Tag Archives: CDC

Straight, No Chaser: Updated Circumcision Recommendations, Risks and Benefits

Circumcision prevalence

This past week, the Centers for Disease Control and Prevention (CDC) released new draft recommendations for healthcare providers on parental and patient counseling on the decision on whether to circumcise. This Straight, No Chaser reviews those recommendations and the logic behind it. It is of note that these recommendations are a step away from prevailing medical thought.

As a medical professional, circumcision has long been one of those things that has made me go hmmm…. If your religious beliefs include this as a ritual or ceremony, fine. I get it, and I have no criticism at all. No disrespect is intended. Otherwise, circumcision has largely been a procedure looking for an indication. Quick, tell me what other elective surgical procedure or harmful activity of any type is allowed on children, much less newborns? While I’m waiting for you to think about an answer that doesn’t exist, let’s recap the procedure and the medical logic behind it.

screamingbaby

As you know (and many men are painfully aware – pun intended), circumcision is the surgical removal of the skin over the glans (tip) of the penis. Over the last 30 years, the rate of males receiving the procedure has dropped from 64.5% to 58.3%, according to the National Center for Health Statistics. Worldwide about 30% of males are circumcised, and of those receiving it, the religious influence is largely present. 69% of those being circumcised are Muslim and 1% are Jewish (Circumcision is part of religious rituals in both religions).

circumcision hiv risks

Let’s cut to the chase (no pun intended): Here are the best arguments for circumcision.

  • It helps prevent certain infections (e.g. yeast and UTIs – which most males aren’t especially prone to anyway).
  • The cells of the inner surface of the foreskin may provide an optimal target for the HIV virus (This is theoretical and not conclusively decided in the medical literature. In any event, this is NOT the same as saying uncircumcised males do or are more likely to contract HIV.). Even more importantly, this is NOT the same as saying uncircumcised males fail to be sufficiently protecting by use of condoms and other means of safe sex.
  • Circumcised males have a lower rate of penile cancer (which is very low under any circumstances).

Now, there are emergency indications for circumcision, but that really isn’t the topic of discussion here. The one I’ve had to address (twice in twenty years) is an inability to readjust a foreskin that too tightly adhered to the shaft of the penis (paraphimosis). Obviously, that’s a medical emergency and not something frequently seen enough to justify universal circumcision any more than a much higher rate of appendicitis would warrant universal and elective removal of everyone’s appendix.

circumcision table

Here are criticisms of the decision to have circumcision.

  • Any surgical procedure has complications, and that should be taken seriously. That said, the complication rate for circumcision is very small and includes bleeding infection and pain.
  • Circumcision is a violation of a child’s body and is unnecessary and disfiguring. The foreskin might not be cut the appropriate length, might not heal properly and may require addition surgery because the remaining foreskin incorrectly attaches to the end of the penile shaft.

Honestly, both the risks and benefits are quite overstated, with exceptions for certain parts of the world with exceedingly high HIV rates. Circumcision doesn’t appear to be a medically necessary procedure, but it isn’t an especially dangerous one. Interestingly, the American Academy of Pediatrics’ latest comment on circumcision is that the benefits of circumcision outweigh the risks, which stops short of recommending routine circumcision for all. Even that equivocal smacks of conflict of interest, given who’s performing the procedure at a significant cost to the consumer. Again, this appears to be a procedure looking for an indication – but…
The CDC appears to be going agains the grain with its latest comments. Their new message is pretty clear: the benefits of the procedure — including reducing one’s risk of acquiring HIV, herpes virus, and human papillomavirus — outweigh the harms. They even go as far as to suggest that adolescents and adult males consider the procedure. Of course, it must be said that the CDC’s focus is on the prevention and control of disease, as opposed to the American Academy of Pediatrics, whose focus is children and their health. This is a subtle yet important decision while likely has played out in the extra consideration given by the CDC.
If I was having this conversation in Africa, where the sexually transmitted infection rate is substantially higher and can be significantly reduced by circumcision, I’m sure I’d be more firmly on board with circumcision. If my Jewish or Muslim friends and colleagues were asking my medical advice on the safety of getting the procedure done as part of their religious ceremonies, we’d be having a different conversation. However, we’re not, and for the population in general, it’s safe to say that – various preferences (for various reasons) aside – there’s no compelling reason to recommend circumcision on all newborn males. It just feels like a recommendation to do so is giving in to the notion that we can’t be trusted to have safe sex.

circumcision questions

The CDC officials emphasize that the choice is still left to patients, the document suggests the parents of newborn boys, as well as heterosexually active men of all ages, be told about those benefits, which is reasonable but somewhat leading. If you’re a parent of a newborn, and I tell you there’s a small risk of HIV, HPV and penile cancer in your child if they don’t get circumcised, am I really giving you a choice or burdening you with guilt?
And that’s medical straight talk. Oh, and guys – sorry about the lead picture. That wasn’t a good day.
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Straight, No Chaser: Prescription Pain Killer (Opioid) Abuse

opioid-withdrawal-symptoms-1

One of the more challenging aspects of emergency medicine is pain management. Emergency departments are filled with patients suffering from terminal and chronic diseases, including cancer, lupus and sickle cell anemia. Unfortunately they are also frequented by drug-seeking patients with manufactured complaints meant to obtain prescription pain medications, particularly opioids.

 opioid30p

Opioids are among the strongest medications that will be prescribed by your physician. You know these drugs well. They include codeine, hydrocodone (e.g., Vicodin), morphine and oxycodone (e.g. OxyContin and Percocet). Other opioids include remedies for cough and diarrhea, including codeine preparations and diphenoxylate (Lomotil), respectively.

 opioid increase

The US Centers for Disease Control and Prevention (CDC) notes marked increases in unintentional poisoning deaths over the last 25 years. Opioid pain medication abuse, often in combination with alcohol or other medications are a major reason for this increase. You may or may not be surprised to know that approximately 10% of high school seniors have used opioids in the last year for non-medical purposes. At the other end of the age spectrum, elderly patients prescribed these medicines for various reasons often find their supplies pilfered.

opioid HS students

You know at least half of the reason why, based on the pleasurable acute effects of opiates. Acute effects of opioids involve relieving pain by dulling the intensity of pain signals headed toward the brain (according to our brains, that tree in the forest with no one around doesn’t make a sound). Basically, if the brain doesn’t receive the signals coming from painful stimuli, you don’t know you’re having pain. Opioids also stimulate pleasure centers within the brain, additionally helping us to ignore sensations of pain. Other acute effects include nausea, drowsiness and constipation.
The other half of the story regarding acute effects of opiates often involve the consequences of snorting or injecting medications meant to be taken orally, or misusing/abusing prescribed medication even if taken orally. Opioids also lead to depressed breathing (respirations), which facilitates coma and death – particularly when used while drinking alcohol.
Long-term effects of opioids are often not thought of by those looking for a high, but they are devastating. In addition to developing tolerance (decreasing effects if taking the same dose over time) and addiction (cravings and inability to function without ongoing drug use), opioids are associated with spontaneous abortions and births of low birth weight babies.

rehabilitation

One of the reasons to avoid getting started down the road of becoming addicted to opioids is ending the addiction is difficult. The withdrawal syndrome includes vomiting, diarrhea, involvement leg movements, restlessness, insomnia, muscle and bone pain and cold flashes. Many individuals attempting to end addiction find themselves relapsing due to the severity of withdrawal symptoms. That said, good treatment options exist for combatting opioid addiction. These include both medications and behavioral therapies that have been proven effective.
There is a time and place for strong pain management. When this is the case, get the medicine you need. Just be aware that there’s a very slippery slope involved with opioids, and a level of caution should be applied when deciding to take pain medications. Feel free to contact your SMA expert consultant for any questions you may have on this topic.
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Straight, No Chaser In The News: Ebola Virus – Likely Not Coming Soon To a City Near You

ebola

We must be doing something right when so many of you are asking about Ebola virus. I say that because of the incredibly high probability that neither you nor I will ever see a case of Ebola. In the news is an outbreak of the Ebola virus in West Africa. In this Straight, No Chaser, we will discuss the threat and spread of Ebola, and in a subsequent post, we will review the disease itself.
The basis of concern of diseases such as Ebola is we have become a global community. Worldwide travel now imports and exports diseases in a way not previously common, exposing far-flung populations to seemingly esoteric and rare conditions. The concept that a deadly disease such as Ebola virus is simply a plane ride away is a scary one.

ebola1

According to the Center for Disease Control and Prevention (CDC), Ebola has infected 1,323 people and killed 729 people in the current outbreak, which includes Liberia, Guinea and Sierra Leone. The Director of the CDC has described this outbreak as follows: “This is a tragic, painful, dreadful, merciless virus. It is the largest, most complex outbreak that we know of in history.” Notably, as the World Health Organization (WHO) has mobilized medical attention and support to those in need, some of those providing care have become infected. As such…
Your concerns are straightforward:

  • Is Ebola “coming” to my country?
  • Can I become infected by the Ebola virus?

Focusing on the United States, the answers to both questions are yes, but the risk of your becoming infected are so remote that you should simply understand how to avoid the threat. Furthermore it is important to understand that bringing an infected American home for treatment (as is occurring in Atlanta) is not the same as exposing the population to the disease.

ebola_virus

And so, here are some quick facts for your consideration:

  • Ebola virus is not transmitted like the cold or flu. It requires significant exposure to blood or bodily fluids.
  • Prior to that contact, you’d be most likely be aware of its presence. Those infected with Ebola are so ill so quick that it’s obvious.
  • The chances of an infected and unrecognized person infected with Ebola making it to the U.S. through commercial air travel are infinitesimal.
  • Over $100 million in medical support is being provided by the WHO and CDC to combat this outbreak.
  • Medical management of Ebola is not especially complicated once identified.
  • It is estimated the current outbreak will be defeated within 3-6 months.

What should you do? Continue the same diligence you should be applying to your health everyday.

  • Engage in healthy habits, including hand washing and maintaining a level of health to support a vibrant immune system.
  • Avoid risky behaviors involving transfer of blood and other bodily fluids.
  • Get prompt medical attention for those appearing sick, particularly after recent travel to areas affected by disease outbreaks.

We end this post with another two thoughts from the Director of the CDC:

  • “Although it will not be quick and it will not be easy, we do know how to stop Ebola.”
  • “Ebola poses little risk to the U.S. general population.”

Thanks for liking and following Straight, No Chaser! This public service provides a sample of what 844-SMA-TALK and http://www.SterlingMedicalAdvice.com (SMA) offers. Please share our page with your friends on WordPress. We are also on Facebook atSterlingMedicalAdvice.com and Twitter at @asksterlingmd.

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Straight No Chaser In The News: Your Teens Have Healthier Habits Than You

teenagers1

Your teens are healthier than you. From the department of good health news – on some very important measures, somehow it seems as if our youth have actually received and read the memo on health. According a recent survey from the Centers for Disease Control and Prevention (CDC), several measures of health have improved significantly in the teen population – with a few important exceptions.

teenhealth

These improvements include the following.

  • Cigarette smoking. Cigarette smoking among U.S. high school students has reached an all time low. Teen smoking is down to 15.7%. It was just over 15 years ago (in 1997) that the rate was 36.4%. Unfortunately, this still translates to 2.7 million high school students who smoke.
  • Armed trauma. The proportion of students threatened or injured with a gun, knife or other weapon on school property has dropped to 6.9%, from a peak of 9.2% in 2003. In the presence of so many school shootings, a ray of hope exists.
  • Fist fights. The proportion of students involved in fist fights was reported at 25%, which is down from 42% in 1991. The number of students having had a fight at school within the last year sits at 8%, which is down from 16%.
  • Soda consumption. 27% of teens had at least one soda daily, down from 34% in 2007.
  • TV viewing. 32% watched three daily hours of TV, down from 43% in 1999.
  • Other: Overall, teens are drinking less alcohol and are having less sex with more birth control use by females.

And now, the not so good news…

  • Condom use: Condom use is declining among the sexually active, being reported at 59%, down from a peak of 63% in 2003. Remember, HIV and other sexually transmitted diseases/infections haven’t gone away at all; we’ve just gotten better in controlling them. Now is not the time to get comfortable.
  • Texting and driving: 41% of those who drove admitted to texting or e-mailing while driving. This is bad anyway you look at it.
  • Cigar and other forms of smoking: Cigars are now as popular as cigarettes with high school boys. Cigars were smoked by 23% of 12th grade boys in the month before the survey. Smokeless tobacco use hasn’t changed since 1999, holding at about 8%. Other surveys have shown increases in e-cigarette and hookah use.
  • Computer time: 41% of teens report using a computer for non-school reasons at least three hours a day, up from 22% in 2003. Apparently this is where the TV time has gone.

What this really means is (wait for it!) your teens are educable. Discuss these topics with them and why it’s important to make healthy decisions. Of course it helps if you model the behavior.
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Straight, No Chaser In the News: The Measles Outbreak and Not Getting Vaccinated

Here’s a cautionary tale to those who rely on non-medical sources to guide their health decisions. 

measlesuscases

The measles vaccine became available in 1963. Prior to then, the virus causing measles infected approximately 500,000 Americans a year. On average, this resulted in 500 deaths and 48,000 hospitalizations per year. Universal administration of the measles vaccine in the United States was so effective that measles was officially deemed “eliminated” – meaning there had been no sustained outbreaks in the subsequent 50 years and no homegrown outbreaks since 2000.

By now, most everyone is aware of medically-unfounded controversies related to vaccine administration. The fear-mongering and isolated reports of adverse reactions, the frequency of which fall into statistic insignificance (with all due respect to anyone actually affected), have led to a not insignificant fall in the national immunization rate. Although the premise of herd immunity is meant to shield the population from outbreaks (roughly meaning that if a certain percentage of the population is immunized, then the entire population is virtually immunized), enough people are now exposed that significant occurrences of measles are being seen. This year, cases of measles have already been reported in 18 states. This represents the most measles cases in 20 years. The largest outbreak is occurring in Ohio.

nonmedical vaccine exemptions

Ninety percent of new cases of measles have been seen among those who have not been vaccinated. The reasons cited by these individuals for not getting vaccinated include philosophical, religious or other personal reasons for not using vaccines. High rates of nonmedical vaccine exemptions are enough to cause an outbreak. There needs to be an exposure.

vaccine preventable outbreaks

According to the Center for Disease Control and Prevention’s National Center for Immunizations and Respiratory Diseases, the proverbial match that started the flame has been exposure to infected travelers. Most notable has been a cluster resulting from the Philippines, which experienced an outbreak in October 2013. It appears that unvaccinated Amish missionaries brought back measles while overseas.
This is an example of what would be expected to occur if individuals not immunized are exposed to the disease. Of course those immunized are protected in this same scenario. This is not an example of the cure being more harmful that the disease. Get objective, factual information about your health decisions. Consider the source, the inherent bias and consequences both for your action and inaction. The many diseases for which immunizations are offered are not to be taken lightly. Part of the equation for deciding to implement mass immunization programs involves substantial consequences (including death) resulting from exposure to those not immunized. The choice remains yours. Just remember: You can have your opinions, but you can’t wish them into being medical facts.
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Straight, No Chaser: The Rapid Explosion of Autism Diagnoses – A Good or Bad Thing?

autism-hands

Sometimes it’s really good to be a physician. I can recall two instances in which poorly qualified, non-physician professionals tried to label my children with specific diagnoses. After my then three-year-old son defended himself from a child trying to take a toy from him, one consulting counselor suggested that I pay $200/hour to get him help for his “aggressive tendencies.” (His “symptoms” remarkably disappeared when I removed him from the environment.) When my otherwise normal daughter displayed signs of delaying speaking, another “professional” immediately wanted to label her autistic. In case you’re wondering, I’m not the guy who marches into everyone’s office and announces that I’m a physician. It’s much more interesting to observe the difference in the first and second conversations (you know, the one after they discover you know something…).
Regarding autism, it is a condition that strikes fear into the heart of many, not just because of the condition itself. It’s the lack of knowledge about the condition. It’s the uncertainty about whether a newborn child will be affected just because we’re having children at older ages. It’s the possibility that common environmental exposures could be contributing to the increase in the condition.

autism-in-toddlers

I’m going to approach this two-part series on autism in reverse order. Instead of simply discussing the basics about autism, I’m going to discuss the recent increases in autism rates. It is very important that you read past the headlines on this. Hopefully you’ll come to a better understanding.
In March of 2012, the Centers for Disease Control and Prevention (CDC) estimated that one of 88 eight-years-olds would have one of the various forms of autism spectrum disorder. Another CDC study that was just released reveals that autism rates now affect one of every 68 eight-year-old children. This is a 30% increase in just two years!
Many of you are aware of some of the controversial claims about possible causes of autism. Regardless of the believability of unproven claims, it is entirely probable that some good has come from shining a spotlight on autism. It is without question that the enhanced attention has resulted in more attention being paid to children with suggestive symptoms. This recent trend in more aggressive diagnoses is resulting in more attention being given to those in need with better outcomes over the long haul.
There is no cure for autism. This may be true and depressing, but it doesn’t have to be. Generally, interventions tend to focus on eliminating symptoms and producing desired outcomes (such as those that will increase independent living and functioning). Coordination of strategies is important, so the use of multiple professionals working as a team is common. The good news is, for many children, symptoms improve with early treatment and with age.  Those with one of the forms of autism will usually continue to need services and supports throughout their lives, but many are able to work successfully and live independently or within a supportive environment. Also, please note: The earlier the diagnosis is made and treatment is started, the better one’s outcome is likely to be.
I have just understated a point that I will take a few words to revisit. There is no cure for autism. Please don’t fall prey to claims of therapies and interventions that promise a quick fix. These claims are invariably are not supported by scientific studies. They are acting on your hopes and preying on your fears. The details of treatment strategies are further discussed at www.sterlingmedicaladvice.com.
The next post will focus on the diagnosis and symptoms of autism.
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Straight, No Chaser: Pelvic Inflammatory Disease (PID) – A Really Good Reason Not to Get a Sexually Transmitted Disease

PID1

We’ve previously discussed sexually transmitted infections (STIs) at length, including gonorrhea and chlamydia. One thing that often gets overlooked or not given enough consideration is the risk of complications that occur when contracting a STI. Pelvic inflammatory disease (PID) is one consideration that should be up front and center as a consideration in your mind. If you’re not familiar with the term PID, commit it to memory, as this is a relatively common condition.

PID

Pelvic inflammatory disease (PID) refers to an infection of the upper genital tract in women. It is usually sexually transmitted. PID is the single most common preventable cause of infertility in the U.S. According to the Center for Disease Control and Prevention (CDC), over 750,000 cases of PID occur in the U.S. every year.
Here’s your concern: PID can negatively affect your reproductive organs, including the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and ovaries. The inflammation caused by PID scars affected organs and can result in infertility, tubal (ectopic) pregnancy, chronic pelvic pain, abscesses (pus pockets, aka “boils”) and other serious gynecological problems.  Most ominous is the fact that up to 20% of women may become infertile as a result of PID.
As mentioned, PID typically begins as an STI. Among STIs, gonorrhea and chlamydia are the most common causes. Here are additional risk factors for PID.

  • Prior episode of PID
  • Under age 25 – The cervix (opening to the uterus) has greater susceptibility to STIs and thus to PID in this age group.
  • Douching — This can force bacteria from the vagina into the upper reproductive organs.
  • IUD use — In some women, using an intrauterine device (IUD) to prevent pregnancy can also cause PID.
  • Medical care — PID may rarely result from gynecological procedures or surgeries.

There is a pretty significant range in the way PID shows up. You may not have symptoms, or symptoms could be quite severe. Symptoms may include lower abdominal pain, fever and foul-smelling vaginal discharge. You may notice pain with sex or while urinating. Your menstruation may become abnormal.
This may sound odd, but the treatment of PID is much more important than its diagnosis. This is because a diagnosis may be difficult to reach due to the subtlety of symptoms, and the consequences of missing the diagnosis are severe enough that presumptive treatment is commonly done. Early treatment can prevent or limit long-term complications such as infertility and chronic pelvic pain. According to the CDC, without adequate treatment, 20-40% of women with chlamydia and 10-40% of women with gonorrhea may develop PID. Among those with PID, fully one in five (20%) may develop infertility and one in 10 (10%) may develop a tubal (ectopic) pregnancy. Chronic pelvic pain occurs in approximately 18% of cases of PID.
If you are thought to have or are diagnosed with PID, you will need antibiotics. It is critical that you take these until they are all gone. This is not an instance where you should stop taking the pills once you start feeling better. More specifics on the treatment of PID are provided at www.sterlingmedicaladvice.com.
What you really want to remember is that prevention is key. The best way to avoid STIs is to abstain from sex or to be in a long-term, mutually monogamous relationship with a partner who has been tested and isn’t infected. In addition, correct and consistent use of condoms further reduces your risk of STIs, including chlamydia and gonorrhea.
One more crucial means of protection from PID is early detection. If you think you or your sexual partner may have an STI, get evaluated and treated promptly.
Feel free to ask your SMA personal healthcare consultant any questions you have on this topic.
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Straight, No Chaser: Flu Myths and Questions

flu-vaccine-facts-myths

Every year 36,000 people die and over 200,000 are hospitalized each year due to the flu—in the U.S. alone. If you’re not getting a vaccine every year, you are subjecting yourself to a significantly higher risk and allowing fears and myths to get the better of you. Knowledge is power. Learn the facts.
Does the flu shot give you the flu?
No, no, no. The influenza vaccine cannot cause flu illness. There are vaccines that involve the delivery of live virus, including mumps, measles, rubella, chicken pox and polio. Influenza is not in that category. Flu shots are made either with ‘inactivated’ vaccine viruses that are not infectious or they contain no flu vaccine viruses at all (and instead have recombinant particles that serve to stimulate your immune system).
The most common side effects from the influenza shot are soreness, redness, tenderness or swelling where the shot was given. Low-grade fever, headache and muscle aches also may occur. These symptoms are among the same symptoms you see with influenza, so it’s easy to confuse them as flu symptoms. They are not.
Controlled medical studies have been performed on humans in which some people received flu shots and others received shots containing salt water. There were no differences in symptoms other than increased redness and soreness at the injection site for those receiving influenza vaccine. The flu shot does not give you the flu.
I swear I’ve gotten the flu right after getting the flu shot! How is that possible if I can’t get the flu from the flu shot?
I always remind people that the flu vaccine does an even better job of preventing you from dying from the flu than it does in preventing you from catching the flu (and it does that at a 70–90% rate).  It primes your immune system to better fight off the influenza virus when you’re exposed to it.
There are several reasons why someone still might get a flu-like illness after being vaccinated against the flu:

  • Influenza is just one group of respiratory viruses. There are many other viruses that cause similar symptoms including the common cold, which is also most commonly seen during “flu season.” The flu vaccine only protects against influenza, so any other infection timed correctly can give you similar symptoms.
  • When you get immunized against influenza, it takes the body up to two weeks to obtain the desired level of protection. There is nothing preventing you from having been infected before or during the period immediately before immunity sets in. Such an occurrence will result in your obtaining the flu despite being vaccinated.
  • An additional reason why some people may experience flu-like symptoms despite getting vaccinated is that they may have been exposed to a strain of influenza that is different from the viruses against which the vaccine is designed to protect. The ability of a flu vaccine to protect a person depends largely on the match between the viruses selected to make the vaccine and those causing illness among the population that same year.
  • It is also the case that the flu vaccine doesn’t always provide adequate protection against the flu. This is more likely to occur among people that have weakened immune systems or people age 65 and older. Even if the vaccine is 90% effect, some individuals will contact the flu despite having been vaccinated.

Please don’t get the wrong message from this section. These explanations are the exceptions, not the rule. In the overwhelming number of cases, the influenza vaccine does an excellent job of protecting against and prevent disease from the influenza virus.
Is it better to get the flu than the flu vaccine?
No. Influenza causes tens of thousands of deaths every year. If you have asthma, diabetes, heart disease or are especially young or old, you are placing yourself at significant risk by not getting vaccinated. Even if you aren’t in one of the above categories and are otherwise healthy, a flu infection can cause serious complications, including hospitalization or death.
Why do I need a flu vaccine every year?
The Center for Disease Control and Prevention (CDC) recommends a yearly flu vaccine for just about everyone six months and older. Once vaccinated, your immune protection decreases over time. These boosters are scheduled and dosed to help you maintain the best level of protection against influenza. Additionally, the virus mutates (changes) every year, so what you were covered for this year may not apply next year.
You can make a decision not to get vaccinated, and Straight, No Chaser has posted tips for you to protect yourself in the event you choose not to. (Click here to review.) However, you’re doing so in the face of the solid consensus of medical evidence and research. You should seriously question the motives or knowledge of someone who suggests that you should not get vaccinate for influenza, particularly if they profess to be involved in healthcare. Get vaccinated.
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Straight, No Chaser: Inappropriate Antibiotic Use

antibioticsabx

Here’s a great concern regarding strep throat and the previous post that leads to a much more important topic (I’ll take the liberty of paraphrasing.): What about the concern of missing strep throat? Significant complications can result, including damage to the kidney (in a condition caused post-streptococcal glomerulonephritis). First I’ll address the concern, then I’ll get to the topic at hand.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned just this week how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.
The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Consider the following lists of conditions that commonly can be treated without antibiotics.

  • Common colds and upper respiratory illnesses, including non-strep pharyngitis
  • Influenza (flu)
  • Most coughs and bronchitis (chest cold with a cough)
  • Many ear infections (also called otitis media)
  • Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.

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