Wednesday, July 30, 2014

Dealing With Cancer

By Jay Ellis, MD

Editor's Note: This is the first 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

I am going to pass out. It won’t be my usual bending over and gasping for breath after running. It won’t be one of those orderly Victorian-era swoons where you collapse into a neat pile, either. It will be a full-on, face-plant, facial fracture, call-911 loss of consciousness. I quickly drop out of my class run and sit on the curb with my head between my knees. The near-syncopal episode passes, but I am left with an overwhelming sense of fatigue and weakness. How did I get so out of shape? I have been doing this exercise class every week for almost 10 years. Is this God’s way of telling me 57-year-old men shouldn’t try to run with 30-somethings? I barely have enough energy to walk back to the locker room to dress and go home.

Two days later the pain starts. I notice it when I awaken one night … or did the pain wake me? It feels like gas, and straining to have a bowel movement seems to make it better. Over the next few days the pain increases in frequency and severity. It seems to get better with some acetaminophen. Other than this new fatigue, I don’t feel ill. I have no fever and my appetite is good, but this pain seems to be getting worse. As the days go on I’m taking acetaminophen more and more frequently and using naproxen. I walk into the office and my partner, Jim Growney, notices my pain and asks what’s wrong. He chastises me for not getting it checked out. He’s right. I need to stop this Dr. Denial act. I may have diverticulitis. I’ll just go over to the Methodist ER, get some antibiotics and go home.

I walk into the Methodist ER, and Miriam Fox, the nurse manager, recognizes me and gives me the VIP treatment. She and her nursing staff couldn’t be more professional or more competent. Dr. David Hnatow, the ER physician on call, examines me and agrees I need a CT scan of the abdomen. I get my lab work done. The ER staff apologizes that I have to wait for the CT scan while it is used for the stroke protocol. I thank them for their courtesy and tell them not to apologize for doing the right thing. They want to take me over to the CT in a wheelchair, but of course I insist on walking. They indulge my whim, and I get my CT scan.

In what seems like a short time, Dr. Hnatow returns and pulls up a chair. This act, of course, is what we all do when we are about to deliver bad news. He goes over the numbers. My white count is 60,000, my hemoglobin is 8.7, and my platelet count is 54,000. (I think to myself that taking the naproxen doesn’t seem like such a good idea anymore.) My CT scan shows a large retroperitoneal mass, splenomegaly with lucent lesions in the substance of the spleen, and retroperitoneal lymphadenopathy. He goes over the differential diagnosis, but I already know the result. I was diagnosed with chronic lymphocytic leukemia (CLL) five years ago, and I hit the jackpot. One in 20 people with CLL will experience a Richter’s transformation and develop lymphoma. I’m in the top 5 percent of my class. The CLL was a nuisance, but the lymphoma will kill me if not treated. I silently berate myself for ignoring my symptoms for so long. What if my platelet count had been 20,000?

I return home and explain the results to my wife, Merrill. She is already angry with me for going to the ER without telling her first. I explain to her what we need to do next. I will call my oncologist, Dr. Greg Guzley, in the morning and get set up for treatment. I then turn to the medical literature to get an estimate for my prognosis. The initial data I read on Richter’s transformation is not reassuring. The data on lymphoma is better. I read the numbers to Merrill. There is an 80 percent chance I will be here in three to five years. There is a 50 percent chance of cure. She asks me to stop. I am upsetting her, and she is right. Statistics apply to populations, not to individuals. I will not be 80 percent here in three to five years. I will not be 50 percent cured. My outcome is binary. I will or I will not survive.

Up Next: Preparing for chemotherapy.

Jay and Merrill Ellis celebrate Thanksgiving in November 2013 following Dr. Ellis' chemotherapy. Courtesy photo

Tuesday, July 29, 2014

The Science Facts About Autism and Vaccines

This blog is no stranger to refuting the false claim that vaccines cause autism. (You can read more about that here, here, here, and here.) The infographic below, created by NowSourcing with help from Upworthy curator Adam Mordecai, illustrates the history and facts behind this "elaborate fraud," perpetrated by one British physician more than 15 years ago. The graphic looks also at the public health fallout from vaccine hesitancy and busts common myths about vaccine safety.

Vaccines and Autism
Source: Healthcare-Management-Degree.net

Sunday, July 27, 2014

The Importance of Vitamin K Injections for Newborns

By Brigitte Ngo, DO
Family Medicine Resident

In the Nov. 15, 2013, issue of Mortality and Morbidity Weekly Report, the Centers for Disease Control and Prevention (CDC) reported four cases of newborn babies in Nashville, Tenn., who suffered from life-threatening spontaneous hemorrhaging between February 2013 and September 2013. Three of these babies suddenly had diffuse bleeding in their brain, and one had gastrointestinal bleeding. After further investigation, it was discovered that the common factor in these cases was the refusal of the vitamin K injection at birth by these infants’ parents. All four newborns had been developing normally for at least six weeks after birth, until they were suddenly diagnosed with late vitamin K deficiency bleeding (VKDB).

Understandably alarmed by this outbreak, the Tennessee health department recruited CDC to delve further into the matter. Data from Tennessee hospitals from 2007 to 2012 revealed zero cases of late VKDB out of the 493,259 births during that time. In 2013, a random sampling of records of infants born from January to October 2013 showed that only 3.4 percent of infants were not administered the vitamin K injection compared with the notably higher 28 percent at birthing centers.

As more and more families are opting for a more “natural” and tailored birthing approach, there has been an emerging trend of parents declining standard preventive measures such as the vitamin K shot, hepatitis B vaccine, and antibiotic eye ointments.

When CDC questioned the parents of the four infants about why they chose to refuse the shot at birth, their reasons included concern for the risk of leukemia from the shot, impression that the injection was not necessary, and the desire to minimize exposure to toxins. In today’s technologically savvy age, “Google medicine” seems to be feeding into parental concerns and fears. Upon surfing through numerous “mommy blogs” on the Internet that advocate refusing vitamin K injections, many other issues that concern parents surface as well, including pain from the injection, the use of synthetic vitamin K, and that breast feeding provides sufficient amounts of vitamin K.

As a primary care physician, preventive medicine is a cornerstone of my practice. It seems like a no-brainer to take simple measures to avoid life-threatening situations and dire consequences. Simply put, the vitamin K injection is a safe and necessary standard of health care that is crucial to protecting babies from a deadly disease. In hopes of alleviating the fears of many parents, and more importantly, to help educate the public about the issue, here are answers to some major questions regarding vitamin K injections.

  1. What is the vitamin K shot, and why do babies need it?
    The vitamin K shot has been a standard of practice since 1961. Vitamin K is needed for blood to clot, and babies are born with low vitamin K levels. They cannot get enough through diet, and their gastrointestinal tracts are not able to produce vitamin K via bacteria like adults. Infants that do not receive vitamin K at birth have an 81 times greater risk of developing vitamin K deficiency bleeding.

  2. What are the current recommendations?
    According to the American Academy of Pediatrics, “Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg. Additional research should be conducted on the efficacy, safety, and bioavailability of oral formulations and optimal dosing regimens of vitamin K to prevent late VKDB. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively.”

  3. Is breastfeeding enough to provide my baby sufficient amounts of vitamin K?
    No.  Breastfed infants are actually at a higher risk for vitamin K deficiency compared with those fed with vitamin K-fortified formula because there is very little vitamin K content in breast milk and colostrum.

  4. Can I just increase the amount of vitamin K in my diet?
    No. No evidence shows a correlation between the vitamin K status of mothers and their infants.

  5. Does it cause leukemia?
    No. In 1992, there were small studies that linked vitamin K injections to leukemia. However, multiple subsequent studies over the past 20 years have discredited these findings. The American Cancer Society states on its website that there is “no link between cancer and vitamin K injections.”

  6. What about oral vitamin K for my baby instead?
    Oral regimens are less effective in preventing late-onset VKDB. The rate of late-onset VKDB bleeding was 1.2-1.8 per 100,000 births for the oral dosing versus zero reported cases for the injection. It also requires multiple doses in the first two months, and the absorption is still not comparable to that of the single injection. 

Friday, July 25, 2014

Select Committee Created to Tackle Texas’ Health Care Workforce Shortage

Texas House Speaker Joe Straus (R-San Antonio) this week created the Select Committee on Health Care Education and Training, which will focus on preparing more Texans for careers in health care.

The state faces severe shortages in the health sector. Out of Texas’ 254 counties, 177 are designated all or partial health professional shortage areas by the U.S. Health Resources and Services Administration. For mental health services, 207 counties face health care worker shortages.

“The strength of our health care workforce directly impacts the quality of care that Texans receive,” Speaker Straus said in a news release. “It also matters a great deal to our economy. Too many health jobs are unfilled, while too many Texans are not prepared to succeed in the workforce. The work of this committee will help more Texans prepare for successful careers in a very important field.”

Chairing the committee is Rep. Susan King (R-Abilene), a nurse, former school board member, and wife of Texas Medical Association President Austin King, MD. The committee also includes Reps. Cecil Bell Jr. (R-Magnolia), Travis Clardy (R-Nacogdoches), Garnet Coleman (D-Houston), Myra Crownover (R-Denton), Bobby Guerra (D-McAllen), Donna Howard (D-Austin), Joe Moody (D-El Paso), Chris Paddie (R-Marshall), John Raney (R-Bryan), and Justin Rodriguez (D-San Antonio).

According to the release, the committee will “assess the demand for health professionals across the state. They will also examine ways to better align public schools, as well as colleges and universities, with the needs of health care employers.”

Thursday, July 24, 2014

The Role of Prevention and Population Health in the Texas 1115 Medicaid Waiver — Part II

by Jeffrey Levin, MD, MSPH; Daniel Deslatte, MPA; Joseph Woelkers, MEd; and Kirk Calhoun, MD

from The Center for Rural Community Health
at The University of Texas Health Northeast

Read Part I here.

The following invited remarks were prepared for the Code Red Task Force deliberations as it updates its recommendations. The comments were delivered on June 18, 2014 in Dallas, Texas. They are presented here as the second of a brief two-part series.

Status of the Waiver Relative to Code Red, Future Extension, and Expansion of Medicaid

As we approach the close of Demonstration Year (DY) 3 of the 1115 Waiver, and with an eye for a prevention framework as just described, we are only now beginning to see how many project initiatives may begin to fulfill several of the key recommendations of Code Red 2012. (Code Red, 2012)

However, our health care system is characterized by enormous inertia.  Implementation of health information technologies and exchange systems is highly dynamic and suffers from various states of evolution, sophistication, and obstacles to integration due to their proprietary nature. Establishing accurate and representative baselines in DY3 with real, but modest improvements in milestones and targets will barely have begun by the end of this Waiver cycle in 2016. Clearly, an extension of Waiver funding for those projects that have achieved metrics and begun to demonstrate early success would prove essential to sustaining improvements while more fully integrating transformative measures into successful delivery systems.

As the largest single source of health insurance coverage in the United States, Medicaid expansion in Texas would also more readily ensure sustainability of successful demonstration initiatives by further increasing the capacity of these projects to meet the needs of patients who presently fall below 138 percent of the current federal poverty level. In particular, said expansion would not only allow Texas and its taxpayers the opportunity to garner substantial additional federal funds for this purpose, but would also help to encourage primary and secondary prevention. Moreover, as strides are made to reduce inappropriate emergency department utilization as well as hospital readmissions, Medicaid expansion would allow building momentum in this new direction. (Crowley and Golden, 2014; Garber and Collins, 2014; Hamilton, 2013; Ryan and Mushlin, 2014)

A Brief Word About Workforce

Raimer presented health care workforce requirements on behalf of Code Red.  (Raimer, 2011) Among a wide range of professional shortages were included primary care physicians, the behavioral health disciplines, dental health providers, and public health workers. The Demonstration Waiver, while helping to build capacity in a number of these areas through traditional educational means, has also emphasized the importance of innovative approaches to workforce development as a means of building capacity for preventive intervention, such as through community health worker and navigation activities, as well as integration of much-needed services such as behavioral health at multiple levels. On a larger scale, building programs for public health at both the undergraduate and graduate level is needed, particularly in rural communities, as well as more aggressive integration of public health service delivery into undergraduate and post-graduate medical education.

In summary, extension of Waiver funding, expansion of Medicaid, and targeted workforce development in Texas can serve effectively to promote health through prevention, while reducing morbidity, mortality, and cost.


Code Red. (2012). Code red: The critical condition of health in Texas, 2012.  Available and last accessed on June 8, 2014, at: www.coderedtexas.org/files/Code-Red-2012.pdf.

Crowley R A and Golden W. (2014). Health policy basics: Medicaid expansion.  Ann Intern Med;160:423-425.

Garber T. and Collins SR. (2014). The Affordable Care Act’s Medicaid expansion: Alternative state approaches. The Commonwealth Fund Blog, March 28, 2014.

Hamilton B. (2013). Smart, affordable and fair: Why Texas should extend Medicaid coverage to low-income adults. Consulting report prepared for Texas Impact and Methodist Healthcare Ministries of South Texas, Inc.

Raime, BG. (2011). Health professions workforce: The health of Texas.  Presentation given at Health of Texas Workshop, available at: www.coderedtexas.org/files/presentations/2011-02/Raimer.pdf.

Ryan AM and Mushlin AI.  (2014).The Affordable Care Act’s payment reforms and the future of hospitals. Ann Intern Med;160:729-730.

Wednesday, July 23, 2014

Border Physicians on Capitol Hill

Texas doctors continued their advocacy efforts today to improve access to health care and strengthen public health infrastructure along the U.S.-Mexico border.

U.S. Congressman Henry Cuellar (D-TX) with TMA President Austin King, MD, and Luis Benavides, MD, kicks off 9th Annual Border Health Conference in DC.
Border physicians, U.S. representatives, and health care experts participated in five panel discussions during the Border Health Conference. After the conference, TMA physicians visited with their Texas representatives.

From left to right: Gilbert Handal, MD, El Paso; Michelle Romero, TMA Lobbyist; Rep. Filemon Viela (D-TX), Yasmin Maldonado, MD, Brownsville; and Luis Benavides, MD, Laredo.
Here’s some media coverage of the conference:
Border region doctors head to Washington for helpKXAN News
Border Health Conference To Look At Impact Of Transient DiseasesCBS DFW

Tuesday, July 22, 2014

Texas Physicians Head to Washington to Advocate for Patients

Texas physicians are heading to our nation’s capital this week to meet with federal legislators and government officials at the 9th Annual Border Health Conference. The purpose of the conference is to address the health care needs and challenges along the U.S.-Mexico border. Chief among the concerns are the thousands of Central American immigrant children and their families streaming into southern border states. Texas physicians say this humanitarian crisis highlights the need for comprehensive care along the border. Other issues the conference will address include ensuring U.S. veterans receive timely care, Medicare’s broken physician payment formula and its impact on seniors and Texans with disabilities, and the need for a strong public health infrastructure.

The following physicians are headed to the U.S. capital to advocate for patients:

Austin King, MD, Abilene – President, Texas Medical Association
Manuel Acosta, MD, El Paso – Chair, Border Health Caucus
Juan Escobar, MD, El Paso – President, El Paso County Medical Society
Richard McCallum, MD, El Paso – Professor of Medicine and Founding Chair, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center at El Paso
Luis Benavides, MD, Laredo – Vice Chair, Border Health Caucus
Yasmin Maldonado, MD, Brownsville – President, Cameron Willacy County Medical Society
Gilbert Handal, MD, El Paso – Vice Chair, Medical Advisory Committee, Texas Health and Human Services Commission
Linda Villarreal, MD, Edinburg – Texas Medical Association Board of Trustees

The Border Health Conference is sponsored by the Texas Medical Association’s Border Health Caucus (BHC). The BHC’s mission is to ensure access to care for patients along the border. 



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