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Friday, October 17, 2014

Poll: Many Unaware How Ebola Is Spread

By Phil Galewitz
KHN Staff Writer

Content provided by Kaiser Health News

A new survey finds the public has a lot to learn about how the Ebola virus is transmitted, which could help explain the growing fears of the disease.



The survey by the Kaiser Family Foundation found that while nearly  all adults (97 percent) know a person can become infected through direct contact with the blood or other body fluids of someone who is sick with Ebola, there are still misconceptions. (KHN is an editorially independent program of the foundation.)

One third of respondents are unaware they cannot become infected through the air. About 45  percent are unaware they cannot contract Ebola by shaking hands with someone who has been exposed to the virus but who does not have symptoms.

And only slightly more than a third (36 percent) of respondents know that a person must be showing Ebola symptoms to transmit the infection, the poll found.

The survey, which was fielded after a Liberian man was diagnosed with Ebola in Dallas, and remained in the field after a nurse who helped care for him contracted the disease, finds most Americans say they trust local, state, and federal health authorities to contain the disease  in the U.S.

The public was near evenly split on the federal government’s response to the crisis. About 45 percent said the government was doing enough to fight the disease in Africa and 48 percent said it was doing enough to protect Americans.

The telephone poll of 1,503 adults was conducted from October 8-14 and has a margin of error was plus or minus 3 percentage points.


Thursday, October 16, 2014

Watch Yesterday’s Ebola Town Hall Meeting

Dallas physician leaders responded to the public’s concerns about Ebola at a town hall meeting yesterday. The meeting was hosted by WFAA and held in the community where a nurse diagnosed with the virus lives. The purpose of the event, titled #FactsNotFear, was to present the facts about Ebola and the situation in Dallas, and to calm escalating public fears about the disease.

Below is a sample of questions audience members asked the physician panelists:

  • How long can the virus live outside the host? 
  • Who is most at risk for contracting Ebola?
  • Is there any chance the virus can become airborne? What does the term “airborne” mean?
  • How did the two nurses become infected, and what is being done now to prevent further infections in health care workers?
  • If you survive Ebola, can you relapse or get the disease again?
  • Where are we today on finding a cure or vaccine for Ebola?

You can get in-depth answers to each of these questions and the entire town hall event in the videos below, also found on the WFAA website.

Part 1:

Part 2:

Part 3:

For more information, TMA has created an Ebola virus resource center that organizes the numerous bulletins, guidelines, and other materials issued by the various county, state, and national health departments and agencies to help physicians and health care workers respond to the Ebola outbreak.

Wednesday, October 15, 2014

#FactsNotFear: Dallas Doctors Host Ebola Town Hall Meeting Tonight

This post has been updated with new information regarding tonight's physician panelists.

Dallas physicians answered the public’s questions about Ebola through a Twitter chat under the hashtag #AskDCMS on Tuesday. More than 2.5 million people tuned in to discuss and learn about the disease that has killed a Texas Health Presbyterian Hospital patient and infected two of the nurses who cared for him. Tonight, Dallas physicians again will answer your Ebola questions and separate fact from fiction.

The #FactsNotFear Town Hall Meeting will take place at Lakewood Theater, 1825 Abrams Pkwy., Dallas, at 6:30pm in the neighborhood where the second nurse diagnosed with Ebola lives. It is open to anyone.

The physician panel includes:

  • Todd Pollock, MD, plastic surgeon and Dallas County Medical Society President
  • John Carlo, MD, chief executive officer of AIDS Arms and former medical director of Dallas County Health and Human Services 
  • Robert Haley, MD, professor of Internal Medicine and director of the Division of Epidemiology at The University of Texas Southwestern Medical Center
  • Richard Besser, MD, ABC News chief health and medical editor

News 8’s John McCaa will moderate the event. Dallas County Judge Clay Jenkins, the leader of Dallas’ emergency response to Ebola, will be there as well.

Anyone unable to attend the event can watch it live on WFAA.com.

Tuesday, October 14, 2014

Choosing Wisely – Created By Physicians For Physicians

By Elizabeth Torres, MD
President, Harris County Medical Society

This article originally appeared on the President's Page of the Harris County Medical Society's Physician Newsletter.

As physicians we know that sometimes the most difficult part of our profession is managing patient expectations. Those expectations often come from advertising, newspaper articles or the television news, promising that new treatments and diagnostic tests are available. So patients, having diagnosed themselves with the help of friends or internet site questionnaires, come armed to their office visit with this new information to share and expect to receive certain tests, treatments and/or prescriptions. We often feel compelled to accommodate these requests, knowing that sometimes the testing or treatments are not necessary, could be harmful and costly, and certainly will not change the outcome of their care. We also know that we cannot diagnose all illnesses with certainty, which is what patients really want. Our listening skills and physical exam are our best diagnostic tools. Symptomatic treatment and watchful waiting is all that is needed in many cases. Indeed, we do see patients that require specific testing/treatments that they may not like, and we must justify the need for such testing as well. Additionally, discussion with our patients about the need for certain tests or treatments can be challenging for us and may be disappointing for our patients if we don’t take the time necessary for them. Patients may lack the knowledge and/or understanding to fully comprehend the situation, and it’s sometimes difficult to fully communicate the scientific background behind our reasoning. The Choosing Wisely® campaign is an initiative that was started by the American Board of Internal Medicine (ABIM) Foundation that aims to help physicians begin these conversations. It now includes more than 60 specialty organizations.

Our current health care delivery system does too little to coordinate care for patients with chronic conditions and the government and payers are requiring physicians to invest in expensive health information technology (HIT) without ensuring that the investment translates into better patient care. Additionally, the government imposed metrics to measure effectiveness and efficiency are often off-target. For physicians, the way to save money is not through rationing of care but to ensure the right professionals provide the right care, at the right time and place. Therefore, the responsibility to coordinate patient care falls to physicians.

Choosing Wisely is physician created, physician driven, and physician supported. The goal of the national campaign is to improve quality and reduce waste by having physicians and patients talk about medical tests and procedures that may be unnecessary and possibly harmful.

In 2010, Howard Brody, MD, University of Texas Medical Branch Institute for the Medical Humanities, published an article in the New England Journal of Medicine challenging the medical profession to lead the charge in defining quality care and reducing waste in the health care system. This article served as the catalyst for what is now the Choosing Wisely campaign. Recognizing that each physician specialty is unique in what it considers low value tests and procedures, the campaign challenges every specialty to develop its own list of five diagnostic tests that are overused and potentially harmful to their patients. We need to explain to patients that our differential diagnosis is based on their history and physical exam. We also need to explain why certain tests or treatments will be needed and discuss our plan of action. This removes the shroud of mystery or lack of understanding that patients feel when they leave the office and their family asks “What did the Doctor say?” The Choosing Wisely program also provides help by including handouts for patients on its website.

Participating medical specialty societies range from the American College of Physicians, the American Academy of Neurology to the American College of Surgeons. Each specialty creates its own top five tests or procedures. For example, the American College of Physicians recommends to not obtain imaging studies in patients with non-specific low back pain. Separately, the American College of Surgeons recommends avoiding routine use of whole-body diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

These lists provide support to physicians by allowing our patients to see that our recommendation came from a consensus of national expertise. However, each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together. Choosing Wisely should never be used to establish coverage decisions or exclusions nor interrupt the patient-physician relationship. This is a tool to help us talk with patients when it comes to choosing any test or treatment for them.

With the passage of Tort Reform in Texas, defensive medicine does not have to get in the way of talking to the insistent patient about not needing that antibiotic, CT scan, or other procedure. One of the most common discussions we have with patients concerns giving antibiotics. As we all know, antibiotic resistance is getting to crisis levels in the U.S. from overuse, fostering the emergence of drug-resistant germs. In September 2013, the Centers for Disease Control and Prevention issued the first solid numbers on the extent of the problem. It said that at least two million Americans fall ill from antibiotic-resistant infections each year, of whom at least 23,000 die from the infections. It is up to physicians to reduce the use of antibiotics, when there is evidence to show lack of effectiveness and real risk of harm.

In the current health care environment, every health care entity is looking at ways to increase efficiency and reduce cost. We physicians, by virtue of our daily practice and scientific literature, know which procedures and tests are valuable and which are not. To protect the safety of our patients, we must be stewards of quality initiatives and lead instead of follow.  Engaging patients in these types of discussions will improve communication and understanding with our patients and should lead to better outcomes and patient satisfaction as well.

If you would like to learn more about the Choosing Wisely campaign, go to the Texas Medical Association website at www.texmed.org/choosingwisely/ or take a continuing medical education (CME) webinars (free for a limited time) for 3.75 ethics credit by going to www.texmed.org/ChoosingWiselyCME.

Thursday, October 9, 2014

Mental Health Awareness Week This Week

Chances are high you know someone struggling with a mental illness. It may even be you. According to Mental Health America, approximately one in five U.S. adults has a mental health disorder, and half of us will develop at least one mental illness in our lifetime.

Mental health is as important as physical health to a person’s overall well-being. If left untreated, mental illnesses can affect physical health and can even be fatal. Suicide is the 10th leading cause of death in the United States, claiming more than 38,000 American lives each year, according to MentalHealth.gov.

If you believe you may be suffering from a mental illness, talk to your doctor. Mental Health America created online mental health screening tests you can take to learn if you show signs of mental illness, as well as resources for seeking help.

Wednesday, October 8, 2014

The Truth About Ebola

By Ed Dominguez, MD, FACP, FIDSA
Medical Director, Organ Transplant Infectious Diseases
Methodist Transplant Physicians
Methodist Healthcare System
Dallas

It is said that the first casualty of war is the truth. Although the American health community is always involved in battles — most recently against enterovirus D68 and chikungunya virus — the arrival of Ebola virus in the United States poses different challenges. In West Africa, Ebola has spread more extensively than in previous outbreaks dating back to 1976. We see the images of suffering and loss wrought by this in various media reports throughout each day. These tragic stories of families and communities decimated by Ebola are rapidly accumulating. The influence of this evolving narrative became clear with the report of the first patient diagnosed with Ebola in the United States, and the response of the community to him and his family. This morning, Ebola claimed its first domestic victim; it is critical that the scientific truth about this disease not be its second.

To begin with, for an infection of this significance, it is worth repeating how Ebola is spread and how it isn’t. Ebola is acquired from an infected individual who exhibits symptoms. According to an Oct. 3 alert from the Centers for Disease Control and Prevention (CDC), these may include “fever, muscle ache, severe headache, abdominal pain, vomiting, diarrhea, and unexplained bleeding or bruising.” However, such symptoms only suggest Ebola infection if the affected individual has been in a region with reported Ebola within the last 21 days or closely associated with someone else who has. The contact required for transmission is direct contact with bodily fluids or secretions from such individuals. Importantly, the virus is not spread through the air or through the food and water supply.

A major advantage that the United States experiences in response to Ebola is the availability and use of disposable medical equipment. Countries with fewer resources initially had to sterilize and reuse medical equipment. While Ebola is not as transmissible as other viruses like influenza, it is not forgiving, either. A single breach of infection control and isolation precautions may be enough to lead to disease in a caretaker. It is not surprising that professional and lay medical personnel are among those at highest risk in West Africa. U.S. hospitals and health care workers are equipped with and trained in the proper use of personal protective and single-use equipment. According to CDC, one experimental study showed the virus may survive up to six days on contaminated surfaces or items but only under ideal conditions. Standard environmental disinfection protocols used in all U.S. hospitals are capable of eradicating the virus. Consequently, there has not been a hospital-acquired case of Ebola in Atlanta, Omaha, or Dallas, cities where Ebola patients have been treated.

The survivors of Ebola — and about 40 percent of symptomatic individuals survive — may hold the key to our understanding of the disease as well as the treatment of it. What determines survival is already a question of intense investigation. However, the survivors’ immunity might be transferrable to others early in the course of illness. This approach of passive immunization has been shown to alter the course of a number of other infections, including rabies. This approach is still being refined for Ebola.

What You Can Do

As citizens of the United States, we have become comfortable with the vigilance that our public health infrastructure employs to protect us from diseases like Ebola, SARS (Severe Acute Respiratory Syndrome), and the like. However, with so many battles against microbes raging simultaneously, as citizens we can participate in this effort by employing simple and effective measures. These include washing our hands and restricting our public activity and travel if we have a fever. As importantly, keeping abreast of public health recommendations ensures that we have a shared knowledge of the disease. We may not yet be able to cure it, but we can contain it, and that is the truth.

Tuesday, October 7, 2014

Physician As Patient Part VI: Recovery

By Jay Ellis, MD

Editor's Note: This is the sixth 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 parts I, II, III, IV, and V.

Dr. Greg Guzley discusses my treatment plan. I credit him with saving my life.
After I left the hospital, I returned home a feeble, debilitated man. For the first time in my life I had to face the possibility that I might be permanently impaired. I also worried that I might not be strong enough to tolerate any more chemotherapy. I had already missed one session, and Dr. Greg Guzley told me it would be at least a week before he would even think about letting me attempt another treatment. I could not climb a flight of stairs. I could barely make it around the backyard. Greg gave me specific instructions before I left the hospital. I would do nothing more strenuous than walk a mile on level ground at no more than a 15-minute-mile pace. At that moment, 15-minute miles seemed the equivalent of running a marathon. I would have to stay home. If I were to go out in a crowd and get the flu, I would not survive the event.

My life assumed a very dull existence. I would get up in the morning and read three newspapers. I would go and try to take my walk hoping to see signs of improvement. Greg also allowed me to lift with light weights, and I used my wife Merrill’s 12-pound dumbbells, which in my impaired condition felt like the Olympic weightlifter workout. That would take me to lunch time, and I had the rest of the day to kill. It was so boring. It truly was house arrest without the ankle bracelet.

On my first attempt at walking away from the house, Merrill needed to run some errands, and I went on my own. She gave me strict instructions to be careful, but I decided I would get out there and push it. After all, no pain, no gain, right? I took my pulse oximeter with me and found that if I walked a steady, measured pace I could keep my saturation above 90 percent, but just barely. I made it six-tenths of a mile and turned to go up a slight hill that I had run hundreds of times before. After about 10 yards, my oxygen saturation hit 85 percent, my heart rate was 120, and I was feeling very lightheaded. I quickly bent over and put my head between my legs. I have no idea what the traffic passing by thought of this strange posture, but after a few minutes I rallied enough energy to turn for home. I walked 1.2 miles, it took me over 30 minutes, and I was exhausted. Merrill returned home to see me collapsed on the couch. She didn’t say a word, but she never let me walk alone again.

CATCHING MY BREATH

It was humbling to walk with Merrill. She has always been an avid walker, moving at a brisk pace that challenges most people. In my recovering state I could not keep up with her. I would put my pulse oximeter on and watch as I struggled to keep my heart rate under 120 and my saturation greater than 90 percent. If we walked up any sort of incline, I would have to stop and catch my breath — or just pass out, which did not seem as appealing. I let her borrow the pulse oximeter for a while just to check her heart rate and oxygen saturation. The normality of her readings was a stark contrast to my physiologic infirmity. It only reaffirmed how impaired the pneumocystis pneumonia left me.

These are just a few of the nurses from Cancer Care Centers of
South Texas who guided me through my chemotherapy.
Despite a difficult start, I did see signs of progress. We monitored our pace with a free app on my iPhone, and my pace per mile went from over 20 minutes a mile to under 18 minutes. I was hoping this would be enough to let me resume my chemotherapy. When I saw Greg for my next appointment, he concurred that I could start treatment again. It was a great relief, at least until the next day. In my debilitated state the chemotherapy hit even harder. I couldn't even go for a walk. I did rally, and Merrill and I continued our daily walks. I tried to do light chores around the house to make myself feel useful. I went out to clean the pool, and when I came in I realized that my wedding band had fallen off my skinny, emaciated finger. I searched the pool, the yard, and the filter equipment without success. I was heartsick, but Merrill told me to stop fretting.

The monotony of my existence was broken by good friends. Ed Rashid came by and brought me some books and movies to watch, as well as a delicious cake. Friends sent notes, emailed, and called. Merrill stood guard at the front door, and anyone with the appearance of illness was given a polite shove toward the street. I made vain attempts to escape. I told her I thought I might go to the gym, and she responded, “How many sick people use that exercise equipment?” I thought we might go to church and sit off by ourselves, and she reminded me how many people we heard cough when we watched services online. She was an effective and diplomatic warden.

I decided I would use my month of enforced confinement as an opportunity for self-improvement and did some online continuing medical education. I continued to read three newspapers every day, and I considered myself the world’s expert on current events for the month of January 2014. Each day seemed to get a little better. My ability to lift weights improved, and I was even able to start doing push-ups again. I would take great pride in my little victories. I began to have some hope that I would recover from this near-life-ending event.

Just before my fifth chemotherapy, I went for my fourth CT scan. After the study Dr. Michael Lane was again good enough to review the results with me. My lungs were dramatically improved, but even more heartening was the effect of chemotherapy. The abdominal mass, the lymphadenopathy, even the splenic changes were undetectable. The results of the chemotherapy after just four treatments were dramatic. I was euphoric.

IMPROVEMENT WAS POSSIBLE

Merrill and I began to push my daily walks even farther. By the end of January, we were able to walk 3.5 miles at just under 16 minutes a mile. I felt like Roger Bannister breaking the four-minute mile. I was certainly exhausted after I performed this otherwise mundane feat, but it gave me hope that greater improvement was possible.

I returned for my fifth chemotherapy and got even better news. My hemoglobin, which had been under nine for most of the course of my illness, was now over 11. No wonder I felt better. Greg allowed me to return to work half-time. It was great to be back in the office and working, even on a reduced schedule. I was able to start going to Spurs games again and to go out to dinner. Prior to this Merrill and my mother were my primary connections to the outside world. It was great to feel part of society again.

I finished my sixth chemotherapy and began counting the days until the ultimate test, my PET scan. I received a list of preoperative instructions for the PET scan. It rivaled the user’s manual for your car. No heavy exercise for 24-48 hours; no sweeteners or artificial sweeteners for 24 hours; high-protein, low-carb meal the night before. No eating for eight hours prior to the procedure. I showed up on the day of the procedure and received my injection from the steel container containing the radionuclide, while sitting inside the metal-walled room. I felt like a toxic fund cleanup site. The scan takes 20 to 30 minutes, but by this time I was so used to the CT scanner that I fell asleep during the procedure. I was hoping to be able to review the results as I had with previous studies, but didn’t get the opportunity this time. I promptly went home and pulled the results up on my computer. Me reading a PET scan is second only to me trying to read Sanskrit. I did know that bright activity outside my kidneys was not good. There was only one tiny spot outside my kidneys that lit up, and it was in my lung. I was confident that this was nothing more than residual effects of my pneumonia, and it was just a matter of time until Greg called me to tell me that I was in remission. It seemed miraculous.

Unfortunately, when Greg called it wasn’t quite what I expected. He did confirm that there was a spot in my lung. However, there would be no way to determine whether this was lymphoma or residual pneumonia without a biopsy. I would need CT scan No. 6 and a needle-directed biopsy to answer the question. OK, I can do this. I believed it to be merely a formality, but if it would save me from more chemotherapy I would let them stick a needle between my eyes. Dr. Beatriz Escobar did my biopsy, and it went smoothly. I began waiting for the results. I would log into the Meditech system and check my results each day waiting to see the report. It took days, but it seemed like eternity. Greg allowed me to go back to work full time since I felt so well. I was even beginning to run again, though anyone watching me would have a hard time calling it running, considering my pace was hardly better than 12 minutes a mile.

Finally, at the end of a Wednesday, just as I finished my cases, Greg called. The results were in. There was no lymphoma on the biopsy, and I was in remission. As Greg would say later, I wasn’t cured, but I had made the first cut. I immediately called Merrill and my Mom to share the news. I tried to stand up, but I couldn’t. My entire body went limp. I believed I was handling all this pressure so well. I then realized that once I had the definite answer, a wave of relief swept over me, and I was free from the stress of not knowing. The subconscious burden had sapped my energy, and I was now exhausted. I sat in the doctor’s lounge at MSTH for 15 minutes surprisingly all alone, until I was finally able to move. I went home and hugged Merrill.
Race day, May 19, 2014. To be so close to death and
disability just four months ago and to feel so well
today feels like a miracle. Courtesy photos

RUNNING A RELAY

I met with Greg a week later, and we discussed my new plan. There was a new protocol that might increase my chances of survival by 50 percent. I would start on rituximab every other month for two years. If there was no recurrence, I would be done. This seemed like a piece of cake. Get one drug every other month instead of five drugs every three weeks? I can do that standing on my head.

My hemoglobin was now over 12, and I felt better than I had in months. My running partner Bob Johnson and I decided to see if I could run three miles. If I could, I would run an entire leg of the Beach to Bay Relay, an annual event I have done with five of my friends each year for the past 18 years. I had signed us up in October, but didn’t know if I would be alive on race day and had little hope that I would be running. If things went well, I hoped I could come to the race and cheer. I started running with Bob, but it did not begin well. I would run for 100 paces, walk for 100 paces, gasping for breath. Slowly but surely we were able to improve the pace. OK, we improved my pace. Bob, as ex-triathlete, wasn’t even winded.

On May 19, 2014, 136 days after I left the hospital and supplemental oxygen and 89 days after my last chemotherapy, Bob stood next to me as I lined up for the start of the race. It was an unbelievably cool day for this race. It wasn’t over 70 degrees, and I can't remember better race day weather. If there was ever a day when I was going to be able to make it, this would be the day. All I wanted to do was finish without walking. Despite the cool weather, there was a 30-mile-per-hour head wind blowing sand in my face. Actually, it was a blessing. It kept me from thinking about how much my legs hurt. I finished my leg, 3.5 miles, in just over 37 minutes. It seemed like a miracle. After being so sick I was back running again, albeit slowly. In January, I thought I would never run again. In October and again in December, I wasn’t sure that I was going to live. Now I was doing both.


Up next: What I learned

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