight loss of 15 lbs can lead to a reduction of 8.5 and 6.5 mm Hg in the systolic and diastolic blood pressure readings. Theses changes do not occur in a vacuum. System obesity is a systemic resistance problem, the body gradually functions better with ongoing weight loss — less obstructive sleep apnea, less fluid retention, less blood pressure, less insulin resistance, less triglycerides, less uric acid (gout), less knee and ankle pain, and the list goes on. As pointed out in prior posts, the behavior is not “weight loss” – the behavior is healthy eating and breaking the emotional eating cycle.

This goes to the final question of preventive options. A medication comes with risks and benefits. As pointed out earlier, the benefits are limited and there can sometimes be significant side effects. Risk for harm from side effects and drug-to-drug interactions increases with more medications. Behavior change is like a magic bullet to medical conditions that are linked to the behavior. After all, what is more effective than removing the condition?

I have found that, unless a patient is running a high risk of harm — a VERY HIGH blood pressure — coaching them on behavior change may be more useful than prescribing a medication — though a collaborative approach with frequent check-backs is likely to be more effective than a single visit.

My recommendation for anyone that is on multiple medications is to brainstorm on strategies to promote a change in the behavior, to work directly with the physician to weigh the risks and benefits of a medication (check indication, check NNTT/NNTH, run through Beer’s list and look for safer alternatives), ensure that your physician is doing a cross-check on a new or short-term medication and collaborate with your physician on taking a smaller “test-dose” for several days to acquaint yourself with the side effects of the medication.

Thanks for reading and hope you found it useful! Dr. Christopher Cirino

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