Using Urgent Care Clinics Wisely

By William Jantsch MD

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I have spent almost 40 years on and off working in Emergency Medicine. Now that I am in the twilight of my career, I have found that I cannot work the overnight shifts in the Emergency Department anymore, so I now staff several Urgent Care clinics in Philadelphia.

The concept of Urgent Care Centers (UCC’s) is very attractive: such a facility is usually open every day for extended hours, and can provide rapid evaluation and treatment of straightforward medical problems for which a primary care doctor is not available. A typical configuration is a doctor and 1-2 medical assistants, and/or a radiology technician who can double as a registrar. Many clinics provide on-site x-ray and rudimentary “portable” bedside testing (called “point of care” testing) for illness such as strep throat, infectious mononucleosis, and influenza.

However, there are limits to the effectiveness of these Urgent Care centers, and these would include:

-        No efficient way to set up a patient for an outpatient workup

-        The Urgent Care addresses only the immediate problem

-        No long-term follow up or evaluation of the efficacy of a treatment

-        High costs for minor/trivial medical complaints

Outpatient testing often requires the ordering physician to solicit the approval of a test by the patient’s insurance company (a process called “pre-authorization”). This process can take anywhere from 15 to 45 minutes, and that is time that personnel at a busy clinic do not have to spare. Also, there is no good mechanism for follow up of results of such testing; in most cases, the doctor at the clinic who reads the test results is not the doctor ordering the workup.

If a patient presents to a UCC with a “chronic” complaint (e.g. headaches for a year, 6 months of episodes of upper abdominal pain), the most likely outcome will be that the patient will be advised to seek care from a primary care doctor as soon as possible. This is a real problem for people without insurance who are reluctant to go to a doctor’s office for fear of racking up a big bill. The tragedy is that such an uninsured patient has already been assessed about $150 by the UCC to be told that there is nothing they can do immediately for the problem.

Usually there is a different doctor working in the UCC every day. Therefore, if a patient is seen for a problem one day, and calls back in with a question the next day, there will likely be no one there who has a full recollection of what occurred the previous day. The medical record can provide some information, but in a busy clinic, often times nuanced information is not documented.

The result of such circumstances means that there are many people who present to the UCC who are apt to receive very poor value for the money and time they spend there. This population could be divided into two broad categories: people who do not really need any special treatment anyway, and people with problems that are not in the Urgent Care scope of practice. Examples follow:

-        Problems not needing specific treatment:

o   Most upper respiratory infections (colds, coughs, bronchitis)

o   Most sore throats

o   Minor injuries

o   Minor abscesses and skin infections (these get better by themselves)

o   Many lower urinary tract infections

o   Most cases of pediatric fever

-        Problems not in the scope of practice in the Urgent Care:

o   “chronic” anything

o   Abdominal pain

o   Menstrual complaints (ongoing pain, bleeding, etc)

o   Chest pain evaluation

o   Severe infections

o   Acute neurological conditions (seizure, stroke, confusion)

o   Massive bleeding

Patients with medical conditions in the latter category are “triaged” either to primary care doctors, or to the hospital Emergency Department, where one will find the resources needed for full medical evaluations of complex problems.

Trying to figure out where to get help can be difficult. This is where a medical chat site like Ns1ghter can really be of service. Within just a few minutes of logging on and answering a few questions, you will be able to learn if you need a primary care doctor’s office, a hospital emergency department, or if your problem could be handled definitively in an Urgent Care center.

How to Eat

By Joseph Accursio NP

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Another highly contentious and fad-driven aspect of wellness is also among the most misunderstood, and most feared– the dreaded “diet.” Let’s have a conversation and attempt to sort through the misinformation and come to a new perspective on what’s for dinner.
The first thing on the agenda is the familiar and unpleasant concept of DISCIPLINE. It can’t be avoided, so we’d best get to it. What you eat, where you go, how you move, how you think – this is all a matter of discipline. And that discipline cultivates good or bad habits. Consider the garden analogy: if you plant a garden and let it “take care” of itself, you end up with a weed bed. If you take a disciplined approach, weed it, water it, care for it, you will end up with an abundant harvest. How does this relate to diet?


A “diet” is a long-term proposition. It’s what you eat, not what book you’re reading on what to eat for the next few weeks. Fad diets and short term eating adjustments are rough on the body and produce nothing in the way of real results, just like going to the gym once every two weeks will make you excessively sore and produce nothing in the way of real fitness. We are all aware of this fact, and yet we’re still easily led away by the next flashy computer ad or TV commercial. 


There is no substitute for paying attention to what you eat and making good choices. Period. Make it an everyday thing; an every time thing. We’ll skip the discussion of “cheat days” and failure, because that’s the wrong perspective. You should, and can, enjoy eating well. And I promise that you will feel and function better. 
Another popular aspect of nutrition is the “superfood” trend. Every few years, it’s the next big thing that purports to provide abundant energy, sharpen mental acuity, increase libido, take away wrinkles, cure cancer and generally turn back the clock. Remember Noni juice? How about the current acai craze? Goji berries? Probiotic water? Tumeric? Kombucha? Kefir? Tiger nuts? And right up there with these quick fixes are things like cleanses, alkalinity diets, gluten avoidance, ketogenic diets…the list goes on and on. 


This is not to say that some of these foods aren’t beneficial, and that certain aspects of programs and cleanses aren’t useful. I regularly enjoy (catch that key word, enjoy) many of these things myself. It’s also not to say that the irresponsible way that many of these things are promoted isn’t potentially dangerous. But the idea that a single magic nutrient or certain program is going to turn your life around is a sales pitch, not a scientific finding. 


One more point of discussion related to “diet” – diet programs. Weight watchers, Jenny Craig, Nutrisystem, Medi-fast. The functional part of each of these systems remains the same – taking in less calories. There is definitely something to be said for this, because the first problem with the traditional American “diet” is that we eat too much. But more striking is the core reason that people meet with great success on these programs – discipline. Because they connect their wallet to their willpower, they achieve success in a way that they wouldn’t otherwise be able to. The importance of a lifestyle change has been converted into cash. This bears great consideration – if there’s nothing to lose, there’s probably nothing to gain. In the case of these folks, they would be wasting their money if they didn’t follow through with the program. 
The truth is that it takes major effort in many different areas of life and - most important of all in every endeavor - a robust support system, if we hope to make any meaningful changes. 

Otitis Media (Acute Ear Infection)

By Traci French MD
 

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It’s 3am and your child is crying out in pain and holding her ear. What do you do? Otitis media or ear infections are a common problem in childhood which cause kids and parents a great deal of grief. Both kids and adults can get ear infections, but small children and infants are more likely to get ear infections due to a weaker immune system and a smaller Eustachian tube. Acute ear infections are the most common cause for kids to receive antibiotics and the most common reason for children under age 5 to see the doctor. About 75% of all kids will suffer from this condition, which occurs when puss collects behind the eardrum during an infection and blocks the Eustachian tube, which helps drain the ear. Pressure from the infected ear causes pain and hearing loss. Symptoms of otitis media include fever, ear drainage, ear pain, tugging at the ear, fussiness, inability to sleep and headache. Children between the ages of 6 to 18 months are at the greatest risk of developing an ear infection. Otitis media often occurs during or after an upper respiratory infection and can be caused by bacteria or viruses. There are many risk factors for otitis media, some of which are:

  • exposure to cigarette smoke during or after birth
  • formula use in infants
  • pacifier use
  • history of allergies or asthma
  • family history of ear infections
  • medical conditions such as cleft palate or Down’s syndrome
  • other siblings in the home and daycare attendance

Treatment

The typical treatment for an ear infection is antibiotics, which your medical provider will prescribe after examining your child to ensure that other, more serious conditions are not the cause of your child’s pain. Be sure to take the entire medication dose in order to avoid recurrent infection or antibiotic resistance, which will cause antibiotics to be less effective the next time an infection occurs. Tylenol or ibuprofen are excellent pain relievers, but please follow label directions for proper dosing. A warm (not hot) washcloth or heat pack is excellent for relieving pain due to infection. Please do NOT use ear candles on a child as they are ineffective and very likely to cause skin burns. Some sources recommend mullein tea which is often combined with garlic. Tinctures made from mullein may be easier to ingest than a tea as there are small hairs in mullein tea preparations which can cause skin irritation. Please consult a knowledgeable herbal practitioner regarding proper use of all herbal remedies. Both remedies are considered safe for short term use for all ages. Warm oil is a common home remedy for relieving ear pain, but please consult a healthcare provider before using substances inside the ear canal as serious damage may result if the eardrum is ruptured. Children typically have some hearing loss during an ear infection, but symptoms should resolve within 2-3 weeks. If you notice that your child has difficulty understanding conversations 4-6 weeks following an infection, please bring your child in for further evaluation as recurrent ear infections or persistent fluid collection behind the eardrum can cause permanent hearing loss and learning disability.

Prevention

The best way to prevent ear infections is to avoid exposing your child to cigarette smoke. Kids are two to three times as likely to get an ear infection if their parents smoke, especially if the child was born prematurely. Breastfeeding your baby is also an excellent way to prevent infections including otitis media. Studies show that infants that receive any formula in the first 6 months of life are twice as likely to get an ear infection (1). Treating seasonal or allergic rhinitis (hay fever) seems to decrease the risk of developing ear infections, as well by soothing chronic inflammation in the ear canal. If your child develops multiple ear infections during the course of a year or her symptoms last after the antibiotic course is completed, please follow up with your healthcare provider to determine if there are other preventable causes for this condition.



Citations:

1) Sonia Shoukat M.D., Thomas W. Hale Ph.D. 2017 Texas Tech University Health Sciences Center. Breast Feeding and Otitis Media in Infants. http://www.infantrisk.com/content/breastfeeding-and-otitis-media-infants

2) Ear Infections in Children. Feb. 2017. National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/ear-infections-children

3) Middle Ear Infection and Hearing Loss. 2016. American Academy of Otolaryngology–Head and Neck Surgery. http://www.entnet.org/content/middle-ear-infection-chronic-otitis-media-and-hearing-loss

 

Coronary Artery Disease

By Traci L French MD
 

Introduction

Coronary heart disease (CAD) is the most common cause of death in the United States. Nearly 1 in 4 Americans will die of heart disease, regardless of race or gender. CAD occurs when inflammation causes raised lumps of fatty tissue or plaques to develop in your arteries, clogging the main blood vessels in your heart. If the blood flow in these vessels becomes completely blocked, the surrounding tissue will die and cause a heart attack. Risk factors for CAD include increasing age, obesity, diabetes, male gender, high blood pressure, smoking and excessive alcohol use. Almost half of Americans are obese and have high blood pressure and high cholesterol, which are the three most common risk factors for heart attack.

Warning Signs

Serious symptoms that should never be ignored include chest pain, pressure or tightness- especially if is accompanied by arm, neck, or jaw pain- as well as shortness of breath, dizziness, nausea, sweating, difficulty thinking and tingling in your arms or legs. Women and people with diabetes may different symptoms of a heart attack including severe fatigue, sweating, and jaw or back pain. CALL 911 immediately if you have these symptoms. Delay can mean death or serious injury. 

Diagnosis and Treatment

Diagnosis and treatment of coronary artery disease is based on the severity of your symptoms and risk factors. Acute symptoms often require emergency intervention to prevent damage to cardiac tissue and prevent development of worsening disease. After the condition is diagnosed and stabilized, your provider and treatment team can help develop a strategy to manage your symptoms and halt disease progression. Yearly checkups can help identify risk factors for heart disease such as high cholesterol or high blood pressure. Discussing any warning symptoms with your doctor is a very important way to minimize the risk of having a heart attack or other serious heart issue.

Prevention

Lifestyle modification is key in the prevention of coronary artery disease. You can decrease your risk of a heart attack by 50% just by quitting smoking. Obesity affects almost 40% of the population and the risk of obesity increases by 5% each year. Diet changes shown to lower cholesterol and decrease the risk of heart attack include eating fatty fish such as salmon twice a week, adding 2 tablespoons of nuts to your daily diet, and increasing the amount of fruits and vegetables in your diet. A nutritionist can assist you in developing a healthy customized diet plan, but a general guideline is that each meal should consist of 50% fruits and vegetables, 25% whole grains and 25% lean protein. Exercise is incredibly important for lowering stress, improving mood, weight loss and adding muscle to the body. Exercising 150 minutes per week decreases heart attack risk by 30%. Other lifestyle changes shown to decrease heart attack risk include consuming moderate alcohol (2 drinks/day for men, 1 drink/day for women) and avoiding the trans fats found in processed and fast foods.

 

Heart disease is a serious but preventable disease. Regular checkups with your medical provider can mean the difference between life and death if you have the warning signs. Don’t neglect them.



Citations: Am Fam Physician. 2003 Apr 15;67(8):1769-1770. Coronary Artery Disease: How Your Diet Can Help. http://www.aafp.org/afp/2003/0415/p1769.html PRINT
https://www.cdc.gov/heartdisease/facts.htm
http://www.webmd.com/heart-disease/ss/slideshow-visual-guide-to-heart-disease
http://www.who.int/tobacco/quitting/benefits/en/

Issues with Antibiotics in 2017

By William Jantsch MD

Prior to the use of penicillin by the general public in the 1940’s, bacterial infections in humans often led to devastating consequences, including amputation and death. When antibiotics became available, such infections were often cured in just a few days. 
Unfortunately, the impressive power of antibiotics to cure has resulted in an expectation that these wonder drugs can cure anything, and the drugs have been prescribed for all sorts of conditions, whether or not the disease is caused by bacterial infection. 
The most devastating result of the overuse of antibiotics is that many bacteria have become resistant. In fact, there are now some bacteria that are resistant to all known antibiotics. A patient with an infection caused by such an organism would have only the same options for treatment that patients had before the development of antibiotic; that is, wound care, debridement (amputation), and general supportive care. Many people with these resistant bacterial infections die.


It is very important to limit the use of antibiotics to cases where there is a high probability that their use is necessary. Doctors have been advised to follow these guidelines:
- No antibiotics for uncomplicated upper respiratory infections
- Use shorter courses of antibiotics for established bacterial infections
- Avoid broad spectrum antibiotics when more focused treatment is reasonable
“Uncomplicated viral upper respiratory infection” includes coughs, colds, most sore throats, and stuffy, congested noses and sinuses. Almost all of these illnesses get better spontaneously, and require no specific treatment. However, the experience of having one of these infections is unpleasant, and can last for 5-7 days. It is very common for people to go to doctors, urgent care centers, and even emergency rooms with these infections. Doctors have unfortunately been in the habit of prescribing antibiotics for these infections, just because that is the only thing they can do, even though the likelihood of benefit is near zero. Patients, then, become used to getting treatment for their coughs and colds, and that has reinforced the expectation of “getting something to knock this out” when going to the doctor. 


There are instances in which the use of an antibiotic is likely to help; for instance, bacterial infections of the middle ears, sinuses, pneumonia, skin and soft tissue infections, and urinary tract infections. However, even in these cases, antibiotics are not always needed for resolution of the infection (the human body has immense powers to ward off infection naturally). 
The dictum now is “treat for the shortest time necessary"- usually just as long as there are symptoms. For instance, treatment for pneumonia now is typically 5 days of oral antibiotic, and sometimes just a single dose for lower urinary tract infections. We often advised patients to “finish all your antibiotics, even though you feel better”, but that has changed. Doctors should be telling patients to stop the antibiotic once there is no more pain, fever, or resolution of whatever symptoms were associated with the original infection. 
Certain broad spectrum antibiotics should be avoided for treatment of infections outside the hospital. That would include the use of “fluoroquinolone” antibiotics, such as Cipro, Levaquin, Avelox, and others. These drugs are very potent, and can help to cure a wide variety of bacterial infections, but their overuse has resulted in the emergence of strains of bacteria that are no longer susceptible to these agents. In addition, it has been recognized that there are potentially serious side effects of the quinolones, including tendon rupture, heart rhythm disturbances, and nerve damage. 


The old paradigm of “get a cold, go to the doctor, hope to get an antibiotic” should now become: “get a cold, treat myself at home, go to the doctor if not getting better, hope NOT to need an antibiotic.”

What is Lupus?

What is Lupus?
Lupus is a disease in which our body attacks itself, especially our skin, joints, kidneys,
heart, lungs and blood vessels. It is called an autoimmune disease because antibodies
are formed by our body to harm organs in our own body. It is also a chronic disease
which means that the symptoms last for more than six weeks and sometimes for several
years.


Are there different types of lupus?
Yes, systemic lupus erythematosus affects different parts of the body; discoid lupus
erythematosus causes a persistent skin rash; drug-induced lupus is caused by certain
drugs; neonatal lupus typically occurs in newborns; and subacute cutaneous lupus
erythematosus causes sores on the part of the skin exposed to the sun.

 

What causes Lupus?
Despite advances, we do not yet know the cause of lupus. Studies indicate that genes
and the environment together contribute to the development of the disease. Some of the
environmental stimuli initiating lupus are:
 Medicines like certain antibiotics, blood pressure medicines and anti-seizure
medicines.
 Exposure to sunlight can trigger skin rash in genetically susceptible people.
 Infections can trigger lupus or its relapse.

 

Are there any risk factors for Lupus?
Lupus typically occurs in women between the 15 to 40 year age group and is more
common amongst African-Americans, Asians and Hispanics. So gender, age and race are
the main risk factors.

 

Is Lupus contagious?
No, it is not contagious and you cannot “catch lupus” from anyone.

 

What are the symptoms?
Your symptoms will depend on which organ in your body is affected by lupus and
whether it develops suddenly or slowly. A majority of people with lupus have mild
symptoms which flare up off and on. Common symptoms include:

- A butterfly shaped rash on your cheeks
- Fever and increasing fatigue
- Muscle pain
- Pain or swelling in the joints with stiffness
- Skin lesions which become worse when exposed to sunlight
- Pale or blue fingers and toes, especially on exposure to cold or during periods of
stress
- Difficulty breathing
- Pain in the chest
- Dryness of the eyes
- Mouth ulcers
- Swelling of the glands
- Confusion, loss of memory and headaches

 

How is it diagnosed?
It is difficult to diagnose lupus as it resembles several diseases, which can sometimes
delay the diagnosis for several years. Your doctor depends on an accurate report from you about your health history along with what is found after examining you to reach a diagnosis. In addition, a blood
test to detect antibodies for lupus (ANA) is obtained and if positive, then more specific
tests for lupus will be ordered. A biopsy from the skin or the kidney may be required to
confirm the presence of the condition. Other tests may also be required depending on
the organ suspected to be affected.

 

Are there any complications associated with Lupus?
Lupus related inflammation can affect other organs in your body, such as:

- Kidneys: severe kidney damage, and even death due to kidney failure.
- Lungs: inflammation in the lungs can lead to pleurisy and even pneumonia.
- Heart: inflammation of your heart muscle and lining of the heart results in a
higher risk of heart attacks.
- Miscarriages: Women with lupus can have repeated abortions due to complications, high blood
pressure during pregnancy, and also premature delivery.


What is the treatment for Lupus?
Your doctor will prescribe medications depending upon the severity of your symptoms,
and the organs affected by lupus. Common prescriptions include NSAIDS (non-steroidal anti-inflammatory
drugs), corticosteroids, immunosuppressant and anti-malarial drugs like
hydrochloroquine.

References
https://www.niams.nih.gov/health_info/lupus/lupus_ff.asp
https://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=47
http://resources.lupus.org/entry/what-is- lupus