Pattern Thinking and Bias in Medical Diagnosis

Medical decision-making and bias

Key Points: Bias infiltrates every step of a clinician’s approach to diagnosis and treatment. A sensitivity to this bias can lead to a greater ability to consider other possibilities to affect decision-making and move toward determining the cause. Doctor-patient collaboration builds a bridge to understanding and reducing the affects of bias on managing health.

BW Pattern

Case I: A 64 yo male is seen in the emergency room for lower abdominal pain. He stated that he noticed when he woke up to get out of bed. The ER physician raised the concern of possible diverticulitis and orders a computed tomography (CT) study. He receives antibiotics for diverticulitis after a “soft call” on CT after the suspicion was conveyed from the doctor to the radiologist beforehand. The radiologist subsequently dictates “there is the possibility of early diverticulitis”.  On a follow-up clinic visit, after a thorough history and physical, a groin pull was confirmed on the exam and the antibiotics are stopped. 

Case II: A 50 year female who is morbidly obese is seen by her primary physician. She mentions that she had woken up and noticed her lower leg was reddened. She remembers possibly bumping it while walking around her bed. She denied any fevers or chills. He notes that her leg is swollen, warm and red. The doctor orders a white blood cell count, which is found to be 12,000 (normal <10,000). She was referred to the ER for possible cellulitis. She is admitted to the hospital and started on intravenous antibiotics, with a gradual improvement of her leg coloring and swelling. She is discharged with oral antibiotics for 1 week. She returns to the clinic after this, stating that the redness returned, and he readmits her to the hospital. She is then given a central line and arranged to received IV antibiotics for several weeks with a different antibiotic. He refers her to the infectious diseases physician. In the office, I examine her leg. She never had any fever or chills at onset and both legs demonstrate swelling , with the side of concern with redness and warmth. I remove her line in the office and discontinue the antibiotics. She was found to have post-traumatic lymphedema.

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A patient comes to the doctor for advice and consultation to better understand the “why” behind his/her disease. Someone may have a general idea of what is going on and would like confirmation or they suspect one cause but it doesn’t completely fit what they read online. They may have googled their symptoms and “the C word” (cancer) came up among the 200 possible causes. Unfortunately, finding answers in the clinic can be more complicated than it may seem.

Determining the cause of a process relies on knowledge base, experience, clinical acumen, medical decision-making and a healthy dose of curiosity and self-doubt. A physician spends approximately seven to ten years mastering the practice of medicine through medical school and residency training.  During this time, s/he makes the transition from a passive role as student learner to an active clinician.  Much of the training is familiarizing oneself with the common presentations of common illnesses.  Physicians are taught early that “when you hear the sound of hoofs, think horses not zebras”.  Given the volume of patients, physicians in training will often see several uncommon presentations of common conditions. Perhaps a few times a month at larger teaching hospitals during the average training of three times, they may even see a common presentation of an uncommon illness, such as malaria or dengue fever. Infrequently during the span of a physician’s career, s/he may encounter an uncommon presentation of an uncommon illness, sometimes without even realizing it. They may still be trying to fit a square peg in a round hole.

Types of Presentation in the Diagnostic spectrum

Type I: Common presentation of common illnesses: Typical cold, pneumonia, heart failure

Type II: Uncommon presentation of common illnesses: MRSA abscess presenting like cellulitis, influenza myocarditis, pneumonia with empyema. C. difficile colitis with toxic megacolon rather than diarrhea.

Type III: Common presentation of uncommon illnesses: Malaria, dengue fever and any other tropical illness presenting like the textbook description

Type IV: Uncommon presentation of uncommon illnesses:   Miller-Fisher variant of Guillain-Barre syndrome, cerebral malaria, Fitz-Hugh-Curtis syndrome from Chlamydia. See National Organization for Rare disorders (NORD).  

Factors affecting diagnostic accuracy

  1. Location of training and practice. Illnesses sometimes have a geographic distribution. One practice location may see more cases of Lyme disease, that there is greater influence on this disease earlier. Malaria, a disease of the tropics, is always the first consideration in a returned traveler with fever. Though the majority of physicians in smaller towns or cities in the US haven’t seen a case. Travel to the malaria belt in sub-Saharan Africa and most physicians haven’t seen many patients with diabetes.
  2. Scope of practice. In the field of medicine, there are many specialties which are divided by systems. A specialist is trained additional years (2-5) in one specific field, such as a nephrology (kidney), infectious diseases, cardiology (heart) or pulmonology (lung) and rheumatology (joint and inflammation). Although this focused training allows for more cases in one discipline, there is still overlap with conditions that are presenting as one problem but are another, such as a rheumatologic problem – lupus – presenting with fever.
  3. Experience base.  A physician who has seen and managed many cases of one particular diagnosis is often more able to accurately diagnose, understand nuances of the condition and appropriately treat a person. This could also be subjected to bias, when overly relies on this to make a decision that may need to be adjusted for a particular case.
  4. Knowledge base. This may allow a physician to generate a more expansive differential diagnosis – a listing of potential causes that are ruled in or out on the basis of the history, physical examination, laboratory and diagnostic information. Nevertheless, experience helps to apply a weight to specific possibility over a range.
  5. Diagnostic Tools available. Having additional tools, such as ultrasound, radiographs, CT and MRI as well as laboratory tests can undoubtedly enhance diagnostic accuracy. They still need to be assimilated by an experienced physician, to weigh likelihoods. This goes back to the example of the patient with a CT showing “early diverticulitis”.

Some degree of medical decision-making is based on one’s previous experience of a condition and one’s ability to detect patterns that are consistent with that condition.  A physician generates a differential diagnosis e.g. a patient presenting with “shortness of breath” can have pulmonary embolism, acute congestive heart failure, acute renal failure, pneumonia.  A clinician then must rank order the possibilities based on the elements of the history and physical examination and work toward a plan, including further tests and treatments, e.g. order a chest radiograph, order a 2-D echo to evaluate the heart valves, etc. 

 As a physician sifts through a barrage of data from patient encounters and lab and imaging studies, s/he must weigh the impact of bias in medical decision making.  Even ordering a test can affect medical decision-making and lead to further tests that may not have been necessary. Although the experience base of a physician provides a foundation in which to consider multiple diagnoses while evaluating a patient, some habits develop that can alter perception of importance and lead a physician down the wrong path. For instance, a physician’s misattribution of a process as infectious (Case 2) had implications on the treatment chosen, such as antibiotic use and duration.

A few common forms of bias include 1) anchoring bias and 2) diagnosis momentum, 3) confirmation bias and 4) omission and 5) commission.  These biases can originate from physicians and patients alike and can occur simultaneously. 

  1. Anchoring bias relates to settling on a diagnosis from early on and following through with treatment toward this potential diagnosis.  A physician may reflexively base his/her diagnosis and decision making too strongly ruling out the worst-case scenarios, even though even as further tests come in that contradict the original fear.  For example, a patient who is complaining to a physician about shortness of breath is sent for a CT angiogram, a CT that requires a dye load to evaluate for pulmonary embolism, or blood clots to the lungs, even after history and testing (e.g. negative D-dimer) do not clearly suggest it. 
  2. Diagnosis momentum can occur after a patient receives a diagnosis, such as cellulitis as described above, without questioning further the original diagnosis. 
  3. Confirmation bias occurs when a physician looks for symptoms and signs that confirm his/her original suspicion, rather than for things that discredit it.
  4. Omission is a lack of action or care to reduce harm, but as a disease process develops, it may cause more harm, for instance not working up further a patient with headaches, who ultimately has meningitis. 
  5. Commission is providing care toward the benefit of the patient, rather than inaction.  Occasionally, a diagnosis is not completely clear, even after review and studies, such as with the patient who was treated for diverticulitis who only had a groin pull or the patent with “cellulitis” coming in from the clinic – with the continued diagnosis.

A physician must consider multiple potential diagnoses while evaluating a patient.  Even the fact-finding task of taking a history can be marred by the patient’s confirmation bias. For instance, a patient coming in stating, “doctor, I have this urinary tract infection,“ without considering other causes.  A patient may consider more uncommon diagnoses and read about chronic Lyme disease and believe that they have this condition, even with a negative Lyme titer and western blot.  The office visit may not be long enough to consider other possibilities or obtain a more detailed history.  The patient may not recall some aspects of the history or recall it a different way based on his/her concerns or pre-reading of the possibility, inviting another bias, recall bias

Ways to Avoid Bias Traps

There are several ways a patient and clinician can avoid the pathway of bias and possibly missing a diagnosis or making an incorrect diagnosis. Below are some suggestions:

For clinicians:

  1. Start with the history and physical and end with the history and physical. The median time it take a physician to interrupt a patient explaining his/her symptoms is 11 seconds. Start by actively listening to the patient without interrupting for several minutes. ACTIVE listening implies eye contact, nodding, verbal confirmation, summarizing back and NOT by cell-phone checks, eyes fixed on the keyboard and cutting the patient off. There will be a time when the patient starts to circle back or become tangential. If there is anything that isn’t clear, go back to the patient and ask more questions. Sometimes their concerns may drive the words they choose to describe the symptoms. If you sense that this is biasing them, ask the patient what they think they have or fear they may have? Oh – and don’t forget to do a proper physical examination. As a patient, I have had to remind the doctor, “aren’t you going to examine me?” A proper physical examination can be very telling. We sometimes joke about the “internists physical examination” being a full body CT scan.
  2. Try to at least think of 2 or 3 other possibilities. Avoid quick decisions that try to explain the problem backwards. Let the symptoms guide the differential, not the other way around.
  3. Order baseline blood tests only when needed and let the severity of the condition dictate the timing of further testing. There is nothing wrong with appropriate watchful waiting. I always like to think that the best exam is one that includes a follow-up visit.
  4. Collaborative care in consults or curbsides is reasonable to get a second opinion and avoid biased conclusions. Though, when a doctor discusses a case with his/her peers, there is an inherent bias in what is relayed to the other as germane. Most of the time, it is better to have a formal consult.
  5. Always be one’s own skeptic, look for bias traps and keep the dialogue open to the patient if a diagnosis is not clear. The patient may help the physician in providing additional information or concerns. Being direct with the patient about the level of uncertainty allows the patient to partner with the physician and usually improves rapport. We are all humans and to err is human – start with doing no harm and then collaborate to explore possible answers.

For patients:

  1. Write the line sequence of the events when they occurred before the visit. This is usually more helpful than just providing a list of signs and symptoms in no particular order. This can help state the concerns more clearly.
  2. Prepare a list of concerns and questions for the visit in advance. I usually recommend 1-2 concerns and 1-2 additional questions for a 20 minute visit. Some things can be saved for a routine follow-up or full physical examination.
  3. Avoid using a diagnosis in your description of the symptoms. Instead of “Doctor, I have a UTI.”, try “doctor it hurts when I urinate and I have increase need and frequency to urinate.
  4. Discuss you concerns with the clinician after you have stated the symptoms and he/she has examined you. The clinician may weigh the concerns and discuss likelihood and a plan of addressing the condition.
  5. Go through plan with physician and contigencies.
  6. Schedule a follow-up visit in 1-2 months that same day to ensure that the problem can be readdressed. This keeps the issue at the forefront and ensures that things get addressed promptly and not put aside. I once saw a patient who had anemia and I wanted to see him back – I gave him a referral to the GI doctor. Unfortunately, he never followed through — he came back 2 years later to see me with severe anemia, apologized for not following back. I examined him that day and sent him to the hospital after a found a mass on rectal exam. I sent him to the hospital he was diagnosed with colorectal cancer.

“Oh, and by the way, doctor”

I am always particularly attentive – or perhaps biased – when a patient brings up a concern the moment that you are saying goodbye. Maybe it is a last chance brainstorm for them to bring up something. Maybe it is after opening up with the physician during the visit, that they can confide in him/her what they are about to say. Maybe it is something that they were keeping an eye on for a while and didn’t think much of it and wanted the doctor’s opinion.

Whatever the reason, it is often prefaced, “Oh, by the way…”  I recall one patient who brought up the “Oh, by the way, what is this lump on my chest, doctor?”  I had my hand on the doorknob when he stated this.  I turned around, agreeing that this didn’t have to wait until the next visit.  His chest exam revealed a lump the size and density of an acorn – a worrisome finding that prompted a referral to the surgeon and turned out to be breast cancer.

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Fractals, the Golden Ratio and Your Health (part I)

Key points: An eye on nature tells us a lot about how things grow and adapt through various pressures. Models such as the golden ratio and fractals illustrate the splendor of growth and life. What happens to these systems when they are perturbed? How does this relate to our bodies when a state of dis-ease arises from what was once optimal?

As a college student, I had the opportunity to take one of the most influential courses in my education: Fractals and Geology. I grew to appreciate how natural phenomenon can be understood and analyzed and how disruption in growth changes the usual signature.

The Golden Ratio, a mathematical interpretation of a natural observation, possibly had its beginnings with Phidias in 500 BC – 432 BC , a Greek sculptor and mathematician, who applied it in plans that led to the building of the Parthenon. The structure correlates well with the Fibonacci spiral.
The mathematical equation to this follows a pattern of 1,1,3,5,8,13,21,34,55 etc. There are many things in nature, I dare say almost everything in nature, that exhibit this pattern, from pineapple structure, sunflowers, pine cones to the nautilus shell and even to the structure of our face and body. It may explain why our appendages have 5 digits.

Fibonacci equation: Fₙ=Fₙ₋₁+Fₙ₋₂, for n > 1

Fractals, in a nutshell, are iterative figures that display self-similarity. These can be created using mathematical equations and most notable of these images is one from the scientist who coined the term fractal – the Mandelbrot set. Once computers were powered enough to handle this equation, they became popular visuals during the late eighties and nineties.

Fractals are on one side finite structures nearing the Euclidean geometric dimensions (e.g. 1 dimension = line, 2 dimensions = square, 3 dimension = cube) but, on the other side, because of the iterations, they are more detailed than our strict understanding of dimensions – they are somewhere in between dimensions. An example would be the scaling effect when trying to measure a coastline. At first glimpse what is linear and finite as measured by a large measuring tool becomes rugged and much longer when you change the tool to an ever increasingly smaller size.

In many ways, the golden ratio and fractals overlap to enhance our understanding of natural patterns. This is in contradistinction to human-engineered structures, in which Euclidean geometry applies.

Mandelbrot equation: F(c) = Z squared + C.

It was in the fractal class, that I became intimately aware of how fractals occur in nature, a new view on things that I sometimes had taken for granted. My project was to measure the fractal dimension of various leaf tracings. The next time you see a leaf on the ground, take a look at how detailed the patterns are. Take notice of the fact that there is a large vein which branches to smaller veins and then smaller veins.

Natural fractals, unlike computational fractals, do not go on ad infinitum. We see similar types of structures when we look at our vascular, pulmonary, lymphatic, neurologic systems and kidney, brain and organ structures.

These structures are not found this way by accident. A number of factors potentially contribute to this growth of these structures in nature and in our bodies. Examples include the specific function of the organ system, the effects of gravity and pressure on the growth, the effect of temperature, the nutritional status and source of the growing structure.

When you look at our lungs, these seemingly simple closed structures are branches upon branches of tubes, arteries, veins and lymphatics – to the cellular level. The main tube, the trachea, branches off into the right and left mainstem bronchi which branch off into multiple bronchioles and then successively smaller bronchioles until we reach the alveoli. The same iterations occur with the venous, arterial and lymphatic systems As the branches become smaller, there is a transition from a structural (moving things in and out) to a functional process (gas exchange and movement of blood). The alveoli are principally where gas exchange occurs from the air sacs to the intricate vessels where the arterial and venous systems meet — from the pulmonary arteries to the air sacs (carbon dioxide rich blood allow carbon dioxide to escape) from the pulmonary veins (oxygen binds to hemoglobin in the blood cells) and returns to the left side of the heart.

The same process is occurring throughout our body to allow proper oxygenation of tissue (our vascular system), detoxification of our blood (liver and kidneys), drainage of fluid outside of our blood acquired in injury and infection, etc (lymphatic system) and sensation and movement (nervous system). The systems grow using energy obtained and grow to maintain energy efficiency.

Now, put these processes in disarray. If there is a damage to the structure, such as with the lungs from smoking, how does the function change. If there are changes in the pressure around the structure, for instance that which would occur in becoming obese, how does the body accommodate for these changes. If there is a change in what nutrition enters the body, how does the body alter its function and structure. How do these changes affect our bodies ability to optimally function in homeostasis?

To be continued

Wellness and Infection Prevention: 10 Tips to Steer Clear of Infections

Checklist for Infection Prevention this Year

We all look for ways in which we can stay healthy and avoid illness. Not only can illnesses be inconveniencing and annoying, but also they can be serious and life-threatening. Below are 10 considerations for anyone that would like to stay infection-free this year (in no particular order):

1. Get vaccinated.

Vaccinations are an excellent protection from infection, though some better than others. In the pre-antibiotic era, the hope of eradicating illness was on vaccine discovery. It is still important as ever. Viral illnesses for which we have vaccinations, such as polio and measles, are still breaking out in various undervaccinated areas.

They are an attempt to equip the immune system with active soldiers ready for battle, by putting an “unequipped virus” or “weapon knowledge” into the body to allow it to form antibodies against them. With the most likely side effect being a sore arm for a few days, it seems like a pretty good trade-off. Generally, a viral vaccine may be 1) live,attenuated (weakened), or 2) killed or component vaccines; Bacterial vaccinations are usually wall or toxin components and are formulated as polysaccharide (sugar) or conjugate (mixture).

Live vaccinations generally induce a more robust immune response. Some examples of live vaccinations include measles,mumps and rubella (MMR), oral polio vaccine (not routinely used in the US currently), Varicella, live influenza vaccine, yellow fever vaccine and oral typhoid (Salmonella typhi) vaccination. Killed or component vaccinations include injectable polio vaccine (IPV), tetanus, diphtheria and pertussis toxoid (Tdap), pneumococcal vaccine (Pneumovac), and quadrivalent meningitis (A,C,Y, W-135), influenza trivalent vaccine.

Anytime there have been disruptions in vaccine administration, ie a misconception that vaccinations are linked to autism (Wakefield debacle) {As an aside, the rate of a severe reaction to MMR vaccine is 1 to 100,000 – including encephalitis in a smaller fraction compared to severe complication or death to wild type measles 1 to 1,000}, religious or other beliefs,etc, there have been clusters of illnesses that would not regularly be seen with vaccination; thus, non-vaccination may cripple “herd immunity” and increase the emergence of an infection. Measles (rubeola) continues to erupt in areas of low vaccine penetration, sometimes imported from higher prevalent countries with less rigorus vaccine systems in place. For instance, Ukraine saw more than 30,000 cases of confirmed measles in 2018. The country has a. estimated vaccination coverage of 46%

As of February 3rd, in Clark county WA there have been 47 confirmed cases and 7 suspected cases of measles, the majority in those unvaccinated (41/47).

Vaccinations are a great option for patients to avoid becoming ill. Get vaccinated! Keep your children on a vaccine schedule ideally without slowing it down.

2. Get plenty of sleep

Sleep deprivation can lead to impairment of immune activation, both natural immunity (NK cell population) and T cell function. Pro-inflammatory cytokines IL-6 and TNF-alpha Receptor 1 were increased after four days of sleep deprivation. There is likely impaired activation of the immune system and inflammation after periods of decreased sleep.

Sleep disorders such as sleep apnea or primary insomnia can decrease efficiency of sleep and lead to health risks. It is important to discuss with your doctor if you have frequent sleeping problems, whether it is getting to sleep or staying asleep. Other signs can include decreased restful sleep, feeling tired early in the day, “caffeinating” possibly more than 2-3 cups reaching for alcohol or sleeping pills at night. Other signs include lower extremity swelling, frequent nighttime urination, dry mouth in the night, night sweats and morning headaches.

3. Avoid or limit medications that can affect the immune system.

A lot of previous prescription medications are now available over the counter. Medications can have direct or indirect effects on the immune system. Medications such as prednisone, cellcept (mycophenolate), imuran (azathioprine) can have a direct effect on the immune system usually by impairing both B-cell (think antibodies) and T-cell (think killer T-cells) function.

Newer medications, known as monoclonal antibodies are directed toward T cell receptor (CD-3) and IL-2a and are associated with some immunodeficiency. There may be an increased risk of activating TB in someone who has latent TB infection as well as Staph aureus infections possibly and other fungal infections.

Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, diclofenac, etc; may lead to an increased risk of infection, such as skin and soft tissue infections – the jury is still out. Careful consideration to the risks and benefits should be discussed in using all of the above medications. On a personal experience note, I have seen much more severe skin and soft tissue infections in patients that take high doses of nonsteroidals.

Antibiotics used for long periods of time or for inappropriate diagnoses can lead to an increased risk of infections, including Clostridium difficile diarrhea, increased carriage of Methicillin-resistant Staphylococcal aureus (MRSA), and increased risk of skin and vaginal fungal infections.

4. Social distance from anyone that may be ill.

This is probably the most challenging thing of which to remain aware. It is not always clear if a contact is ill. He or she may not be aware of this in the prepatent period, the time before a patient becomes clinically aware of an illness, yet is able to spread the illness. Children have a hard time with this, and usually the whole family gets the virus after a child comes down with the illness.

It is a good practice to not shake someone’s hand if they have coughed or sneezed or picked their nose with it. But one doesn’t always know… Can I get a fist bump instead? Since it is kind of cool now to do that, the other person will never know. Maybe you can still wipe your hands with that keychain alcohol hand sanitizer – carry alcohol or wash your hands after shaking hands and before eating.

5. Keep physically active and Keep levels of Stress Low

Regular exercises strengthens the body and provide richly oxygenated blood to the body. Regular physical activity leads to a reduction of stress reaction and enhances sleep. Rapid increases in Natural Killer (NK) cells were found after exercise secondary to norepinephrine release.

Stress hormones, such as cortisol, are released in a fight or flight perceived or real situation or with sleep deprivation. These hormones can lead to T-cell dysfunction and leukocyte adhesions molecules which allow T-cell to traffic to sites of infection. Exercise and meditation will likely reduce one’s reaction to stress and lead to decreased cortisol secretions.

6. No smoking and marijuana and limit excessive alcohol intake

If you are a smoker, NOW is the best time to quit. A smoker has a three-fold higher risk of bacterial pneumonia than a non-smoker. Tobacco paralyzes respiratory cilia (tiny hairs) movement, limiting the body’s natural ability to clear bacteria and other particles away from the lower respiratory tract.

Excessive alcohol intake may lead to an increased aspiration risk. Alcohol in excess can also impair the bone marrow, leading generally to a macrocytic anemia with a low platelet count and low white blood count.

7. Good dental hygiene. See a dentist twice yearly.

Good dental hygiene is an important defense from infection. The mouth harbors billions of bacteria. In the setting of poor hygiene, the barrier of the gingiva is altered, increasing the likelihood of bacteremia. Serious infections, including a heart valve infection (endocarditis) can result from a breach in this barrier. Regular brushing and flossing cleans the teeth of any residual foods that can cause fermenting Strep bacteria to produce acid that leads to dental caries and gingivitis.

8. Healthy skin keeps the primary defense strong. Keep the skin moisturized so that there is risk for skin abrasions, cuts or fissures of the skin, such as in dry skin. Be careful with the razor, ensuring razor is not dull, it is treated with rubbing alcohol, shaving cream is used and the skin is moisturized after. Any traumatized area should be protected and avoid unroofing any scabs. I routinely see patients with recurrent Staphylococcus aureus infections and they ask me how to reduce this. Most of them happen to be body shavers – men and women!

9. Yearly physical evaluation and medical visits and screening studies as needed.

Even with the availability of medical information on the internet, there is still substantial knowledge asymmetry. Therefore, a patient relies on the expertise of a trained clinician. I use the analogy of “taking your car in for service”. It is often the case that a person is not able to fully determine the root cause of a problem on account of the subjectivity of their interaction with the symptoms and signs and limited medical knowledge base. A clinician can process the information and approach it more objectively. A clinician can approach your health with a thorough history, physical examination and screening tests that may uncover medical conditions that would increase the risk of infections, e.g. diabetes mellitus, thyroid disease, hepatitis C, HIV,etc. Another example of the value of a medical visit is to mitigate a risk that would predispose to an infection (e.g. treating asthma) or treat an infection before it worsens.

Thus, a good way to ensure that you stay clear of infectious diseases would be to have medical visits. In someone who is healthy, probably a yearly visit is a good place to start.

10. Keep a healthy weight and a nutritious diet.

An optimally functioning body will be able to neutralize an infectious particle and reduce the severity of disease process. As one becomes more overweight, the body is already taxed by its attempt to compensate. This impacts the way the immune system functions as well. There was an association with high Body mass index results (BMI>35) and increase need for being hospitalized in the ICU or even death during the swine flu outbreak in 2010. Reasons are multiple: 1) Sleep deprivation from obstructive sleep apnea lead to cortisol hypersecretion; 2) chronic hypoventilation of the lungs increases the risk of pneumonia: 3) aspiration of gastroesophageal reflux leads to an increased risk of pneumonia. 4) Long-term obesity can lead to liver and spleen disease, which impairs the immune system substantially.

smallpox art

In summary, protection from infectious diseases does not always require a non-rebreather mask or a biohazard suit. Practicing a common sense approach to keeping healthy is often all that is needed.

Guidelines for Antibiotic Decision-making

Key points: Antibiotics serve as a potent therapy that enable clinicians to protect patients from infections (surgical prophylaxis, use in cancer chemotherapy) and contribute to life-saving measures for patients who are ill with an infection. The following measures provide a framework for decision-making related to antibiotic selection and duration.

Alexander Fleming at his lab

The first report of penicillin use on Anne Miller on March 14, 1942 (HIPAA waived) for “blood poisoning” left an indelible impression on the practice of medicine. With an otherwise untreated infection after a miscarriage the month before, she was given an injection of teaspoon equivalent dose of penicillin every 4 hours. After 24 hours, her fever had abated and after one approximately one month of therapy, she was cured. She was able to live a full life to the age of 90 and died in 1999. (Eric Lax, The Mold in Dr. Florey’s Coat).

Unfortunately not long after penicillin’s mainstream use did reports of bacterial resistance come. It followed a common theme observed in nature before the discovery of antibiotics and thereafter – an antibiotic selection pressure leads to the growth of resistant bacteria. Are we approaching a post-antibiotic era, where patients will succumb to infections, or can a more judicious use of antibiotics delay further resistance?

Example of testing for resistance — the discs are antibiotic-impregnated. A solution of bacteria is smeared onto the entire plate. Where there is clearance, this is a sign of no growth of bacteria. When there is growth adjacent to the disk, this would mean resistance.

Below are six general guidelines that every patient should know:

  1. Antibiotics are best used in patients with infection.

This seemingly obvious statement is not always so in medicine. Sometimes a patient isn’t able to sense the source or reason for an infection, because of the nature of the infection or problems with their immune system. An examining physician may not have enough findings or clues to discern between an infection versus another condition. Initially, if a patient is showing signs of instability, even if it remains unclear after evaluation, a “shoot first, ask questions later” approach is necessary and possibly life-saving. Both infectious and non-infectious processes can sometimes present with instability. It is incumbent on the physician to advance the workup, looking for potential sources of infection, weighing in and out likelihoods and risks and narrowing in on the diagnosis. Other times, when a patient is clinically stable, a work-up toward a cause with a “watch and wait” approach is reasonable. If a patient is not found to have any obvious infection, a patient may be observed off of antibiotics while advancing toward a more definite answer. Blindly administering antibiotics without recognizing the source or differential diagnosis is fraught with dilemma and subjects a person to potentially stopping a work-up for causes or unnecessary exposure to antibiotics. An abating fever may just be coincidental to starting antibiotics, such as with a viral infection.

2. For most infections, antibiotics just buy time.

In most infections, the antibiotics can help reduce pathogen burden until the host immune system can overtake and neutralize the infection. It is not unusual that supportive measures alone can improve a patient, even if the firstline antibiotic given is insufficient. For example, a patient presents with a kidney infection (pyelonephritis), a more serious ascending urinary tract infection, and is found to have a positive blood and urine culture for a multi-drug resistant E. coli which was resistant to the original antibiotic administered intravenously in the emergency department and the prescription. She was feeling better after they hydrated her and two days later, she is called to come back to ER to discuss results and possibly admit her for intravenous antibiotics. She is feeling better and there is an oral antibiotic option. Clearly, the infection had improved regardless of the antibiotics. Often for more severe infections, the initial days of the antibiotic are the most important, after which time healing and reduction of inflammation occurs and the body strengthens its immune response. The art of treating infectious diseases is to determine the “sweet spot” of treatment, the point where the infection is treated and not able to relapse.

3. Antibiotic treatments are best used for short periods of time in appropriate doses.

Most antibiotic durations are not evidence-based and are consensus-driven, meaning guided by a panel of experts. The optimal duration of antibiotics has become an area of increasing research given increase awareness of bacterial resistance and complications of longer-courses of antibiotics. Historically, antibiotics were used until the patient improved clinically by a reduction of fever, inflammation, erythema (redness at site) or other symptoms. In the last few decades, more rigid and longer antibiotic durations have been employed, often without regards to the specifics of the individual case. Duration of therapy can vary from a few days in the setting of a urinary tract infection (UTI) to approximately four or more weeks in the setting of a heart valve or bone infection. For some infections, recent studies have compared shorter courses with longer courses and have found these to be equal, with a risk reduction of antibiotic-associated complications. However, source control* is paramount in infection control and is enough to reduce the duration of antibiotics.

Examples of durations of antibiotics:

UTI (uncomplicated): 3 days
UTI (complicated* with bloodstream): 7 days
Community acquired pneumonia: 5-7 days
Endocarditis (heart valve): 4-6 weeks
Osteomyelitis (bone infection), contiguous 5-21 days (prior 6 weeks)
Abdominal abscesses*: 5-7 days

4. Antibiotics are chemotherapy that come with risks.

The term “chemotherapy” was used originally in the early 1900s by Paul Ehrlich to refer to any chemical used to treat disease. Most people are familiar with the term in the treatment of cancer, but it was also used for antibiotics. Perhaps the term conveys more greatly its risks. Patients may develop any number of reactions from antibiotics, including immune responses to the foreign substance, toxicities associated with the chemical, as it relates to liver and kidney metabolism of the substance or its affects on the bone marrow, after effects of the medication or complications from its administration. A physician should weight risks and benefits accordingly when selecting an antibiotic, administration route and duration.

5. Antibiotic use can shift bacterial flora of the host and environment.

This relates to the concept that “nature abhors a vacuum”. In and on the patient, there is increased colonization with resistant bacteria (e.g. MRSA or C. diff) or yeast after exposure to antibiotics. I have noted this particularly with quinolones and cephalosporins. The antibiotics can become a risk factor for future infections, for example Clostridium difficile diarrhea which can become a severe, life threatening colitis in some. On a micro-scale, patients that are exposed to antibiotics develop more resistant bacteria from an antibiotic selection pressure. On a population and epidemiologic scale, antibiotics used haphazardly in nature (for example to promote better livestock growth – a whopping 70% of total antibiotic use in the U.S.) or prescribed in clinics can lead to the development of resistant bacteria. Diseases such as tuberculosis, which is believed to infect about a third of the world’s population (mostly latent TB infection), are emerging with extensive drug resistance (XDR-TB).

6. Antibiotics used judiciously produce immediate and long-term benefits.

Simply shifting from a 14 day course of treatment for pneumonia to a 5-7 day course leads to similar outcomes but can reduce bacterial resistance rates in a hospital and risks of antibiotic-related complications, such as an adverse reaction, C. difficile and gut microbiome disruption. On a larger scale, with less antibiotic selection pressure, bacteria often shift to more favorably growing wild-type forms.

Please Share this information. Thanks from Your Health Forum. Dr. Cirino

8 Questions and Answers for the Measles Outbreak NW

Update 2/28/2019: As of today, there have been 65 confirmed and 4 suspected cases of measles in Clark county , Washington; 57 of the cases were in those unvaccinated; 6 cases with unverified vaccine status. The majority (47) of cases were in children 11 and under. There was 1 confirmed case of measles in King county. In Multnomah county, there have been 4 confirmed cases of measles and 1 suspect.

Update 2/12/2019:  As of today, there have been a total of 53 confirmed cases of measles in Clark County, Washington.  The majority of cases have been found in unvaccinated (47/53) and in children within the ages of 1 and 10 (38/53).  With no new cases reported in the last few days, there are hopes that the current outbreak may be dissipating.  Nevertheless, measles has an attack rate of 90%, so it is possible there could still be new cases in the next several days — the greatest period of infectivity is up to 4 days after the presentation of the rash.

At this point, many in Clark County Washington and adjacent Portland, Oregon are in a little bit of a scare. As of January 28th, there have been 35 confirmed cases and 11 suspected cases of measles in Clark County. In Portland, there has been 1 confirmed case of measles. This is likely going to be a moving target for the next several weeks. Measles was a disease that was essentially wiped out in the United States in the early 2000s.  Since then, there have been outbreaks yearly from imported disease and  unvaccinated children.  The same goes with this outbreak.

What is an outbreak?  An outbreak defined by WHO as the “occurrence of cases of a disease in excess of what would normally be expected in a defined community, geographical area or season.  As with measles in the United States, only one confirmed case is consistent with an outbreak.

Still in the world there are an estimated 7 million cases of measles yearly (2016 data), with the majority of deaths occurring the developing countries. Places in Europe like Romania, Ukraine and Italy saw a 300% increase in measles cases in 2017. Last year, Ukraine had an estimated >30,000 cases of measles and the Philippines saw 18,000 cases.

These cases are largely due to a breakdown in vaccination programs in these countries. Reasons include infrastructure, logistics and vaccine declination under the basis of fear of severe side effects (extremely low risk and largely fleeting), autism (debunked) and philosophical (get vaccinated). Otherwise, measles is a vaccine-preventable disease.

With such few cases of measles in the US, it is likely that many physicians haven’t actually seen a case in the clinic. A heightened awareness is necessary. This is not equivalent to panic. Regarding the outbreak that has hit the regions of the NE and the NW, I will go through 8 questions that may come to mind, now that all of this has gotten our attention and we already read something about the disease:

1.  Do I need to worry about measles  if I have been vaccinated?

No – The vaccine is 97% effective after receiving the second dose (age 4-6y), unless you are in the unlucky 3% like me (I got the measles at age 15 traveling to see family in Italy). After the first dose (age 12-15 months) of vaccine, there is likely 93% effect. If you have not been vaccinated, it is not too late. Get vaccinated.

2.   Do I need to worry about measles if my child is younger than 1? 

Yes and No – Maternal antibodies are little gifts that mothers give their infants. If a mother was vaccinated or had the disease, the infant should have a robust passive immunity for 3-6 months after birth. The severity of a measles outbreak relates to the caseload and the herd immunity (goal >90% or more immune). For now in Portland (est. 87%), only having one case is low enough to make acquiring measles still extremely unlikely. In Clark county (est 78-80%), there is a little more concern, but this is still a disease in direct contacts only and almost all of the cases are unvaccinated.

3.  How contagious is measles and does a mask help?

Very highly contagious. Yes. Measles can be transmitted on fine respiratory droplets (<5 micrometers) and are more densely packed on these than larger droplets (this is based on a study of influenza virus and masks in 2013). A person with measles becomes contagious 4 days before and 4 days after they develop the rash. Wearing a mask likely results in a three-fold reduction of transmission of virus — this means in short – that a mask over the mouth and nose is very useful. Any child that is presenting with the early findings of measles the 3 c’s– cough, conjunctivitis (red, itchy eyes) and coryza (runny nose) — should wear a mask and avoid social settings for now. Whether they actually will allow this is another thing. Contact your doctor for further instructions if you believe that someone you know may have the infection. The public health group or clinic will sometimes go as far as take a sample in the parking lot to confirm this.

4.  When does the rash appear and does everyone get it?

3-4 days after symptoms start. Yes. When you get the measles, expect to get a rash (exanthem). The rash usually starts initially inside the mouth (enanthem) as Koplik’s spots. Next, the rash starts along the trunk and neck as sparse spots (maculae) and then become confluent in a generalized red, itchy rash.

Morbilloform Rash

5.  Are there any treatments for measles?

No. There are no treatments available for measles other than a big dose of TLC (tender loving care, not THC) and a tincture of time. There have been some interesting studies performed on a similar virus model in animals – (science jargon alert) canine distemper virus (CDV). Ferrets given an oral RNA polymerase inhibitor after a lethal CDV dose (this is even a more severe disease as well in ferrets (100% lethality) at time of viremia recovered from infection. Vitamin A (historically in developing countries) and pooled serum have been used.

6. What can I do to prevent getting the measles?

Get Vaccinated. This is an easy question. The majority of cases already reported in Clark County and the child in Portland were NOT VACCINATED. I cannot locate the vaccination status of the Brooklyn and Rockland county cases but I would predict that most were unvaccinated. If you were concerned about the vaccination for your child, now would be a good time to get vaccinated. Although it would take about 2-4 weeks to confer maximal resistance, it would likely be protective against this outbreak and future ones to come. The risk of vaccination is mostly injection site related pain. It is a live, attenuated vaccination but not a risk if you have a normal immune system.  Anyone with HIV, cancer, cirrhosis or on medications that impair the immune system, should not get vaccinated.

7. Will there be more outbreaks of this vaccine-preventable disease?

Sadly, Yes. This is a serious illness. Take it from me — At 15, I was in the tourist destination of Italy, yet couldn’t move more than the steps it took to get to the bathroom and back to bed for 8 days. There are still children mostly under 5 that die of this illness every year.  In the US, the mortality rate is 1 in 1,000, the risk of encephalitis (infection swelling of the brain) is 1 in 1,000, but as many as 1 in 4 may need hospitalization.  We have a world in which one can encircle it in 18 hours or less.  As long as there are hot zones of measles in the world, any place in the US with a low herd immunity will get outbreaks.  Especially in the Northwest.

KGW8 News Report where I was featured

8.  Are there any risks from the measles vaccine (MMR)?  Can I get it now?  Why do parents decline vaccination for their children?

Yes.  Yes.  A  brief  discussion  on  human  behavior.  When it comes to vaccination, anytime is fine to receive a vaccination, if you do not have the infection, for which you are vaccinating.  The MMR vaccination is a live, attenuated vaccination and includes measles, mumps and rubella viruses.  It is usually given initially at the age of 12 through 15 months, followed by a booster at the age of 4 to 6 years.  In 1989, a second dose was recommended by the Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).  If you were in the same cohort as me who just received the initial vaccination, you would have been at risk of contracting measles – like I had. 

Regarding severe side effects of vaccination, the rate of a serious consequence from vaccination is 1 in 100,000 – which includes anaphylaxis (3.5 to 10 per million doses), seizures (mostly febrile seizures) 1 in 1,150 to 3,000 doses.  These are related to vaccine-associated fever and not long-standing seizure disorder precipitated by the vaccination.  Thrombocytopenia (low platelet counts) risk is 1 in 30,000 to 40,000 and is usually transient and benign.  Encephalopathy/encephalitis: compared to the natural risk of measles of 1 per 1,000 infected persons, the risk with vaccination has been found to be about 1 per million doses (1,000 times less than risk from measles infection).  Subacute  sclerosis  panencephalitis  (SSPE)  vaccination has reduced these cases and there has not been an association of vaccine-strain measles virus in a patient with SSPE.  Guillain-Barre  Syndrome  (GBS): has not been determined to be causally linked.  Autism  or  Inflammatory  Bowel  disease : the MMR has not been causally linked to these conditions.

The risks of developing complications from the wild-type measles virus is much higher than from vaccination with the attenuated virus.  With regards to complications, the severity of outcomes is very low with measles (1 per 1,000) less than 0.1%.  Statistically this is SIGNIFICANTLY HIGHER (by a hundredfold) than the risk of complications with the measles vaccination, our minds generally go toward the RARE SEVERE EVENTS.  This is the way we as humans are wired – all of us. 

There will be those who have declined and will continue to decline vaccination for their children, even in the setting of a measles outbreak.  Although concern for vaccination complications is present, other reasons of opposing vaccination in these groups include autonomy (opposing regulation), distrust (holding back information, more focus on group over individual) and deferring to natural immunity.  There is likely to be a component of social acceptance or social capital and symbolic capital (perceived as a positive sign).  You can refer to this link  for everything you want to know about the sociology of vaccination refusal and more.  Ultimately, it is a decision that usually isn’t modified by education or a measles outbreak, as in this case since it has a low enough severity.  The risks and benefits ratio of disease:vaccination would undoubtedly sway toward vaccination if the disease were to have a greater risk of complications, like smallpox or Ebola virus. 

“Vaccines save lives; fear endangers them. It’s a simple message that parents need to keep hearing.” Jeffrey Kluger

Thanks for reading!  Dr. Cirino

Respiratory Infections and Antibiotic Decision-making

Respiratory Infections and Antibiotic Decision-making

By Dr. Christopher Cirino

Key points: Antibiotics are often used in the outpatient clinic for viral infections. Antibiotic decision-making is subject to a form of bias in both physician and patient, confirmation bias, and makes opaque an already difficult set of decisions. This article will review subjective findings that sometimes are rooted in this bias and how a patient can partner with their doctor in ensuring that antibiotic therapy is justified.

As an infectious diseases physician, this is a topic near and dear to me. Most patients presenting to the clinic, ER or urgent care with “cough” have a viral syndrome or post-viral bronchitis/reactive airways disease. Antibiotics are being given – even to these patients who have illnesses that usually improve with a tincture of time (and chicken noodles soup) and that antibiotics will not improve. These medications also have risks, including side effects and more severe consequences.

Behind these practices lies a behavior that has been reinforced both in the clinician prescribing and the patient requesting — thus creating an altered perception, or bias. This post will outline the basis of this problem, summarize typical signs and symptoms of these infections and advise how a patient can protect themselves and ensure appropriate care.

A clinician will have seen thousands of patients with viral syndromes by the time they complete formal training It is the most common cause of cough with no localized pulmonary signs/symptoms. Even for patients presenting with a pneumonia as indicated on a radiograph, virus were still more readily detected than bacteria. In one study on the cause of pneumonia in 2,300 adults, 27% were from a virus (most commonly rhinovirus and then influenza in this study) and 14% from a bacteria (most commonly Streptococcus pneumoniae). That means that almost 62% of patients had no determinable (to the routine tests) pathogen. Likely the majority of these were viral causes, though some could be caused by more difficult to grow bacteria. Rapid molecular testing has decreased this unknown percentage and will likely continue to overtake more traditional laboratory methods.

Most patients who come in the clinic often have to schedule their visit a few days earlier and generally are not as acutely ill as someone having to go to the ER. They may have a nagging cough that has persisted, ongoing drainage. The majority of these patient visits for respiratory tract infections are for viral infections. Clinicians in a busy clinic have the task of triage – deciding whether a patient’s history and physical findings require further testing, e.g. a radiograph or bloodwork, or antibiotics.

Bias affects decision making when there are multiple variables, time constraints and expectations. Doctors occasionally rely on a syndromic characterization — quickly determining if the process warrants further work-up. The experience-base of the clinician, since it is drawn upon by specific patient presentations, is unfortunately a glimpse of a disease manifestation as it relates to a few patients — and may be a framework of bias. Clinicians may listen for key words such as “green sputum”, “sweats”, “fever” and begin to consider whether antibiotics may be needed. Clinicians may confirm that a patient improved after antibiotics in the past when they receive a call “it made me better by the next day”, not factoring in other characteristics, such as the coinciding improvement of a viral infection or anti-inflammatory properties of some antibiotics (e.g. azithromycin, levofloxacin,etc) or from other things taken or prescribed. This type of bias is known as Confirmation bias. Not seeing alternative stories as valid and fixing on cause and effect anticipated is confirmation bias.

This form of bias does not only come from the clinician but also from the patient — sometimes even before they enter the clinic! I frequently see patients who are concerned, even convinced, that their respiratory infection requires an antibiotic. Occasionally, they will call the office, requesting that an antibiotic be ordered, as if they are ordering take-away from a fast food restaurant. Although it is not my objective to hold therapy when therapy is needed, I find that the overwhelming majority of patients that call or come into my office for respiratory infections do not need an antibiotic. They will often state that in the past, when they received an antibiotic — or that they almost waited too long and they were having a worsening cough — that the antibiotic worked. Not only are they equating their current illness with what happened in the past but they are looking for characteristics that are not specific enough to discern between a viral and bacterial infection.

How do these misconceptions arise?

These beliefs are intrinsically connected with an individual’s prior encounters with the medical system, lack of knowledge of what differentiates a viral from a bacterial infection, and perhaps physician-patient enculturation in the “antibiotic era”.

If a patient had a respiratory illness and received an antibiotic in the past, they will attribute the spontaneous, gradual resolution of the viral infection to the potent antibiotic regimen that was given to them. These past positive experiences (post-antibiotic yeast infections forgotten or forgiven) fuel future expectations. It is why patients occasionally use the statements “Well I get something like this every year, but only when the doctor writes me a Z-pack, it gets better.”

How common does a doctor write an antibiotic prescription for a respiratory infection?

In one study of 366 pediatric and family physicians in Georgia polled, 38% (pediatrics) and 58% (family practice) indicated routine prescribing for the common cold; 81% and 93% routinely prescribed antibiotics for “bronchitis”. In a chart review of this same study, 19% of antibiotic prescriptions were called in after telephone encounters.

Perceived or real pressures placed on physicians by parents or patients themselves was cited by more than 50% of the physicians polled.

Factors that influence antibiotic decision-making or seeking which are not specific enough:

  1. The color of sputum/mucus:

This is a common concern that is brought up by patients and sometimes a reason why clinicians order antibiotics. Most patients would not seek physician consult if their secretions were clear. However, the shift from clear to yellow- or green-colored secretions does not increase the probability that a bacterial infection exists, except possibly in patients with chronic obstructive lung disease (COPD). Though it leads to greater patient preoccupation.

The yellow/green color of mucus originates from inflammation and is directly related to leukocytes (white blood cells) migrating to the area of infection.

2. The duration of the cold symptoms:

The length of time of the cough or cold symptoms (if cold symptoms think virus) has little bearing in differentiating a viral infection from a bacterial infection. Viral infections and their aftermath may cause cough and drainage symptoms for several weeks, particularly if one develops a reactive airway disease (aka bronchitis). Occasionally, one may even be co-infected with another viral infection which may be a factor of severity. I would be more concerned if a patient develops sudden onset of fever with rust-colored sputum and chest pain after improving from a viral syndrome – this is the classic presentation for Pneumococcal or Staph aureus pneumonia. Otherwise, setting an arbitrary time-point in deciding on antibiotic therapy is a common misconception by both clinician and patient.

3. Underlying diseases such as COPD or mild immunosuppression with a viral infection:

Although chronic lung disease increases concern and risk of respiratory issues, these conditions do not in and of themselves merit consideration for antibiotic therapy when the patient only has a viral infection. One exception is a more significant exacerbation of COPD: studies have supported the role of azithromycin in exacerbations (possibly from the anti-inflammatory role). Even viral illness can cause enough issues to lead to hospitalization in a patient with more severe disease. Treatment may require stabilizing the reactive airways, including a COPD exacerbation, with bronchodilators (albuterol) and inhaled or oral steroids or a brief course of IV steroids. The goal in these patients is to rule out concomitant bacterial infection often with a radiograph if their clinical examination alone is challenging to sort out and alert the patients for warning signs to seek further care – and they come in when they are worse — and get treated.

What are the Clinical exam factors between viral and bacterial infections?

Discerning between a viral infection and a bacterial infection is usually possible with an accurate history and physical. A patient with a viral process will present with a runny nose, sore throat, ear symptoms, muscle aches and cough. A bacterial process may develop acutely with chest pain (not just from coughing as in bronchitis) possibly one-sided, less commonly bilateral, persistent fever and productive rust-colored sputum. The most common history for bacterial pneumonia is “double hump” fever or presentation — where a patient had a viral syndrome and improving and then develops a bacterial pneumonia. The virus is weakening the tissue of the respiratory tree and contributing to bacterial overgrowth and invasion (usually of normal flora = Strep pneumoniae or Staph aureus, less common Klebsiella). Less commonly is a bacterial superinfection in the setting of findings of a viral infections – and is more commonly seen with influenza. The least common is a bacterial infection acquired from the environment e.g. Legionella, Chlamydophila psittaci, Coxiela, etc) or an acute fungal pneumonia (Cryptococcus, Coccidiodes,etc)

In both a bacterial infection or viral syndrome, a patient may have fever and chills. There may be an elevated pulse and respiratory rate in more serious viral pneumonitis or bacterial pneumonia.

The examination often reveals nasal membrane swelling and mucus bridging in the nares. The posterior pharynx (back of the throat) is often inflamed, with some glandular tissue swelling or “cobblestoning”. Exudates or white patches within the pharynx may be seen in viral infections (mononucleosis, adenovirus, etc) and are not confined to Strep throat alone. Occasionally, there will be some mucosal drainage in the posterior pharnx. The neck will often have some lymphadenopathy or lyphadenitis. (enlarged, tender lymph nodes).

The lung exam will occasionally reveal wheezing. The auscultation of rales (or wet, crackling sounds) raises concern for a bacterial infection, though occasionally viral infections (eg. flu, adenovirus) can cause a significant, even life threatening pneumonitis. I will often request a chest radiograph upon hearing these sounds. If nothing is seen and pneumonia is not confirmed (CXR will not pick up 20% of those with bacterial pneumonia at outset, then I have to weight options and decide to treat or not to treat. Either way, close follow-up is paramount.

  1. What are The Harms of Antibiotic exposure?
  • Yeast infection owing to a shift in skin flora to yeast predominance and infection.
  • Clostridium difficile, a potentially serious overgrowth process where a toxin is secreted by the bacteria and causes diarrhea and sometimes serious bowel swelling or colitis.
  • Antibiotic toxicity, not only nausea, vomiting, rash, but also a severe, exfoliating rash (Steven-Johnson’s Syndrome)
  • Shift/Selection of skin and mucosal flora that are resistant to antibiotic; a close link has been found in patients receiving antibiotics and the development of Methicillin Resistant Staphylococcus aureus. I see the association with MRSA colonization after cephalosporin or fluoroquinolone use.
  • Altered gut flora and association with obesity. There has been an association found with the use of antibiotics during childhood and risk for obesity.
    • What can you do to prevent the inappropriate use?
  • Avoid seeking care if symptoms are consistent with a viral infection. If many people are sick in the household, it is exceedingly unlikely that it is a bacterial infection. That includes even in circumstances, when a physician decided that one of your children has an ear infection and gave him/her antibiotics (though I would question whether that child REALLY has a bacterial infection).
  • Ask the physician whether it is necessary for antibiotics if you are found to have a cold or a bronchitis.
  • Arrange an appointment if the cough is persistent or if you have developed bronchitis/asthma exacerbation. Usually a bronchodilator like albuterol or a short course of an inhaled steroid/bronchodilator mixture is enough to improve the condition over the course of 5-7 days.
  • By all means, if you have persistent fever, shortness of breath or chest pain, you need to be seen! A lingering post-viral cough that suddenly worsens to include chest or back pain, high fever and productive sputum makes bacterial infection more likely. Usually the process comes after the lung tissue is injured by the virus. Bacteria are capable of growing and are not mobilized out because of the injured tissue and then cause an acute pneumonia.

In summary, bias can affect antibiotic decision-making and requests. Most outpatients that are not sick enough to go to the ER are presenting with viral syndromes. Patients need to ensure that they are getting appropriate treatment by being actively involved in the decision process.

Have an uneventful flu season. Thanks for reading this. Please share this!

Obesity: A Health Appraisal

Obesity: A health appraisal

Key points: History and physical examination can often reveal clues of decompensation due to being overweight and obese. Some of these subtle clues are attributable to other conditions or reasons. Most people who have an elevated BMI in the obesity or upper overweight range likely have some signs and symptoms owing to their weight.

A person who comes into a clinic and would like a preventive visit with a physical examination and bloodwork is often looking to identify an underlying health condition that may develop into a greater concern.  Sometimes, they are hoping to verify that their current health is good enough or to make sure that they won’t get a condition that a family member had, like cancer or a heart attack or stroke.  Sadly, the yield of a general health check is fairly low.  One review of 14 trials by Krogsboll in 2012 showed no reduction in morbidity of mortality in cardiovascular or cancer related causes with physical examinations.   

Is there any benefit in performing a physical examination and evaluation?  Perhaps, we shouldn’t throw out the baby with the bathwater just yet.  It may be that some issues are not completely addressed with the provider’s (in)attention to early examination findings that may characterize a health risk.  Most doctors will pick up the skin lesion that needs to be biopsied, but it may be less obvious if a patient has mild lower extremity swelling or a slightly elevated blood pressure.  Also, it is often more difficult to provide recommendations for a person who has an insidious disease process such as being overweight, beyond “lose weight” and “exercise more”.  In my practice, there have been numerous occasions when I have found a patient with obesity having near normal routine bloodwork screening, including normal cholesterol, kidney function and electrolytes and mild elevated liver tests.  Yet, there may be adjustments occurring in the body to maintain homeostasis that are resulting in some effect, even without more than a subtle change on the exam.  Perhaps what we are not checking on the exam and not seeing in these blood tests that gives us a more complete picture.

As the body usually compensates for being overweight to a certain point, it is useful to look for clues that might alert one of early decompensation.  The best place to start is a recall of any signs of symptoms such as with a review of systems checklist.  You can fill this out before you are seen by the clinician.   I look for several things: fatigue, shortness of breath, sleep issues, dry mouth, nighttime urination, increased thirst, night sweats, palpitations, swelling in the legs, weight gain and fibromyalgia.  Any of these items leads me to ask follow-up questions and directs me in the examination.  Sometimes, when asked further, people will comment on things that they weren’t sure should be included, e.g. increased swelling after eating a high salt meal, during the summer months or with traveling or see an indentation where the socks were on their legs.  Patients with insomnia may describe having no problem sleeping during the day but racing thoughts that prevent them from sleeping at night or waking up from sleep because of pain or the need to urinate.  What is difficult is that sometimes these behaviors get normalized by the patient, such as “I used to work the graveyard shift before I retired” or “I have always been a night owl” or “I drink a lot of fluid”.       

Sometimes people who have signs of decompensation try medications over the counter or take substances to aide them. When people drink more than 3 to 4 cups of coffee or 1 to 2 cans of soda, it alerts me to the possibility that they could be stimulating themselves in the setting of poor sleep efficacy, such as in obstructive sleep apnea. They may also be taking common over the counter sleeping medications, such as benadryl or other products and even alcohol. Unfortunately, these substances can feed into behavioral cycles and make it more complex to evaluate a patient.

On the examination, I will look at several physical measurements, which have been found as risk factors to conditions seen with increasing rate in obesity.  I use the body mass index (see body mass index table), which factors in height and weight, as a useful estimator of risk.   A BMI of 30 is associated with obesity.   Certainly, in someone who has a high muscle mass, the BMI can be a less useful predictor.   A lower BMI cutoff of 26 for a person of Asian ancestry has been associated with similar metabolic consequences as a BMI of 30. In addition to that the waist measurement (at level of umbilicus) can often be a useful finding for visceral obesity. A waist circumference of greater than 40 inches in a man or 35 inches in a women is a sign of increased risk of obesity-associated health problems. A neck circumference greater than 17 inches in a man and 15 inches in a woman can also signal possibility of obstructive sleep apnea (OSA). Another measurement which is useful for looking at risk of OSA is the mallampati index. It refers to how visible your posterior mouth (uvula and pharynx) is on examination. The higher the index (I to IV), the greater the risk of obstructive sleep apnea. Consult with your physician to determine the role of weight on your health.  Sometimes, we attribute our health issues to short-term concerns, while the health problems linked to our weight persist.  A trained clinician can determine subtle physical findings that may raise concerns of health impact of your weight.

Other examination findings are present. Vital signs may often signal obesity-related decompensation. These include an elevated blood pressure, systolic and possibly diastolic and a rapid heart rate. These are signs of increased resistance from increased fatty tissue around the vascular beds. A narrow pulse pressure (subtracting systolic from diastolic numbers) can be a sign of low functioning thyroid. The heart sounds can be heard on the chest wall — sometimes more dampened from obesity but a louder pulmonic site (just left of the upper sternum) second heart sound is common, as the heart as to pump harder into the pulmonary bed from increased tissue resistance.

There are also a number of skin findings from obesity on the examination. The body may have darker, scalier, sometimes velvety-appearing skin in the back of the neck or sometimes in the groin area or under the arm. This is known as acanthosis nigricans and is related to a higher insulin production in the body and “insulin resistance”. This can be a marker of diabetes and prediabetes. There may be vertical markings on the abdominal wall from tissue stretching. A very red or violaceous appearance could be a sign of the body producing too much cortisol, such as in a condition known as Cushing’s syndrome. The skin of the legs can be compressed and leave a marking known as “pitting edema”. This can be a seen in the setting of decompensated obesity and indicate likelihood of obesity-associated sleep apnea and high blood pressure.

In summary, there are multiple signs and symptoms of obesity. These findings become more apparent at higher levels, as the body is no longer able to compensate from the excess weight. As these changes are gradual, they may be misattributed to other causes or syndromes. Anyone who assess their BMI, waist circumference, neck circumference and mallampati index or who has been found to have an elevated blood pressure or fasting glucose should consider working on a health optimization plan to reduce the harms of excess weight.

Thank for reading. Dr. Cirino

The Art of Medicine

                                                The art of medicine

Doctors often spend time looking for medical conditions that are treatable.  For instance, a patient who is diagnosed with an acute bacterial pneumonia has myriad findings that correspond with this diagnosis, including the preceding symptoms, physical findings, radiographic findings and less commonly a positive sputum culture.  Although we do not always have a conclusive diagnosis, we have enough information to treat the process with empirical antibiotics.

Sometimes with chronic conditions, we don’t acknowledge that it may be causing a problem until it can no longer be denied.  The same is with regards to obesity – the health effects worsen with the degree.  Earlier on, a person may note a feeling of fatigue, swelling in the legs, worsening heartburn or sleeping problems.  He or she may wonder if they have chronic fatigue syndrome, because they are not feeling as much energy during the daytime. 

As is common with chronic conditions, people may take medications that treat the symptoms and delay medical visits.  They may consult naturopaths, chiropractors or acupuncturists with these concerns and be given different treatment options, sometimes not addressing the association with their weight and their health.  Terms like fibromyalgia, chronic fatigue syndrome, “adrenal fatigue”, or even chronic Lyme disease may be brought up during these visits, without realizing the process may be linked to their obesity or other behaviors.  Sometimes, clinicians may enable these concerns without doing any major work-up of conditions that can present similarly.  Many times patients will have limited benefits or be informed that “treatment options may take several months”, only to end up back to the problems that they hadn’t had fully addressed in the first place.

Not only are patients seeking information with other clinicians, they are also seeking out information online.  Information has become more available at an alarming rate.  In the past twenty years, literature that was once only available in specific libraries is now available at the click of a button or swipe of the finger on personal computers or cellphones.  The transition has not been without its growing pains.  With the information comes sifting through material that could be a source of bias or change the emphasis of evaluation.   By searching a diagnosis and checking symptoms, the process of determining a potential issue can be driven in reverse, an attempt to rule out the concern.  What would be ideal is that a process is identified before it becomes more severe and leads to more, potentially irreversible or life-threatening damage.

Although there are information databases that allow one to list out their symptoms and provide a possible diagnosis with statistical likelihood, it hasn’t replaced the job of a physician, who has been trained to sift through information on history and physical examination and work toward a greater understanding of the health issues.  Even this training has its shortcomings as it manifests in the modern age of medicine.  Tests have sometimes usurped the decision-making skills of a physician and can sometimes send a patient on a roller coaster of anxiety and stress while a process, possibly discovered incidentally on one test, obligates a physician to order further tests.  This is compounded by the fact that the average patient visit has decreased to around 10-15 minutes a visit, which is seldom enough time for the patient to work through his/her concerns, or a physician to review and truly understand how the patient’s complaints related to an underlying condition.

Sometimes by spending more time with a patient can be useful to develop a rapport with the patient and open a bridge of communication that sometimes leads to more informed decision-making.  A patient and physician can come up with an agreement of time points and concerns for further testing and monitor the process through time.  Sometimes it provides reassurance that it is being evaluated through time, and allays the fears that came up from self-searching online.  In some cases, asking the patient what is their reason of coming in – or major underlying motivator- of health seeking behavior can be a good way to explore their condition and interact with the patient toward the goal of understanding the condition.

The Benefits of Weight Loss: A Work in Progress

A focus on the “endgame” of weight loss can be discouraging as you embark upon a health journey.  The reality is that becoming healthier is a work in progress.  Although a body weight gohal can serve as a long-run goal, health gains can be realized even in early weight loss.  As little as 3-5% of weight loss (e.g. 5-15 lbs) can produce sustained health benefits, including an improvement in glucose control and insulin functioning, a reduction in blood pressure and diastolic dysfunction and a reduction in severity of sleep apnea. 

As one loses weight, there is a gradual, whittling away of the forces that are exerted on the heart and the rest of the body by obesity.  For instance, a weight loss of approximately 15 pounds leads to a reduction of systolic and diastolic blood pressures by 8.5mm Hg and 6.5 mm Hg.  In another study, with the same average weight loss, there was also reduced peripheral resistance and increased cardiac output.  There were also improvements in glucose levels (fasting (5% reduction) and after meals (10% reduction) as well as reduction of insulin levels (approximately a 15% reduction).  A weight loss of approximately 10 kilograms would amount to a significant reduction in severity of obstructive sleep apnea, as measured by Apnea hypopnea index by 11 events per hour.    

Sustained behavior change places priority on the moment-to-moment behavior over the long-term goal.  A person who focuses on the choices that he/she faces in the day will gradually bolster the new behavior when the days become weeks and the weeks become months.  The day to day activities involve not only healthy eating but managing overall stress levels, nurturing mindfulness and avoiding any triggers to stress-eating and other unhealthy eating patterns.

While some diets boast short-term weight loss goals, the most sustainable diet relies on a gradual strengthening of one’s consistency in healthy eating in order to reinforce new, healthier patterns.  As one pursues this direction, the body will not stop at a 5 to 15 pound short-term weight loss goal but will continue to shed weight until it reaches a new steady state at or near one’s ideal weight.

Momentum builds as one begins to feel feedback from their body or receive it from others.  One might notice less knee pain or find bending down to put on socks easier.  S/he may wake up more restored from the night with greater energy during the day.  One develops a greater self-esteem and efficacy as they continue to see the results of strengthening discipline fortified by a collection of moments when healthy eating was chosen. 

The role of exercise in weight loss, I would suggest, is more for stress reduction and coping.  While not required to achieve weight loss, it is a part of optimal fitness.  The body starts to thrive activity as one loses weight.    What once may have been nearly a work-out just walking from the bed to the bathroom or from the car to the store becomes more manageable, so increased activity follows.  In stride, the person may develop a new routine such as walking or other physical activity for daily stress management and conditioning. 

In the beginning of an exercise regimen, it is more important to focus on consistency rather than on the amount of time or level of difficulty.  Walking may be sufficient to avoid injury or strain and begin in the direction on physical conditioning.  There are often chronic tendonitis issues of the feet, knees, hips and back in someone who is obese.  It is crucial to avoid overworking the body and aim for consistency and an activity as tolerated.  An injury could set a person back enough to make it possible to lose their efficacy and go back to prior unhealthy behaviors.

Homeostasis and the Body

Homeostasis of the body and development of the diseased state

All living organisms have systems which work in concert to maintain functions in the setting of external or internal perturbations.  This process is known as homeostasisWhether it is the acquisition of energy through food or the ability of the body to adjust to threat of physical harm, or “fight or flight”, the body is able to accomplish and optimize its function to allow for maximal effect.  From a single-celled organism to advanced animals, the ability of an organism to adjust becomes a multi-systemic process.

While a single-celled organism could die (“lyse”) if it came across too much alcohol, sodium or sucrose (table sugar) in its environment, an advanced organism has a multi-cellular system to buffer the direct effects of these substances up to a point.  What might be poisonous on a cellular level, in an advanced organism, multiple cells lining its digestive tract can begin to manage these substances and reduce the direct harm.  After the substance is absorbed from the intestines and filters into the liver cells, toxins can be metabolized to less harmful products.  For example, alcohol is broken down in two steps by alcohol dehydrogenase and its product aldehyde by aldehyde dehydrogenase in liver cells to form acetate, which is then converted to carbon dioxide (exhaled) and water (urinated).    For alcohol, the lethal dose 50 (LD50 = a calculation of a dose in which a level is expected to kill half of the population) is a blood alcohol between 0.35 and 0.40 percent, which constitutes about 17 beers in 1 hour for a man weighing 180 pounds.  For sugar, a potentially LD-50 for the same adult would approach 5 lbs  – or more than 250 pieces of “fun size” Halloween candy (20,000 calories).  That’s a lot of candy corn!  For salt poisoning, a more common event with drowning survivors or drinking sea water if stranded at sea, it is estimated that as little as 25 grams of sodium (around 4 tablespoons) at one time for an adult and 7-13 grams for a child could be lethal.  It is definitely not a wise decision to conduct a salt-eating challenge to boost your social media followers.

The greater the perturbation in the system, the less compensated the adjustment and more harmful or life-threatening the consequence.  The body’s shift from “compensated” to an “uncompensated” or “diseased state” can occur rapidly, such as from a poison or drug ingestion or insidiously, such as the long-term effects of high glucose levels on the tissue of the kidneys, eyes and nerves.     It is at this crossroads where a patient may present with symptoms or have signs of a developing dysfunction. 

I am always amazed when I see a patient with severe anemia from a slow-bleeding colonic tumor presenting with no more than a gradual fatigue and weakness to the point.  If a patient were to develop an acute, significant gastrointestinal bleed from a stomach ulcer, s/he may suddenly become weak and dizzy – and probably pass dark, tarry stools or even blood in the stool.  At a much higher blood count than the patient with a slow-bleeding tumor, their systems decompensate.

Our body makes similar functional adjustments as one gains weight through time.  The adjustment process can become more severe as weight gain occurs, leading to a breaking point, when the health effects of weight impact the quality of life.  Many people may have noticed early signs and symptoms of these changes, including fatigue, body aches or fibromyalgia symptoms and sleep disorders.  They may have already sought out providers or tried different medications or used substances to treat the problems with a temporary effect.  A person may take ibuprofen for back pain or body aches.   He or she may drink caffeinated beverages for an energy boost.  They may take sleeping pills for sleep apnea.  They may take herbal or homeopathic medications and potentially delay the recognition of the underlying problem.