CV Risk Calculator - American Heart Association and American College of Cardiology's Changes

Guidelines change, and recently new material was released concerning cardiovascular risk.   The spreadsheet enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and the work of Lloyd-Jones, et al., respectively. The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status. However, the more I play with different patients' numbers, even my own mother's, the more it is very obvious the calculator overestimates risk fairly significantly.  We can expect, I guess, statin snack machines to pop up everywhere since most will now be candidates to be on a statin.

Read more about this in a fabulous NY Times article that really goes in-depth concerning the embarrassment and application in the future.

The controversy set off turmoil at the annual meeting of the American Heart Association, which started this weekend in Dallas. After an emergency session on Saturday night, the two organizations that published the guidelines — the American Heart Association and the American College of Cardiology — said that while the calculator was not perfect, it was a major step forward, and that the guidelines already say patients and doctors should discuss treatment options rather than blindly follow a calculator.

Bring on a Pharmacist... Please

WASHINGTON –  Federal health officials are alerting doctors to the recall of an injectable antibiotic made by B. Braun Medical, due to floating particles found in vials of the drug. The Food and Drug Administration posted the notice late Tuesday, warning health professionals that the company has recalled lot H3A7444 of its Cefepime for Injection USP and Dextrose Injection USP. Visible particles were found in a sample from the lot, including specs of metal, cotton fiber and hair.

The agency warned that using the drug could result in blood clots causing stroke, heart attack and other catastrophic problems.

The drug was distributed to hospitals, pharmacies and medical suppliers nationwide, according to the agency's release.

Patients experiencing health problems should contact their physician and report all issues to the company at 1-800-854-6851.

Hearing the newsanchor mispronounce cefepime threw me off.  Initially thought he was talking about some drug I had never heard of.  If news can bring on a Dr. Oz or the Doctors show, how about bringing in a pharmacotherapy specialist to discuss medications?

23andMe: Knowledge is Power

In 2008, Time magazine called 23andme the invention of the year!

Call me a skeptic. I would have been that prior to the results I received in the mail from 23andme. You see several weeks prior to my results, I received this ambiguous kit in the mail where I had to submit a copious amount of saliva in a cup provided and return back to 23andme. Needless to say, I was ready for my results.

Not only do you obtain insight into your own ancestral history but also medical history. Given the recent decision by many women to have a mastectomy after finding out they are testing positive for one of the breast cancer genes, I wanted to see if I had any increased risks compared to others.

The information received was and is (still combing through all the material) overwhelming. I found out there is a particular enzyme I am deficient in that could pose a problem with a certain class of medications. I am a fast metabolizer of caffeine!

An example of some of the medical conditions seen (compared risk to average):

Name	Confidence	Your Risk	Avg. Risk	Compared to Average
Coronary Heart Disease		29.3%	24.4%	1.20x
Age-related Macular Degeneration		22.2%	7.0%	3.16x
Atrial Fibrillation		20.5%	15.9%	1.29x
Venous Thromboembolism		14.3%	9.7%	1.47x
Restless Legs Syndrome		5.2%	4.2%	1.24x
Ulcerative Colitis		0.66%	0.51%	1.30x
Celiac Disease		0.42%	0.24%	1.77x
Lupus (Systemic Lupus Erythematosus)		0.31%	0.25%	1.26x
Bipolar Disorder		0.20%	0.14%	1.44x
Esophageal Squamous Cell Carcinoma (ESCC)		0.09%	0.07%	1.21x
Stomach Cancer (Gastric Cardia Adenocarcinoma)		0.08%	0.07%	1.22x
Abdominal Aortic Aneurysm
Alcohol Dependence
Alopecia Areata
Dupuytren's Disease
Hay Fever (Allergic Rhinitis)
Hodgkin Lymphoma
High Blood Pressure (Hypertension)
Hypothyroidism
Keloid
Narcolepsy
Primary Biliary Cirrhosis: Preliminary Research
Progressive Supranuclear Palsy
Restless Legs Syndrome: Preliminary Research
Sarcoidosis
Sarcoma
Stomach Cancer: Preliminary Research
Cleft Lip and Cleft Palate
Hypertriglyceridemia
Tourette's Syndrome

Very insightful! And there are many more diseases covered.

You can also connect with others who share DNA and are possible relatives. So far I see that I am matched with several 3rd-5th cousins.

There are a few videos you can investigate to obtain more information about this valuable service:

• Muhammad Ali & 23andMe Parkinson's research video
• 23andMe inspirational stories by customers
• Khan Academy & 23andMe - Where do genes come from?
• Khan Academy & 23andMe - What are genes?

23andMe provides over 240 health reports

With over a quarter million members, 23andMe is the largest DNA-based ancestry service worldwide.

When 23andMe was founded, the price of the personal genetic service was $1,000 and over time they have been able to reduce it to $99, making it a widely available information tool

I cannot wait to see where these results take me. I have already been in touch with some potential relatives. I will update as to what knowledge is gained.

I was selected for this opportunity as a member of Clever Girls Collective and the content and opinions expressed here are all my own.

CDC's National Influenza Campaign: Flu Activity Still High

Flu activity is still high across the country and CDC wants to make sure people know the importance of getting vaccinated and caring for yourself and loved ones who are sick. CDC recommends “take 3 actions” to fight the flu – get vaccinated, take every day preventative actions to stop the spread of germs (avoid sick people, stay home when you’re sick, cover your nose and mouth and wash your hands), and take antiviral drugs if your doctor prescribes them.

·         CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu.

·         U.S. flu season continues; influenza-like-illness has fallen in the East and risen sharply in the West.

·         The timing of flu is very unpredictable and can vary from season to season. Flu activity most commonly peaks in the United States in January or February. However, seasonal flu activity can begin as early as October and continue to occur as late as May.

·         Symptoms of the flu may include fever, cough, sore throat, runny nose, body aches, headaches, and fatigue.

·         For information on weekly flu activity, please visit http://www.cdc.gov/flu/weekly/fluactivitysurv.htm

·         People seeking vaccination may need to call more than one provider to locate vaccine at this time. The flu vaccine finder at http://flushot.healthmap.org/ may be helpful.

·         Antiviral treatment can avert serious outcomes and should begin as quickly as possible in high risk persons, including people 65 and older, young children, pregnant women, and people with certain underlying conditions like asthma, heart disease, diabetes and neurological disorders.

·         While antiviral drugs work best when given within 48 hours of symptom onset, observational studies have shown that giving antivirals 48 or more hours after symptom onset can still prevent serious flu-related outcomes.

-- From CDC Message to Readers About 2012-2013 Flu

The Best Health Blogs You Must Read in 2013

1.  Health Beat by Maggie Mahar - Maggie Mahar created HealthBeat in 2007. Earlier this year, she began posting regularly at the healthinsurance.org blog and she’ll continue to write on both websites. The author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006), Mahar also served as the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney.

Before she began writing about health care, Mahar was a financial journalist and wrote for Barron’s, Time Inc., The New York Times and other publications. (Her first book, Bull: A History of the Boom and Bust 1982-2003(Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report. For more on her books, click here.

In an earlier career, Mahar was an English professor at Yale University where she taught 19th and 20th century literature.

2.  HealthBlawg  - David Harlow is a seasoned health care attorney and consultant recognized as an accomplished, innovative and resourceful thought leader in health care law, strategy and policy.  His experience in both the public and private sectors over the past twenty-five years affords him a unique perspective on legal, policy and business issues facing the health care community.

3.  But Doctor I Hate Pink - Breast Cancer? But Doctor, I hate pink is a brutally honest, laugh out loud funny, raw account of navigating life with metastatic breast cancer. Breast cancer is not all pink ribbons and fun runs and survivorship memorabilia, and Ann tells it like it is, what it's like to live life when you know you are going to die.

4.  The Health Care Blog - You can think of us as a little bit like the Huffington Post with a focus on medicine, science and the business of medicine.  Since passage of the Obama administration’s health reform law, we’ve paid close attention to the Affordable Care Act, tracking the implications of the landmark legislation for the industry and consumers, as well as the looming legal battle over the law’s future in Washington.

5.  Health Care Informatics - Mark Hagland's blog about informatics.

6.  Simply Healthy - Marta Montenegro has been inspiring people to live healthy lives by giving them the tools and strength to find one’s inner athlete. Inspired by her father’s last words to her, “Find your victory,” she dedicated herself to living a healthy lifestyle and sharing her personal journey with others. Her personal website MartaMontenegro.com combines health and fitness advice, first-person stories, and tips on nutrition, beauty and fashion.

7.  Runblogger - The best running blog out there (running is health right?) and you can read more about the author.

8.  Wall Street Journal Health Blog - Great resource from the WSJ.

9.  Jay Parkinson + MD + MPH - If I had gone to medical school instead of pharmacy school, THIS is the kind of doctor that I would want to be.  Love this blog.

After completing a residency in pediatrics and one in preventive medicine at Johns Hopkins, I started a practice for my neighborhood of Williamsburg, Brooklyn in September 2007. People would visit my website; see my Google calendar; choose a time and input their symptoms; my iphone would alert me; I would make a house call; they'd pay me via Paypal; and we'd follow up by email, IM, videochat, or in person.

Fast Company calls me The Doctor of the Future. I've got a startup called Sherpaa. Read more about me here.

10.  NPR's Shots - fascinating daily information about health around the world

So there is my top ten list of blogs I enjoy at the moment.  Hope you enjoy!

BCPS 2013: Vaccines

Vaccines:  the memorization of when and what and when not to if the patient has certain conditions.  Imagine questions that are simple but complicated.  For example, perhaps an age is given and you need to know what vaccinations were due by that age or if the child had never had vaccines what could be given as catch-up?  It is really not complicated and again if you are a parent this may be an easier topic if you are of the pro-vax crowd (as I am). Below see the schedule from the CDC that is also approved by the American Pediatric Association along with the recommended schedule for catching up on vaccines if missed.

Special Population Considerations

1. Preterm infants

• Immunize on the basis of chronologic age.
• Do not reduce vaccine doses.
• If birth weight is less than 2 kg, delay HepB vaccine because of reduced immune response until the patient is 30 days old or at hospital discharge if it occurs before 30 days of age (unless the mother is positive for HepB surface antigen).

2. Children who are immunocompromised

• No live vaccines
• Inactivated vaccines and immune globulins are appropriate
• Household contacts should not receive oral polio vaccine
• MMR, influenza, varicella, and rotavirus vaccines are recommended

3. Patients receiving corticosteroids

a. Live vaccines may be administered to patients receiving the following:

• Topical corticosteroids
• Physiologic maintenance doses
• Low or moderate doses (less than 2 mg/kg/day of prednisone equivalent)

b. Live vaccines may be given immediately after discontinuation of high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for less than 14 days.

c. Live vaccines should be delayed at least 1 month after discontinuing high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for more than 14 days.

4.  HIV Positive Patients

a. MMR should be administered unless patient is severely immunocompromised. b. Varicella should be considered for asymptomatic or mildly symptomatic patients. c. Inactivated vaccines should be administered routinely.

BCPS 2013: Pediatrics Otitis Media

Such a fun topic!  Who loves it when the kid says his/her ear hurts?  I cringe just thinking about this one: Otitis Media:  The Bane of all Daycare and all School-aged Youngsters

Common Pathogens

• Viral
• S. pneumoniae
• Nontypeable H. influenzae
• Moraxella catarrhalis

Treatment

• Watch and wait if > 2 yo and pain/fever less than 48-72 hours
• Bulging tympanic membrane/perforation = antibiotics
• Always antibiotics if < 6 months old 4. Middle ear fluid does not indicate repeated treatment unless persists > 3 months
• Corticosteroids, antihistamines, and decongestants are not recommended

Antibiotic regimens a. Amoxicillin (high dose: 80–90 mg/kg/day): Recommended by AAP as the first-line therapy for acute otitis media b. Amoxicillin/clavulanate c. Cefuroxime d. Other antibiotic options (e.g., cefdinir, cefpodoxime) may be effective. e. Duration i. The most appropriate duration is unclear. ii. In general, 7–10 days, but a shorter course (5 days) has been used in children older than 2 years iii. For confirmed cases of acute otitis media not responding to the initial antimicrobial regimen within 48–72 hours, a change in antibiotic regimen is warranted. Failure of the the above warrants ceftriaxone IM for 3 days or tubes i. Intramuscular ceftriaxone may also be considered if adherence is a concern. ii. Tympanostomy with tube placement may be most beneficial for children with persistent otitis media with effusions and significant hearing loss (e.g., greater than 25-dB hearing loss in both ears for more than 12 weeks).

Prophylaxis 1. Reserved for patients with recurrent acute otitis media 2. Reduces occurrence by about one episode per year 3. The risk of promoting bacterial resistance may outweigh the slight benefit

Coca-Cola Commits to Obesity Reduction

[embedplusvideo height="298" width="480" standard="http://www.youtube.com/v/zybnaPqzJ6s?fs=1" vars="ytid=zybnaPqzJ6s&width=480&height=298&start=&stop=&rs=w&hd=0&autoplay=0&react=1&chapters=&notes=" id="ep6358" /] All the while trying to fight the ban in NYC on giant servings.

Read more:  Obesity Epidemic in America

The Obesity Epidemic in America

I am amazed daily when I am working at the hospital at the correlation between heavy weight or obesity and chronic illness.  Home medication rec sheets reach pages and pages with blood pressure medications, statins for high cholesterol, diuretics, and the list goes on. (Even sadder is the hospital cafeteria, but I have yet to dine in a hospital cafeteria and find healthy food which is odd to me)

Today, I was in Costco where I observed a couple of obese customers in electronic wheelchairs buying their food...  IN BULK.  We then went to Sonic (I know) and instead of ordering a Route 44 which can hold the contents of a person's daily urine output with normal renal function (seriously) I ordered a medium.

Guess what?  The medium was what x-large was years ago.

The stats:

• More than one-third of Americans are obese (> 30 BMI).  Another third are overweight.  Combined this means that almost 70% of the US are either obese are overweight.
• 16% of children and teens are obese
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death
• Medical costs associated with obesity were $147 billion in 2008
• There was a dramatic increase in obesity in the United States from 1990 through 2010
• The average size of a bagel doubled in size from 1983 to today.  Three-inch diameter with 140 calories to 6-inch diameter at 350 calories.  Super-size me please.
• One in three children born today will be diagnosed with diabetes in their lifetimes

So why lose the weight this 2013 and make this the year of change?

• Obese workers are less likely to be promoted
• Obesity related healthcare costs will take more money out of your pocket
• Obesity mortality rates are surpassing smoking-related deaths

Flu Vaccine or Fired

As hospital healthcare professionals, we stand at the frontline of patient care of very sick patients.  Our patients include those with cancer struggling with an infection, patients on the ventilator with sepsis and the list goes on.  Where does personal liberty end and responsibility to our patients begin? Eight employees were just fired from Indiana University Health Goshen Hospital in Goshen, Indiana for refusing the flu vaccine.

“As a hospital and health system, our top priority is and should be patient safety, and we know that hospitalized people with compromised immune systems are at a greater risk for illness and death from the flu,” explained hospital spokeswoman Melanie McDonald to the Elkhart Truth. “The flu has the highest death rate of any vaccine preventable disease, and it would be irresponsible from our perspective for health care providers to ignore that.”

Amen and amen.

First do no harm reminds the health care providers that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

What about the harm of possibly transmitting the flu virus to a patient?  Yes, there is an argument that the flu vaccine doesn't always cover every strand of flu of the current year, but even in my case this year I was the one in my home that did NOT get the flu.  My husband and son were not vaccinated and they tested positive for Influenza A.  I know it's not always effective, but this year the going percentage I am hearing is 60% effective.  That is significant.

Among those who do have symptoms when they get flu, they may be shedding the virus up to 24 hours before the onset of symptoms.

American Academy of Pediatrics (AAP) became the latest organization to issue a policy promoting mandatory immunization against influenza for health care workers, with exemptions for health reasons. In July and August, the Infectious Diseases Society of America (IDSA) toughened its policy on flu vaccination for health care workers by removing an exemption for religious reasons and specifying that annual vaccination should be a condition of employment in health care settings and/or a requirement to receive professional privileges. The Society for Healthcare Epidemiology of America adopted a similar policy. In November 2009, the National Patient Safety Foundation had voiced its support for mandatory vaccination of health care workers.

My stance?  If you refuse the flu vaccine and work in a hospital, find another job.  You are putting your patients at risk.  Egg allergy?  Read this.