Please leave your questions or comments!

I need an outlet for my questions, comments, or we hope are a few complaints or improvements as I like to call them. I’m sure you would appreciate any opportunity to communicate with me as well. I have changed many things over the years based on recommendations and questions from patients and colleagues alike. Use the comments section below for your writing space and I’ll delete the old messages so this section will always remain at the top of the page.

COVID Conundrum

https://www.ama-assn.org/delivering-care/public-health/what-tell-patients-about-myocarditis-after-covid-19-vaccination?utm_source=BulletinHealthCare&utm_medium=email&utm_term=071621&utm_content=physicians&utm_campaign=article_alert-morning_rounds_weekend

Our hot topics and angry controversies about not only COVID infections but now COVID vaccinations reached the boiling point this past week, resulting in protests over COVID vaccination mandates all over the world. Organized medicine (ie, the AMA) has been accused of covering up the origins of the virus and now the side effects of taking the vaccine. To counter these false claims, I would invite you to examine a recent publication from the AMA discussing the side effects of the vaccine and steps to take in order to report unwanted side effects.

As the country continues to push for more people to get vaccinated against COVID-19, some remain concerned over rare cases of heart inflammation—myocarditis and pericarditis—linked to the Pfizer-BioNTech and Moderna mRNA vaccines. While some parents may be thinking twice about teen vaccination, medical experts reassure that the risk of myocarditis and pericarditis are far lower than the risks of serious illness or death from contracting COVID-19.

Since April, there have been more than 1,000 reports to the Vaccine Adverse Event Reporting System (VAERS) of cases of myocarditis and pericarditis occurring after mRNA COVID-19 vaccination in the U.S. with more than 300 cases confirmed. Myocarditis is inflammation of the heart muscle and pericarditis is inflammation of the lining outside the heart. In both cases, according to the Centers for Disease Control and Prevention (CDC), the body’s immune system is causing inflammation in response to an infection or other trigger.

“As physicians, nurses, pharmacists, public health and health care professionals, and, for many of us, parents, we understand the significant interest many Americans have in the safety of the COVID-19 vaccines, especially for younger people,” the nation’s leading doctors, nurses, pharmacists and public health leaders, including the AMA, said in a joint release.

Here is what physicians should share with patients about incidents of myocarditis and pericarditis after Pfizer or Moderna mRNA vaccination.

These are rare cases

Confirmed cases have occurred mostly in male adolescents and young adults aged 16 years or older. But given the hundreds of millions of vaccine doses administered, says the CDC, reports of myocarditis and pericarditis are rare.

“The CDC’s Advisory Committee on Immunization Practices, or ACIP, met to discuss this issue last week,” AMA Chief Health and Science Officer Mira Irons, MD, said during an episode of “AMA COVID-19 Update” on vaccination challenges and masking guidance. “While the CDC did determine the mRNA COVID-19 vaccines can, in rare instances, be linked to myocarditis or pericarditis, the majority of patients have recovered.”

“This is an extremely rare side effect, and only an exceedingly small number of people will experience it after vaccination,” the joint release says. “Importantly, for the young people who do, most cases are mild, and individuals recover often on their own or with minimal treatment.

“In addition, we know that myocarditis and pericarditis are much more common if you get COVID-19,” the release adds, emphasizing that “the risks to the heart from COVID-19 infection can be more severe.”

Symptoms appear after second dose

Severity of myocarditis and pericarditis cases can vary, but “reports have increased since April, mostly in young males 16 and older, several days after vaccination, and more often after the second vaccine dose. Symptoms include chest pain, shortness of breath and palpitations,” Sandra Fryhofer, MD, an Atlanta general internist who serves as the AMA’s liaison to the CDC’s Advisory Committee on Immunization Practices, said during an episode of “AMA COVID-19 Update” about COVID-19 vaccines and variants. Dr. Fryhofer also is a member of ACIP’s COVID-19 Vaccine Work Group.

Sandra Fryhofer, MD

Sandra Fryhofer, MD

While these cases are rare, “ACIP agreed that a warning about the potential risks should be added to the FDA’s official fact sheets on the vaccine so that people would not ignore symptoms,” explained Dr. Irons.

If a parent or their child has any of these symptoms within a week after COVID-19 vaccination, it is important to seek medical care. For instances of myocarditis and pericarditis after mRNA COVID-19 vaccination, most who received medical care have responded well to medications and rest.

Vaccination far outweighs risk

“The benefits of COVID-19 vaccination far outweigh the risks of heart inflammation in young people,” said Dr. Irons, adding that “it’s important to remember that the risk for COVID is far higher.”

“Teens and young adults account for the largest proportion of new cases in the United States,” she said. “And we know that COVID infection itself can affect the heart, so myocarditis after COVID vaccination is still a rare event and the vast majority have recovered.”

https://www.ama-assn.org/delivering-care/public-health/what-tell-patients-about-myocarditis-after-covid-19-vaccination?utm_source=BulletinHealthCare&utm_medium=email&utm_term=071621&utm_content=physicians&utm_campaign=article_alert-morning_rounds_weekend

COVID-19 vaccines “will help protect you and your family and keep your community safe. We strongly encourage everyone age 12 and older who are eligible to receive the vaccine under Emergency Use Authorization to get vaccinated, as the benefits of vaccination far outweigh any harm,” the joint release said. “Especially with the troubling Delta variant increasingly circulating, and more readily impacting younger people, the risks of being unvaccinated are far greater than any rare side effects from the vaccines.”

Discover what to tell your patients when they ask which COVID-19 vaccine to get.

Related Coverage

Dr. Bailey to Senate: Doctors are nation’s best vaccine ambassadors

Submit cases to VAERS

For physicians who have “a patient with myocarditis … or anything else unusual after COVID vaccination, please send a report to VAERS … so they can check it out,” urged Dr. Fryhofer. “Without this reporting, CDC can’t know the scope of a potential issue, investigate it and provide communication.”

“If you do report a case and CDC asks for medical records, send them ASAP—it’s not a HIPAA violation,” she said, adding that “anyone can submit a report to VAERS—it’s not just limited to health care” professionals.

The AMA has developed frequently-asked-questions documents on COVID-19 vaccination covering safety, allocation and distribution, administration and more. There are two FAQs, one designed to answer patients’ questions, and another to address physicians’ COVID-19 vaccine questions.

Learn more from the CDC about myocarditis and pericarditis following mRNA COVID-19 vaccination.

#covid-vaccines

Do You Answer Medical Surveys?

Today, I had the opportunity to review a patient satisfaction survey from our allergy office. Now that COVID-19 pandemic isn’t at the top of everyone’s agenda (but may be changing soon with delta variant), I expect you’ll be asked to complete more surveys and as doctors, we’ll be asked to review more of your responses. This raises several questions for me and I hope you as well– I’ll share with you some “science” about answering survey questions, and you might just be surprised at the results.

  • Do you even answer medical survey questions?
  • How honest are you with your responses? Are you confident that changes will be made based on your survey responses?
  • Do you think doctors/providers really read their individual surveys?
  • Should compensation depend on your survey results?
  • Can I sue you if you have good patient satisfaction surveys? Does it matter?

Yes, we have to do something about our medical system, and hopefully, we’ll all do our part. As promised, there is actually information on what patients like or don’t like about their physician interaction that shows up in physician surveys. I’ll see if I can’t relate this to an allergy visit with surveys included.

What Patients Value in Physicians: Analyzing Drivers of Patient Satisfaction Using Physician-Rating Website Background: Customer-oriented health care management and patient satisfaction have become important for physicians to attract patients in an increasingly competitive environment. Satisfaction influences patients‘ choice of physician and leads to higher patient retention and higher willingness to engage in positive word of mouth. In addition, higher satisfaction has positive effects on patients‘ willingness to follow the advice given by the physician. In recent years, physician-rating websites (PRWs) have emerged in the health care sector and are increasingly used by patients. Patients‘ usage includes either posting an evaluation to provide feedback to others about their own experience with a physician or reading evaluations of other patients before choosing a physician.
Methods: We analyzed large-scale survey data from a German PRW containing 84,680 surveys of patients rating a total of 7038 physicians on 24 service attributes and 4 overall evaluation measures.
Results: The proposed approach revealed new insights into what patients value when visiting physicians and what they take for granted. Improvements in the physicians‘ pleasantness and friendliness have increasing returns to the publicly available overall evaluation (b=1.26). The practices’ cleanliness (b=1.05) and the communication behavior of a physician during a visit (b level between .97 and 1.03) have constant returns. Indiscretion in the waiting rooms, extended waiting times, and a lack of modernity of the medical equipment (b level between .46 and .59) have the strongest diminishing returns to overall evaluation.
Conclusions: The categorization of the service attributes supports physicians in identifying potential for improvements and prioritizing resource allocation to improve the publicly available overall evaluation ratings on PRWs. Thus, the study contributes to patient-centered health care management and, furthermore, promotes the utility of PRWs through large-scale data analysis.

J Med Internet Res 2020; 22(2):e13830

How about that? If you like your doctor, you are more willing to follow provider directions on the care prescribed. In allergy & asthma, this means using your inhaler as soon as you feel shortness of breath or wheezing, not just when you’re so sick the ER is the next logical decision. Or how about using a biological that takes care of your asthma by 1-2 shots per month?

Physician-rating websites can be very helpful if you’re choosing a physician. But buyer beware, some patients have used these PRW’s to “vent” their frustration with a medical office visit that reflects more of an emotional dislike for some aspect of the visit, rather than bad medical advice. On a personal note, I try and implement “shared decision making” with every patient that I see, but sometimes, I don’t end up on the same page as what meets patient’s expectation. For instance, I can tell you that you probably have asthma, and some are not ready to hear that. My advice: just let your doctor know about your concerns and 99% of the time, your questions are answered and life is good again. I can tell you from personal experience that doctors go to school for >10+ years to make patients happy and provide the best possible outcome for any medical condition.

  • So what will cause a “bad” rating on physician-rating websites? (or diminishing returns to the overall evaluation)
  • Indiscretion in the waiting rooms. Unfortunately, I’ve seen this too many times when health care providers or staff talk without discretion outside of the waiting room. Doors are never sound proof and no one wants to be “that guy” that feels embarrassed at what the office staff is saying about HIM. Never once did I think I’d have to say this, but social media doesn’t help with our lack of discretion. You can say what you want and when you want to on your favorite platform, whether it’s Facebook, Twitter, or even LinkedIn. Give some respect to even those that irritate you or you don’t agree with. My favorite sign I saw recently in a medical office: “viewer discretion advised!”
  • Extended waiting times will always hurt your P-RW. Nobody likes to wait, but it’s even worse if you don’t think the office or doctor cares about your time as well as theirs. From the outside looking in, it’s a challenge to get patients in when needed and at the same time, keep on schedule. I do try to apologize for making anyone wait > 15 minutes, but even that isn’t good enough at times. I understand your dilemma, and maybe that’s just a good reason to have surveys and pay attention to the results by changing schedule demands.
  • Lack of a clean office environment and modern equipment/facility is also a deterrent to favorable reviews according to the above study. This one is almost a “no-brainer” but even old chairs in the waiting room and otoscopes falling off the walls, probably don’t make you feel comfortable with the level of medical expertise in your doctors’ office. Granted, the medical advice you receive may still be correct even if the upholstery is ripped in the waiting room, or the exam tables were possibly used by your grandmother; you still want to hear medical advice in a clean, modern facility. As an example, medical offices are now “open” with large nursing stations rather than the old model of small exam rooms and nursing staff hidden in obscure corners, trying to hide from patients to not be bothered; the change is somewhat like our new kitchens!

So what have I really said so far? First of all, medical surveys are becoming another part of our health care system. Like it or not, patients will be asked for their opinion about medical care they received and doctors will be paid based in part on their performance. As expected, this can create some unintended consequences that I will talk about below. One of the positive benefits from patient interaction, which definitely includes patient satisfaction surveys is better relationships with your doctor and less conflict which has to be resolved by formal intervention such as lawsuits or arbitration. The best way to prevent malpractice claims is not perfection, but rather an improved physician-patient relationship.

A Survey of Sued and Nonsued Physicians and Suing Patients
Authors:Shapiro, Robyn S.
Simpson, Deborah E.
Lawrence, Steven L.
Talsky, Anne Marie
Sobocinski, Kathleen A.
Schiedermayer, David L.
Source:Archives of Internal Medicine; October 1989, Vol. 149 Issue: 10 p2190-2196, 7p
Publication Year:1989
Abstract:• To systematically assess the impact of malpractice litigation on the doctor-patient relationship and to collect data that might suggest effective tort reform, we surveyed 642 sued physicians, nonsued physicians, and suing patients in Wisconsin. Parallel forms of survey instruments obtained information regarding changes in physicians’ practices, changes in attitudes toward patients or physicians, and changes in physical and emotional well-being as a result of malpractice litigation or the threat of the same. In addition, opinions regarding causes and deterrents of malpractice litigation were obtained. Results suggested that claims or threats of malpractice suits had a negative impact on physicians’ practices and emotional well-being; that this negative impact was more pronounced when the sued physician had been more personally involved with his patient prior to the malpractice claim; and that suing patients’ and sued physicians’ understanding of their relationship before the malpractice claim significantly differed. All respondents viewed improved physician-patient communication as the most effective method of preventing malpractice claims. Informal, alternative dispute resolution mechanisms in hospitals and clinics and improved peer review may decrease litigation and its deleterious effects.(Arch Intern Med. 1989;149:2190-2196)

“As physicians, we want our patients to have not only better outcomes but also a positive experience of care,” gastroenterologist Shivan J. Mehta, MD, MBA, wrote in the AMA Journal of Medical Ethics® (@JournalofEthics). “If we care about the experience of our patients, why shouldn’t we measure it and strive to improve our performance?”

The answer is a complicated one, wrote Dr. Mehta, assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania and director of operations at the Penn Medicine Center for Innovation.

On the one hand, patient-experience scores can help physicians think more broadly about outcomes. They can also carry huge financial stakes, such as through the incentives and public disclosures that are Centers for Medicare & Medicaid Services’ efforts to improve quality through value-based purchasing.

But patient-experience measures aren’t infallible in their collection or their application. Following are three concerns about surveys for physicians, hospital administrators and policymakers to consider. Reference: https://www.ama-assn.org/delivering-care/ethics/3-legitimate-concerns-about-patient-experience-surveys

Patients may seek low-value treatments 

Physicians often spend less time than they would like with their patients, and can feel  pressure to expedite selection and explanation of treatment plans. When confronted with low patient-satisfaction scores—or even the threat of them—some doctors may assent to requests for low-value or unnecessary treatments that patients have come to expect.

One large study even showed that high patient satisfaction was associated with higher utilization, expenditure and mortality—the very opposite of high value.

What could this possibly mean for an allergy practice? Take for instance, a patient who comes in to the office with a chief complaint of headaches and wants to be tested for food allergy. The correct answer is most food allergy (ie, anaphylaxis) doesn’t cause isolated headaches and testing for foods won’t give you any clues about which foods to suspect anyway. A satisfaction survey would “ding” you because you didn’t provide something the patient was looking for, but wasn’t medically necessary.

Gains could concentrate at the top 

It’s typical for safety-net hospitals to score lower on patient satisfaction than hospitals that provide less care to underserved populations—not surprising given the challenges of caring for sicker populations with fewer resources—so it follows that one-size-fits-all financial incentives could produce even wider disparities in care and satisfaction.

https://www.ama-assn.org/delivering-care/ethics/3-legitimate-concerns-about-patient-experience-surveys

In addition, concerns over penalties for low satisfaction scores could cause physicians to avoid caring for more challenging patients, such as poorer people and persons with mental illness.

Responses can be suspect

Patients’ expectations and perceptions may not lend themselves to technical or objective measures of quality.

Also, voluntary surveys can be long and may not be filled out immediately following consultation or recovery, producing selection and recall biases in those with experiences at the extremes, and limited sample sizes can similarly skew results. There may even be a crowding-out effect of surveys on other, more reliable quality metrics.

“Physicians can no longer choose not to participate in, but they can decide how best to engage with, incentive programs,” Dr. Mehta wrote. “Patient experience scores should also be evaluated in the context of other clinician incentives, whether productivity or quality metrics.”

https://www.ama-assn.org/delivering-care/ethics/3-legitimate-concerns-about-patient-experience-surveys

So what can we do together to improve our physician-patient relationships and avoid the dread of patient surveys?

Be honest with your doctor….if you don’t agree on an issue, let them know in a courteous and respectful manner. You may even want to write a letter or e-mail at a different time to avoid a disruption in the medical office “flow”.

Options are always a plus. Working with your doctor to find a solution is often called “shared decision-making” and just like it says, you should have input regarding the medications you’re on and the concerns you have about your condition should be expressed in a friendly, open manner.

Unfortunately, blowing off steam at your doctor’s office through a practice survey is just that–hot air! Medical offices don’t usually change their protocols following angry criticism because this is usually an outlier on the scale meant to improve working relationships.

Do unto others as you would have them do unto you–this mantra has worked in the past, and should definitely improve our task of answering those pesky surveys!

#compensation-for-doctors, #patient-satisfaction-survey

Capsaicin for Nonallergic Rhinitis

February 5, 2021 by Alan Khadavi

Here’s the full update and thank-you Alan for sharing

Capsaicin nasal spray may be an effective treatment for patients who have nonallergic rhinitis. A significant proportion (25-30%) of patients suffering from rhinitis have nasal symptoms without an infection or allergies, this is referred to nonallergic rhinitis. Up to 50% of these patients have idiopathic #rhinitis after excluding work, elderly, gustatory, hormonal and drug induced rhinitis. Nasal steroid sprays are ineffective for this condition. Astelin, Atrovent are nasal sprays that have also been used for this condition and they have showed some improvement. But for others, these treatment options have failed. Capsaicin is the active ingredient of chili peppers. It is available as an over-the-counter nasal spray (ei, Sinus Buster, Sinus Plumber, others).

Capsaicin is another treatment option available for patients with idiopathic rhinitis. This treatment has limitations though, it can be uncomfortable, time consuming and incompletely understood in terms of its working mechanism. Research for better capsaicin treatment is needed.

A recent study looked at 2 different dosing of #capsaicin nasal sprays to see if it could suppress nasal symptoms. Daily nasal administration of low-dose capsaicin was well tolerated and reduced nasal symptoms. The study also evaluated the levels of Substance P which has been shown to be higher in patients with idiopathic rhinitis.

Symptom reduction was seen between 70-80% of patients with idiopathic rhinitis. Daily administration of low dose capsaicin was well tolerated and reduced nasal symptoms. Levels of Substance P were reduced and there was a positive correlation between Substance P and nasal obstruction, suggesting that rhinitis symptoms result from abnormally increased Substance P levels. As Substance P increases mucus secretion, suppressing it might represent a novel approach.

This study looked at different concentrations of Capsaicin nasal spray. There are various different manufacturers of Capsaicin spray, although the exact concentration isn’t well defined. As always speak to your doctor before beginning any treatment.  Patients who participated in this study were excluded from any allergies or infections prior to beginning treatment.

In conclusion, capsaicin low dose is effective in suppressing nasal symptoms and it may be a good, novel option for patients with non-allergic rhintis.

I have several reasons to write about “non-allergic” rhinitis.

  • Granted, this is the allergy season, but not everything that sneezes is allergy. Patients are always confused when skin testing is negative, yet they have consistent “allergy symptoms”. Heck, I even use the term “allergy” when I’m writing about non-allergic rhinitis.
  • Allergy has to have IgE (that’s the molecule binding to both allergens and subsequently to the mast cell causing histamine release). No IgE, no allergies and unfortunately, no allergy shots will work.
  • As Alan has mentioned, the typical nasal sprays such as Flonase and other nasal steroids don’t work well for this condition. Much of what you see advertised on TV is designed to encourage you to buy intranasal steroids, but many of those conditions are “non-allergic” rhinitis and listening to the TV ads won’t do you a bit of good.
  • I would disagree with the incidence of “non-allergic” rhinitis @ 30%–it’s more like the majority of rhinitis sufferers at ~70% and maybe more during the winter.
  • It is true that treatment of “non-allergic” rhinitis is frustrating because of lack of good nasal sprays, but PLEASE don’t give yourself capsaicin or hot pepper sauce in the nose before getting a prescription to dilute those hot babies down or you’ll be swearing at me all the way to the ER. Pepper spray will reduce that runny nose only if you compound the formula by an experienced pharmacist and deliver it into the nose carefully. Police grade pepper spray will get you into a whole lot of trouble!
  • As a research project, I’m looking into using nasal challenges for patients who have local allergic rhinitis and this may provide some additional use of desensitization even though skin testing and blood work is all negative for IgE. More on that later.
  • Bottom line: Not all that sneezes is allergy and a significant number of patients have runny nose, sneezing and sinus infections without having the opportunity to use allergy shots for desensitization.
  • If this is you, there is hope. See your local allergist for discussion about Astelin, Atrovent (hardly ever used), and if needed, I can work in conjunction with a local compounding pharmacy to get some capscaicin spray to help with that sneezing.

In the meantime, enjoy your tacos!

#if-not-allergy

Teen Saves Mom Driving with Anaphylaxis; Confusion on Labels

Quick thinking kid. Publishing a good outcome was really nice for a change. Thanks for the info

Published: February 4, 2021 Mom’s Scary Anaphylaxis at the Wheel Courtesy Bustin Family / Today Show A cool-headed 13-year-old saved his mom’s life …

Teen Saves Mom Driving with Anaphylaxis; Confusion on Labels

Johnson & Johnson’s single-dose vaccine 66% effective in global trial —

Jan 30, 2021 – 09:41 Kyodo News Building of the company Johnson and Johnson in the Juan Carlos I Business Park in Madrid, it is an American multinational of medical, pharmaceutical and perfumery products, Spain.(Getty/Kyodo) WASHINGTON – Major U.S. pharmaceutical company Johnson & Johnson said Friday that its single-dose experimental vaccine was 66 percent effective […]

Johnson & Johnson’s single-dose vaccine 66% effective in global trial —

Many patients are now asking about which COVID-19 #vaccine would be best for them. I find it best to summarize questions into a list:

  • The COVID vaccine is designed to illicit an immune response and headaches, fever, muscle aches are really not side effects at all, but rather your immunity “gearing up” to meet the real virus. There are now 2 vaccines that can do this, and one more probably on the way. (Johnson & Johnson)
  • Patients who have allergies always want to know if it’s safe to take the COVID vaccine given the fact that they have allergies. It is recommended that all Americans, regardless of their allergy status, receive some vaccine in order to prevent COVID-19 infections.
  • That being said, anyone can have a reaction to a viral vaccine, including COVID. These reactions can be anywhere from mild itching at the site of injection to anaphylaxis requiring assistance with your breathing. Yes, rates of these severe reactions are low, but here’s what’s important about allergic reactions to COVID vaccines: you can’t predict them.
  • Previous reactions to non-COVID vaccines should be noted and those patients should wait longer at the injection facility (up to 45 minutes) to make sure they will tolerate any allergic reactions. But still, you can’t predict who will react and who will tolerate the vaccine just fine. Allergies involve IgE ; an antibody that is unique to asthma, atopic dermatitis, hay fever, and even the production of eosinophils. We use IgE to predict who will develop an allergic reaction, and because IgE is not involved with COVID-19 infections or immunization, we can’t predict who will react and who won’t.
  • The Johnson & Johnson version of COVID-19 vaccination has not been approved by the FDA as of 2/16/21, but I expect it soon. This vaccine is DNA (not mRNA), but is implemented into the cell nucleus to produce the same Spike protein produced by both mRNA vaccines. Why the J & J version has fewer adverse events isn’t fully understood, but you’re likely to only get a mild fever with the DNA vaccination. What I like best about the J & J version is “one and done!”
New England Journal of Medicine–found on 2nd page of Google search

So does the new vaccine work well enough to keep me from getting COVID? It is helpful to search Google for your own answers as I did with the above article from NEJM. Find ZDogg.com to help you with questions about the vaccine and laugh a little bit in the process. What does appear to be reasonable about the new vaccine is:

  • Less effective compared to the 2 dose schedule (mRNA) in terms of MILD infection. In other words, you may still have cold like symptoms, but you won’t end up in the hospital, ICU, or death as we’ve seen so much with COVID-19.
  • One vaccination is all you require for at least this season and with the variants we currently know about. Just keep in mind that the influenza vaccination changes every year because of variants–who knows if COVID will be the same?
  • The CDC is your friend. Even though you may not agree with everything the CDC has done in the past year, they’re website gives you lots of great information that everyone can agree on. https://www.cdc.gov/coronavirus/2019-ncov/index.html (right click your browser and it will take you there)
  • We have so many options in fighting this year long COVID-19 pandemic and much information that is true can be found on reliable websites that I’ve mentioned above.

Whatever vaccine you decide to get, you’re working towards regaining our lives back–don’t give up now!

The Time Course of COVID-19 Vaccine Development–It’s Been Studied for a Long Time!

#anaphylaxis, #covid-19, #ige

Spring is Just around the Corner

What Am I Doing? It’s only 1 degree outside and I’m sharing about pollen?
Nothing to sneeze at: Climate change has worsened, lengthened pollen season across the US
Doyle Rice
USA TODAY
Published on Feb 8, 2021

As bleak as our winter has been, don’t be fooled by all that snow and freezing temperatures. Moisture in the form of snow and ice feeds the root systems of spring trees that will blossom by the end of this week. Warm winter coats and scarves will soon turn into light jackets and shorts. Your runny nose will no longer be a cold or viral infection, but will probably be classical hayfever due to tree pollen. This article from USA Today caught my attention not only for timeliness, but proven increase in the “pollen load” that our growing seasons are providing more warmth, length of season and generally more favorable conditions for growth of vegetation or “anything green!” I know, you can’t say the pollen season is starting early this year, but over the past 20 years, more ragweed is being collected based on the weight of this very important pollen than every before. What a job, right? I find it interesting that allergies are the only medical condition that patients are disappointed when they don’t have them. Even if your allergy testing is negative, enjoy learning the impact of pollen and where you find it!

Continue reading

#pollen-counts, #spring-trees

Reddit Has It All

Not sure I want to rinse my nose everyday for sinus problems, but here goes. I advise rinsing the nose for chronic sinusitis every day, but patients initially turn their nose up at this suggestion (pun intended). I find myself intrigued at the interest in nasal irrigation, flushing, or whatever else you want to call it. So who did I turn to but #Reddit Allergy. So what to my wondering eyes did appear, but questions abound for the right sinus rinse! Google search for sinus rinse yields > 7,000,000 hits and searching PubMed 750–you think there might be a problem there? Misinformation abounds and of course every advertiser/company has the best product! Who do you believe? I’m about to give you some guidelines that you can rest assured have at least been studied in one published article. And by the way, to answer your question below, if the water doesn’t come out the other side, you’ve got nasal congestion that needs further evaluation by your allergist or ENT. My comments are highlighted in RED in the lists after each article. There is no test at the end, but maybe next time….

For the Reddit Junkies
One of the few articles published on the true effects of nasal irrigation!
  • Budesonide is a steroid that can always be added to ANY device you use to flush the nose
  • When you hear “double-blind, placebo-controlled, randomized clinical trial” you’re on the right track to some real (and reliable) research. In this study participants didn’t know if they were getting budesonide or placebo; now remember, in any study the placebo effect can be as high as 30-40% and this is why you can’t make recommendations only based on your treatment “experience”.
  • SNOT-22 score–really? Let me know if you want more information on this one. No takers yet!
  • The results? Budesonide was better than saline for the sinuses, but it’s difficult to measure clinically meaningful benefits to sinus treatment. And who’s going to admit to a better SNOT score?
  • The good news: no side effects noted with the irrigation; so it may look bad, but won’t hurt you!

Here’s the abstract from the above study–>

IMPORTANCE: Recent studies suggest that budesonide added to saline nasal lavage can be an effective treatment for patients with chronic rhinosinusitis (CRS). PARTICIPANTS: This double-blind, placebo-controlled, randomized clinical trial was conducted at a quaternary care academic medical center between January 1, 2016, and February 16, 2017. A total of 80 adult patients with CRS were enrolled; 74 completed baseline assessments; and 61 remained in the trial to complete all analyses. Data analysis was conducted from March 2017 to August 2017. INTERVENTIONS: All study participants were provided with a sinus rinse kit including saline and identical-appearing capsules that contained either budesonide (treatment group) or lactose (control group). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the change in Sino-Nasal Outcome Test (SNOT-22) scores, pretreatment to posttreatment, in the budesonide group compared with the control group. Secondary outcome measures included patient-reported response to treatment, as measured with a modification of the Clinical Global Impressions scale, and endoscopic examination scored by the Lund-Kennedy grading system. RESULTS: Of the 74 participants who completed baseline assessments (37 in each study arm), mean (SD) age, 51 (14.7) years, 50 (68%) were women. Of the 61 who remained in the trial to complete all analyses, 29 were randomized to budesonide treatment, and 32 to saline alone. The average change in SNOT-22 scores was 20.7 points for those in the budesonide group and 13.6 points for those in the control group, for a mean difference of 7 points in favor of the budesonide group (95% CI, -2 to 16). A total of 23 participants (79%) in the budesonide group experienced a clinically meaningful reduction in their SNOT-22 scores compared with 19 (59%) in the control group, for a difference of 20% (95% CI, -2.5% to 42.5%). The average change in endoscopic scores was 3.4 points for the budesonide group and 2.7 points for the control group. There were no related adverse events. CONCLUSIONS AND RELEVANCE: This study shows that budesonide in saline nasal lavage results in clinically meaningful benefits beyond the benefits of saline alone for patients with CRS. Given the imprecision in the treatment effect, further research is warranted to define the true effect of budesonide in saline nasal lavage.

Adults have chronic sinusitis too!
  • Inflammation is once again the key to sinus problems even in the adult population.
  • 1-2% of total physician visits, not just allergists or ENTs. Very impressive.
  • Evidence-based approach to assist in optimizing patient care is the “Holy Grail” of being a doctor. If only we had this for COVID-19. Truth of the matter is, it takes years to analyze and accumulate enough data to make statements about evidence-based medicine, so for some issues, you’ll just have to wait.
  • I won’t bore you with the details, but these results come from HUUGE databases such as MEDLINE and Cochrane. It’s nice to be able to “mine the database” and combine multiple studies in the analysis of your final conclusion.
  • Compared with no treatment, saline irrigation was good, “add-in” topical steroids were better; leukotriene antagonists (Singulair) and oral antibiotics also showed improvement in not just sinusitis, but also resolution of nasal polyps.
  • And now let me introduce DUPIXENT! Approved for use in treatment of nasal polyps even without steroids. That is the problem with research–shelf life isn’t the greatest.

I’ve included the abstract below for easier reading–>

IMPORTANCE: Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the Sino nasal cavities lasting longer than 3 months. It accounts for 1% to 2% of total physician encounters and is associated with large health care expenditures. OBJECTIVE: To summarize the highest-quality evidence on medical therapies for adult chronic sinusitis and provide an evidence-based approach to assist in optimizing patient care. EVIDENCE REVIEW: A systematic review searched Ovid MEDLINE (1947-January 30, 2015), EMBASE, and Cochrane Databases. FINDINGS: Twenty-nine studies met inclusion criteria: 12 meta-analyses (>60 RCTs), 13 systematic reviews, and 4 RCTs that were not included in any of the meta-analyses. Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42 [95% CI, 1.01 to 1.84]; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]; a negative SMD indicates improvement), improved polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]). Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P < .001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P < .01). Macrolide antibiotic for 3 months was associated with improved QOL at a single time point (24 weeks after therapy) compared with placebo for patients without polyps (SMD, -0.43 [95% CI, -0.82 to -0.05]). CONCLUSIONS AND RELEVANCE: Evidence supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis. A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps. A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps.

  • Fungus among us–we don’t think very often about fungal sinus infections, but in this study, symptoms improved with antifungal treatment. Fortunately, this is topical amphotericin B as the IV route was called “amphoterrible” for good reason.
  • IgE is an antibody used for diagnosis and treatment of allergic rhinitis (one of the biological measurement of IgE is skin testing), but can also be used to measure inflammation due to infection.
  • In this study, almost 25% of ALL participants had recurrence of chronic sinusitis, but it was improved in the amphotericin B rinse group. IgE went down as well. It’s nice to know that something works for sinus problems, but now that we have DUPIXENT, the results are probably even more of a game changer!

OBJECTIVE: To determine the effect of topical antifungal irrigation fluid containing amphotericin B on nasal polyp and their recurrence pattern, and to study the association of serum IgE in predicting the presence of fungus along with the nasal polyps. METHODOLOGY: All adult patients having nasal polyps, who had not undergone any previous nasal surgery, were included in the study. Patients aged under 18 years, history of granulomatous diseases, immunosuppression, invasive fungal sinusitis, and pregnant ladies were excluded from the study. The ratio was kept as 1:2; one receiving irrigation with amphotericin B and the other only saline nasal irrigation without the medicine. Serum IgE level of more than 250 ng/ml was taken as a high value. RESULTS: A total of 87 patients were inducted. Overall 22 (25.3%) patients had recurrence of symptoms at six-month followup visit. Twelve (13.7%) of these were in the placebo group and 10 (11.5%) were in the amphotericin B nasal irrigation group. Serum IgE level preoperatively ranged between 52 – 9344 ng/dl; postoperatively it ranged from 13-1050 ng/dl. CONCLUSION: Amphotericin B improved the CT scan score of the patients. The nasal irrigation of amphotericin B did not show significant change in the recurrence pattern of chronic sinuses with polyps. Serum IgE can be used as marker for the presence and response to treatment for non-invasive fungal sinusitis.

  • Bacteria have evolved sneaky ways to protect themselves from death by antibiotics. Thus, bacterial infections in the form of adherent biofilms are frequently implicated in the pathogenesis and recalcitrance of chronic rhinosinusitis. You dirty rat! That’s for you Jimmie Cagney from “Taxi” (actually a misquote, but that’s for another time!)
  • Lots of methods to suck out your boogers from battery powered to suction from your own mouth into a separate “trap”. Oh parents will do anything to suck out moist mucous!
  • Who would be recruited for this study? Yuck
  • We are left with that SNOT score again to measure any benefit from our treatment with the Snot Sucker.
  • Battery powered nasal irrigation (snot suckers) came up with 2.5 million hits on Google–it’s popular.

I copied parts of the above abstract for details–>

The Hydrodebrider, a disposable powered irrigation and suction device, has been developed specifically to remove biofilm from the paranasal sinuses. We conducted a prospective study to evaluate the tolerability and efficacy of the Hydrodebrider in the office setting with the use of local anesthesia. Of the original 13 adults we recruited, 10 completed the entire study protocol. All enrolled patients had previously undergone sinus surgery that involved the creation of a maxillary antrostomy large enough to allow placement of a Hydrodebrider device, and the endoscopic findings in all patients were consistent with chronic sinusitis. In conclusion, powered irrigation with suction is a well-tolerated procedure in the office setting and might be a useful short-term adjunct in the management of recalcitrant chronic sinusitis.

Surely, there has to be some conclusions from all this?

  • Don’t get overwhelmed with all of the choices for cleaning out your nose.
  • Using nasal irrigation can include antibiotics, topical steroids, anti-fungal medication, baby shampoo just to name a few. Every doctor who deals with this has their own cocktail.
  • Although clinical research shows that nasal irrigation has a place in the treatment of chronic sinusitis & nasal polyps, you may just want to see your allergist for more aggressive measures such as allergy immunotherapy (AIT), Dupixent, Fasenra, Xolair or many of the other biologics available to treat nasal polyps and chronic sinusitis without using all of those steroids.

#chronic-sinusitis, #nasal-flush, #neil-med-irrigation, #netti-pot, #sinus-irrigation

1-year-old Oklahoma girl fighting COVID-19 transferred to multiple hospitals in order to find an available bed

This is what we all want to avoid….no room in the inn!

As rural Oklahoma hospitals continue to stay full, medical officials tell KFOR they are having to send more patients miles away to metro areas. However, metro hospitals reveal they are already fill…

Source: 1-year-old Oklahoma girl fighting COVID-19 transferred to multiple hospitals in order to find an available bed

What Else Besides Allergy Shots?

If you’re like me, I don’t think of allergies during the holiday season. But wait. Spring season here in Tulsa is less than 3 months away, and this year we’ll probably have a #COVID-19 vaccine by the time Spring hits in full bloom. I’m quite amazed at the ignorance surrounding the use of allergy shots, even by physicians.

Continue reading

#allergy-shots-2, #chronic, #chronic-sinusitis, #warren-clinic-allergy

National Jewish Health Study May Offer Hope For People With Multiple Food Allergies

A clinical trial is underway at National Jewish Health to see if eating small, gradually increasing amounts of three of those allergens, along with a medication, can prevent a severe reaction.

Source: National Jewish Health Study May Offer Hope For People With Multiple Food Allergies

Much is now being published about food allergy–the main question for researchers is can patients be desensitized to foods safely? At Warren Clinic the answer is yes! We’re working with a product called Palforzia which gives you small amounts of peanut over the course of one day and then every 2 weeks thereafter–it’s working great and patients really love the idea of tolerating the food (peanut) they have dreaded for so many years.

But there is much more to treating food allergy than just desensitization. The above article reports a study at National Jewish Health that adds a common asthma medication, Xolair, to food challenges. This process would be especially helpful for those patients with multiple allergies as Jeremiah in this report can’t tolerate > 6 foods. That is a bummer! Be thankful you don’t have that many food allergies, but also be thankful for new research that is looking for a cure!