Monday, September 22, 2014

PBS Video Tackles Vaccine Fears

Thanks to pockets of vaccine hesitancy in the United States, preventable diseases are making a comeback. In its latest “NOVA” special, “Vaccines — Calling the Shots,” PBS “examines the science behind vaccinations, the return of preventable diseases, and the risks of opting out.”

The special is a crash course on all things vaccine. It outlines the history of vaccination, from its origins in ancient India, to Edward Jenner’s smallpox breakthrough, to today’s continuing efforts to improve immunizations and stay one step ahead of evolving diseases. “NOVA” does not shy away from the current controversy but confronts it head-on, explaining the reasons we should fear opting out of vaccines and not the vaccines themselves.

“As a mother, and as a pediatrician, I think one of the biggest fears that I have and have always had is that one of my children will get sick and I can’t do anything about it, or that one of my patients will get sick and I can’t do anything about it. And to be able to prevent that [through vaccination] is such a gift,” says Amy Middleman, MD, an Oklahoma City adolescent pediatrician.

The program profiles several families whose lives have been affected by the vaccine debate in some way. In a particularly difficult scene to watch, a mother stood helpless as her 7-week-old son fought for air while battling whooping cough. Watch the video and listen to their experiences.

Thursday, September 18, 2014

Surprise at TMA's Science Teacher Awards Presentation

A wonderful surprise occurred during the 2014 presentation of the Texas Medical Association's (TMA's) Ernest and Sarah Butler Awards for Excellence in Science Teaching. Dallas cardiologist Richard Snyder II, MD, recognized the woman receiving the high school teacher award, Janet Jones of Jesuit College Preparatory School of Dallas, as his old high school biology teacher.

"I was so tickled by that, because she was my inspiration that really triggered in me an interest in medicine and biology," said Dr. Snyder.

Not long after Ms. Jones received her award, another physician came forward as one of her past pupils. "I am who I am because of the mentors that have come into my life, and Jan Jones is one of those people," said Jason Terk, MD, a Keller pediatrician and former student at Jesuit College Prep.

The special moment reaffirmed that the award’s mission, to recognize excellent science teachers in hopes they will inspire young minds enough that one day they might pursue a career as a physician … really is possible.

Tuesday, September 16, 2014

Is This Any Way to Treat a Doctor?

Today’s physicians must wade through ever-increasing red tape and bureaucracy, and it’s taking time away from patient care. Take a look at the many federal regulations and administrative hassles your doctor has to deal with now.

Thursday, September 11, 2014

Is Unhealthy the New Normal?

Obesity rates in America have doubled since 1980. Too many of us lead sedentary and unhealthy lives, and it’s putting us at risk for obesity-related diseases like cancer, heart disease, kidney disease, diabetes, depression, and anxiety. This knowledge is nothing new, yet every year the obesity epidemic refuses to budge. Is unhealthy the new normal?

That’s the question posed to a panel of physicians and health care experts at TEDMED Austin. The discussion touched on the obstacles Americans, specifically Texans, face in the fight against unhealthy lifestyles. Panelists shared ways they are making a difference in their communities through direct patient care, community programs, and technology.

One Step at a Time

Julie Reardon, MD, spoke about Walk With a Doc, an organization that encourages healthy physical activity in people of all ages by organizing physician-led walks with patients. The walks are an opportunity for physicians to encourage an active lifestyle and answer their patients’ health-related questions in a less intimidating environment. Mostly, it’s a way to get patients moving. “The way we can get from unhealthy to healthy is one step at a time,” said Dr. Reardon.

A Social Movement for a Healthier Life

“We as a society do not adequately value health,” said Baker Harrell, CEO and founder of It’s Time Texas, a movement that seeks to empower Texans to lead healthier lives and build healthier communities. “The obesity epidemic is a symptom of a societal crisis, and the only solution is societal change,” said Mr. Harrell. He spoke of his own experience as an unhealthy child, and how by making the decision to become healthy he wound up transforming his community into a healthier, fitter place as well.

Stopping Childhood Obesity

When it comes to encouraging children to lead a healthy life, “be nice, and be patient,” said pediatrician Stephen Pont, MD, MPH, medical director at the Texas Center for the Prevention and Treatment of Childhood Obesity at Dell Children’s Medical Center. “The blame and shame game doesn’t motivate people, it only makes them feel worse.”

Dr. Pont said a great way to get kids moving again is to tap into their interests and their natural enthusiasm. If children love videogames, “find a way to bring movement into technology.” If faith is an important part of their family life, “find a way to embrace health of the body as well as the soul and the spirit,” he said.

Wednesday, September 10, 2014

Complications of Treatment

By Jay Ellis, MD

Editor's Note: This is the fourth in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the Bexar County Medical Society Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness. Check out part I, Dealing With Cancer, part II, Getting Ready for Chemo, and part III, In the Chemo Room.

The enthusiasm generated by my CT scan results was not a match for the reality of continued chemotherapy treatment. The excitement about my CT scan continued with my visit to Greg Guzley for my next chemo. I felt as if I had reached a major milestone. He tempered my enthusiasm. After my physical exam, I thanked him for saving my life.

“You aren’t out of the woods yet,” he replied.

“I know, but if we hadn’t started treatment I wouldn’t have lived more than two to three months.”

Greg looked up from his computer with a quizzical look and said, “Two to three months? You weren’t going to last two to three weeks.” Some things are best learned after the fact.

My euphoria did not survive much longer. After my third round of chemotherapy the cumulative effects of treatment became manifest. The fatigue was oppressive and ever present. No matter how much I slept, I always felt tired. I would go to the gym and try to exercise, but if my heart went over 100 bpm I worried that I would pass out and drop the barbell on my head. Two flights of stairs looked like Mount Everest. My fingers and toes became numb from the vincristine. I had a constant metal taste in my mouth and almost no ability to perceive the taste of food. I stopped drinking alcohol during chemotherapy, though the truth is I couldn’t discriminate Cabernet from Gatorade. Food had no taste, and I ate only because it was time to do so. I certainly had no appetite. I had the sex drive of the palace eunuch. It seemed that all of the sensual pleasures of life were gone. Worst of all, I feared that I would never ever feel well again, even though the chemotherapy nurses assured me that it would pass.

I tried to work a full schedule after taking a few days off after each session of chemotherapy. I normally keep health issues private (though these manuscripts would beg otherwise), but my patients knew something was up when I went bald and lost 25 pounds. Coupled with my office staff aggressively screening for anybody who appeared even remotely contagious, my secret was out. My patients were wonderful. Everyone wanted to hug and pray over me because this is Texas and that’s what we do. It was hard to get through clinic because everyone wanted to talk about my problem instead of theirs. Work remained a refuge, but in retrospect I should have cut back on my hours. I was completely spent at the end of each day.

In December I developed recurring fever, and the night sweats returned. I would go to the ER or to see Greg. The Methodist ER staff was wonderful with their oncology protocol. As soon as I hit the door, usually in the middle of the night or early morning, I would get my IV, blood cultures, lab studies, chest x-ray, and my first dose of antibiotics. The professionalism and attention to detail of the ER staff was reassuring. The workup was always negative. I would feel better for a few days after the antibiotics, and then repeat the sequence a week later. I secretly feared that despite the excellent CT scan, the lymphoma was making a comeback against chemotherapy.

My CT scan from Sept. 29, 2013, showing my mass and the lymphadenopathy from lymphoma.
My CT scan from Dec. 6, 2013, after two rounds of CHOP-R chemotherapy. Arrows point to the mass.

With negative cultures and a negative chest x-ray, the most likely diagnosis was viral illness. That’s how I treated it, even though I was feeling worse. The day after Christmas I went to bed even earlier than usual, telling myself I would call Greg in the morning because I just felt awful. I would never make the call. At 3 a.m. I awoke in a drenching sweat with a searing headache. I slipped out of bed so as not to wake my wife, Merrill. It is difficult to remember all the details after that. I remember being in the kitchen and feeling very ill. Somehow, I made it to the garage, getting my bag out of the car. I don't know how I got there or how I got my car keys. I made it to the couch and put my pulse oximeter on my finger. It read 66 percent. My first reaction was, “Crap, this thing is broken.” I moved it from finger to finger to finger. The results were the same. My saturation was 66 percent, my heart rate was 120, and if I coughed and breathed deeply I could get my saturation all the way up to 70 percent. The pulse oximeter wasn’t broken, I was. I tried to consider my options, but I was not thinking clearly. I briefly considered the idea of Merrill driving me to the hospital, but I realized I might not be conscious much longer. I tried to call Merrill, but I didn't have enough wind to shout and wake her. On the third try I summoned all my breath, shouted, and she heard me.

“Call 911,” I told her.

“Why?” she asked.

“Because I can’t breathe.” Merrill sprang into action. Someone would later ask me if she “was freaking out.” The answer is not once, not ever. She called 911, threw her clothes on, and ran out to flag down the ambulance. I sat on the couch and wondered if this was the day I was going to die. I felt surprisingly calm, maybe from the intoxication of the hypoxia, maybe because lymphoma forced me to ponder my mortality for the previous weeks. I have had a great life. My faith tells me that I will die and go to a better place. If I have anxiety, it is about the possibility of being left a pulmonary cripple. We all die, but please, Lord, don’t leave me an invalid.

EMS arrived quickly. I would remember a strange moment where they held the oxygen mask above my face with me waiting for them to apply it. Finally, I said, “I am ready for that when you are.” With 100-percent oxygen my saturation quickly increased to 92 percent and my headache melted away. Better yet, the fog lifted from my brain. We made the ride to the hospital to find ER swamped with flu patients and the hospital census at 100 percent. We waited four hours for a bed in the ICU. Greg saw me in the ICU and ER. My chest x-ray showed my lungs in white-out with an overwhelming pneumonia. He suspected pneumocystis pneumonia, but we would need to make sure that we weren’t missing something else.

Once in the medical ICU, I began to accumulate more doctors. Dr. Manica Isiguzo and her partners, Drs. Quresti, Puente-Cuellar, and McReynolds, were the critical care/pulmonologists caring for me. Dr. Richard Thorner and Dr. Richard Fetchik were my infectious disease doctors. Greg’s partner, Dr. Manuel Santiago, covered for him over the holiday as well. As my list of doctors got longer and longer, I remembered my old joke that the more doctors you have, the worse the prognosis. The nursing staff of the Methodist medical ICU were outstanding. They made me as comfortable as possible as I began to spend my first night in the hospital as a patient. Merrill insisted on staying in the ICU with me. Both the nurses and I tried to explain to her why that was a very bad idea. She wasn’t leaving. I tried to explain to her that there was nothing that she could do and both of us had been up since 3 a.m.

“You need to go home and get some sleep,” I told her.

“What if you get scared?” she replied.

“I’m not scared,” I answered, and I truly wasn’t.

“Well, what if I am?” In the chaos of the day I neglected to stop and think about what all this was doing to her. Her love for me was never more obvious than in that moment. I promised myself that if I survived, I would work every day to make her feel as loved as I did that night.

I had spent the day on my iPad reviewing the medical literature on oncology patients who develop respiratory failure, especially that due to pneumocystis. I then used my iPad to check my own lab results. My doctors had many patients, but that day I had only one. I was surprised to find out that patients with HIV have a higher survival rate from pneumocystis pneumonia then do oncology patients. As I read further, I began to understand why. HIV patients developed the symptoms gradually over time. Oncology patients, like me, develop a sudden respiratory illness with little prodrome. In retrospect, it seems like the diagnosis was obvious. However, during the course of my febrile episodes I saw four different doctors, all of them diligent in looking for a source. Despite all our modern technology, some diagnoses present only on their own schedule.

Both of us had a rough night. Every time I fell asleep, my saturation fell, and the nurses came in to rouse me. Merrill would try to drift back to sleep, and I would lie awake staring at the ceiling, then watch Merrill wrestle with the recliner, trying to find a comfortable position. The recliner got the best of it, one time almost pitching her out onto the floor.

When you have nothing to do but think, you recall unusual events. For some reason, I began to think about a young woman I cared for during my first military assignment in Germany. She was admitted to our ICU with varicella pneumonia, and my partners and I cared for her while she gradually deteriorated, despite everybody’s best efforts. We tried truly heroic measures, but she eventually died from overwhelming pulmonary failure after a prolonged course on the ventilator. I remember thinking how tragic that she died from chickenpox. Something affected her immune system, and she never survived. I wondered if that was going to be my path.

In the morning, my mother arrived, and Merrill finally agreed to go home and get some rest. My mother just moved to Texas from Chicago to avoid, as she puts it, “bad weather and bad government.” She also spent years caring for my father as his health deteriorated, sitting in hospitals just like she was now. It had been my hope that when she moved here we could care for her as she had cared for him. Now she was sitting in a hospital again, which just added to my distress.

“I never dreamed that you would have to sit in a hospital watching over me. I am so sorry things turned out this way,” I told her.

“There is no place I’d rather be,” she replied. Mothers always know the right things to say.

I was blessed with plenty of visitors while I was in the ICU. My partners, Jim Growney, Tim Orihel, and Arnold DeLeon, came by. My office manager, Marta Reyna, brought food and snacks, as did my running partner and travel companion, Dr. Bob Johnson. Friends from my military days came by, Dr. Bob Joyner, just reinforcing my idea that those ties formed during military service are some of the strongest. My son, Nathaniel, and his wife, Lindsay, sat with me and brought reading material. I communicated with my daughter, Lauren, in Germany and her family via my iPad. Their visits brightened my days and kept me from staring at the ceiling too long.

Merrill, of course, was a constant presence, leaving only when my mother was there, the only one she trusted to monitor me in her absence. She became upset with the quality of the hospital food and would call the nurses in to look at my dinner tray, something they of course viewed daily. Merrill would voice her displeasure, and the nurses, ever diplomatic, would say, “I can understand why you feel that way.” Merrill finally got disgusted and just brought me food from Aldo’s, which I enjoyed even when critically ill. After I ate, I would read my lab results and my findings in the medical literature to her, which sometimes just increased her distress. All the culture results were negative. The only remaining possibility was pneumocystis, and that would require bronchoscopy for definitive diagnosis. Neither Dr. Fetchik nor Dr. Quresti thought that I would get through bronchoscopy without ending up on a ventilator. My iPad medical research already taught me that if you have pneumocystis pneumonia and you’re on a ventilator, the mortality rate is 90 percent. For the first time, I felt a sense of anxiety. Fortunately, they recommended that we stop all other antibiotics and start treatment with trimethoprim sulfa. Twenty-four hours later, my oxygen requirement decreased, and I slept through the night for the first time in weeks without a drenching sweat.

After five days of bed rest, I was well enough to leave the ICU and move to the rehab floor. I became friends with Thomas, my rehabilitation aid. He would come by several times a day and help me get up and walk so I could reach my goal of walking for six minutes without stopping and while keeping my oxygen saturation above 90 percent. On my first try, I made it 285 feet before I was gasping for breath and my saturation dropped to 85 percent. Each attempt was better, and after two days, I made the six-minute walk, though Thomas still had to give me a pass on a brief period when my saturation hit 89 percent. I could now go home. Greg gave me very strict instructions. I would do no activity more strenuous than walking at a 15-minute pace. I could lift light weights, but nothing heavy and nothing strenuous. Most importantly, he told me I would stay home and only at home for a month. If I were to come down with influenza, I would likely not survive. It would be a month of house arrest without the ankle bracelet, but it would be a step toward getting better.

Up next: The economics of serious illness.

Monday, September 8, 2014

More Texas Homes Go Smoke-Free

More households in Texas are smoke-free now than two decades ago, according to the latest data from the Centers for Disease Control and Prevention (CDC). In 1991, 46 percent of all households in Texas were smoke-free. Homes with at least one adult smoker were only 11 percent smoke-free and homes without any smokers were 60 percent smoke-free. In 2010, 85 percent of all Texas households were smoke-free, including 52 percent of households with a smoker and 93 percent of households without a smoker.

CDC lists smoke-free laws for public places and work spaces, an overall decrease in smoking rates, and a social stigma against smoking around nonsmokers as likely reasons for this decline.

The home is the primary source of secondhand smoke exposure in children. In 2006 the U.S. Surgeon General reported secondhand smoke is never safe. More than 7,000 chemicals are found in secondhand smoke, hundreds of which are toxic and about 70 of which cause cancer. Secondhand smoke kills an estimated 41,000 nonsmoking American adults each year, and causes 150,000-300,000 new cases of bronchitis and pneumonia in children annually. Since 1964, 2.5 million nonsmokers have died from exposure to secondhand smoke.

Read the NPR story on the report.

Friday, September 5, 2014

Texas 15th-Most Obese State

The latest data from Robert Wood Johnson Foundation (RWJF) ranks Texas 15th in the nation for adult obesity and 10th in the nation for adult physical inactivity. More than 30 percent of Texans 18 and older are obese and more than 65 percent of them are either overweight or obese. These numbers are already taking a medical toll on the population: 11 percent of Texans have diabetes, and 31 percent have hypertension. Texas ranks 10th for childhood obesity with nearly 20 percent of adolescents aged 10-17 obese.

RWJF warns obesity can bring with it a host of related health problems, including maternal health conditions, obesity-related cancers, kidney disease, arthritis, dementia, depression, and anxiety. If Texas continues this way, RWJF projects heart disease cases will rise from 1.26 million in 2010 to 5.69 million in 2030, and obesity-related cancer will increase from nearly 330,000 to more than 810,000.

Despite these grim statistics, obesity rates in many U.S. cities and states have leveled off or declined, even among young children in low-income families, writes RWJF Senior Vice President John. R. Lumpkin, MD, MPH. This is good news, since “research shows that kids who receive a healthy start in life stand a much better chance of graduating college, earning higher-paying jobs, avoiding chronic diseases, and living longer lives,” Dr. Lumpkin says.

Read the full report.



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