I thought it might be a good idea to write my weekly post early this week since there is so much anxiety about swine flu.

The media and officials in many countries have contributed to much fear and misunderstanding which may turn out to be more harmful than swine flu itself.  Let me try to shed some light without raising the heat.

The swine flu virus has been around for a long time as a cause of respiratory illness in pigs.  Sporadically, it has caused illness in humans who had a lot of contacts with pigs.  What’s unusual now and causing concern is that the swine flu virus for the first time has recently evolved the ability to be transmitted from person to person.  (By the way, though unfortunate, this is a beautiful demonstration of evolution happening before our eyes.  Yay, Darwin!)  The swine flu that is currently infecting humans is a blend of genes from the avian flu, the human flu and the swine flu.  Not surprisingly, given its makeup, it causes an illness in humans just like the flu.  Meaning (human) patients with the swine flu have fever, muscle aches, a cough and sore throat, just like a regular flu.

At this point the attentive reader is asking “But the swine flu must be worse than the regular flu, otherwise, why the big kerfuffle?”  Nope.  There is no reason to believe that the swine flu causes an illness worse than the regular flu.  As of today, 40 cases have been identified in the US.  There have been no fatalities and only one hospitalization.  All of the patients have recovered.

“So why the hubbub?”

Well, what makes this unusual and to public health officials potentially worrisome is that there is a new virus that can spread from human to human and it has about 6.7 billion potential hosts to infect that don’t have immunity for it.  Old viruses, like measles or chicken pox, can cause a little outbreak here or there, but most people are immune either due to vaccination or because they already had the disease.  Other old viruses like the regular flu or cold viruses constantly change, so they can infect new people all the time, but there’s still only a limited population that hasn’t been exposed to the current strain.  What’s different now is that, depending on the rate of spread of this virus, we might all catch it at about the same time.  That’s not a big deal for most of us.  Again, the illness won’t be worse than a regular flu.  But imagine if even a quarter of the 3.8 million people in Los Angeles had the flu at the same time.  The consequences for the vast majority of individuals would be just a major inconvenience, but for the frailest among us, and for public health and safety services, it would be catastrophic.

“But what about all the fatalities in Mexico?  Those numbers sound a lot worse than a regular flu.”

There have been some fatalities from respiratory illnesses in Mexico.  Some of them have not been confirmed to be from the swine flu, but some have.  Some of the apparent difference in severity between the cases in the US and the cases in Mexico has to do with the very aggressive surveillance and tracking being done by the CDC in the US.  The CDC is aggressively trying to find as many cases as possible in the US, so the 40 cases that we know about are the result of those efforts.  In Mexico there’s no way to know how many cases there have been.  Some of the cases only came to the attention of public health officials because they were fatalities.  So Mexico may have had thousands or tens of thousands of undiagnosed cases which recovered without treatment, and dozens of fatalities which were noticed.  Just like a regular flu season.  (Statisticians call this a sampling error – an apparent difference between two groups when no actual difference exists caused by sampling the two groups differently.)

“But won’t the swine flu get more lethal as it mutates?”

There’s no way to tell how the swine flu will change in the future, but what we know about previous epidemics suggests that it won’t get more lethal.  A mutation that makes the virus more quickly incapacitating and lethal is unlikely to be passed on to other hosts.  On the other hand a mutation that makes the disease milder so that the host goes to work, doesn’t feel so bad, and coughs all over his coworkers for the next two weeks before recovering will infect a lot more people.  That’s why in general epidemics get milder as time goes on, not more severe.

“I’ve been avoiding eating pork.”

That might be good for your cholesterol, but you can’t get swine flu from eating pork.  It’s transmitted from person to person, like the regular flu.

“What do I do if I get sick?”

If you develop flu symptoms, don’t go to work.  Cover your cough.  Call or see your doctor right away, since the same anti-viral medicines that shorten the duration of the regular flu work for the swine flu also.

“So I should call my doctor now, and demand a prescription for anti-viral medicine just to have around in case I get sick later?”

No.  You should not get anti-viral medicine unless you are sick.  We will not run out of anti-viral medicine.  By the way, what happened to that Cipro you forced me to prescribe for you back in 2001 because you were worried about anthrax?

“I still have that.  It’s got cobwebs on it.  Is there anything I can do to avoid getting sick?”

Avoid sick people.  Wash your hands frequently.

“So we’re not all doomed?”

No.  The world will not end because of the swine flu.

“But what about the coming zombie apocalypse?”

Well!  Look at the time!  Gotta go.

Learn more:

The Centers for Disease Control and Prevention swine flu information page

Today’s press briefing from the Centers for Disease Control and Prevention

Do your homework about zombies before it’s too late

In the last year I’ve written about a major change in our understanding of diabetes treatment.  The goals of treatment used to be to get blood glucose as close to normal non-diabetic levels as possible.  That usually meant increasing medication doses or adding additional medications until the glycated hemoglobin was down to normal.  (Glycated hemoglobin, or hemoglobin A1c, is a blood test that measures an average of blood glucose over the previous 3 months.)  Targeting normal glycated hemoglobins frequently meant complex medication regimens, occasional low blood sugars and the side effects caused by the medications.  But we were willing to accept this because we thought that getting the glycated hemoglobin down to normal prevented strokes, heart attacks, and other complications of diabetes.

Then the ACCORD and ADVANCE studies turned that thinking on its head.  They were both large randomized trials that looked at the effects of strict glucose control on outcomes in diabetes.  Rather than confirm the benefits we assumed, they showed that diabetics who were treated to get their glucose down to the normal range did no better (and in one trial did worse) than diabetics who were treated with more lax glucose control.  Suddenly the goal for the glucose and the glycated hemoglobin was no longer clear.  How low should we go?

A perspective article just released in the Annals of Internal Medicine attempts to review the issue and make recommendations.  The review reminds us of what we definitely know about tight blood-sugar control in diabetes: it causes more frequent hypoglycemia, more weight gain, and frequently requires a more complex and more expensive medication regimen.  But the benefits are now uncertain.  The article suggests that we instead focus on the interventions that have proven benefit in diabetes: smoking cessation, blood pressure control, cholesterol control, dietary modification and exercise.

The authors suggest for the glucose goals:

“Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients’ personal and clinical context and their informed values and preferences.”

Which sounds to me like a nice way of saying “We’re not really sure what we’re doing any more, so try to prescribe medicines that the patient can afford and won’t cause harm, and focus on the sugars a little less.”

Learn more:

Annals of Internal Medicine article:  Glycemic Control in Type 2 Diabetes: Time for an Evidence-Based About-Face?

My previous posts:

What We Don’t Know About Diabetes – Part 1

What We Don’t Know About Diabetes – Part 2

Several of my patients have developed nasty colds in the last few weeks, so it seemed like a good time to cover this perennial source of misery.  Even though the cold is one of the most common illnesses, many people are still confused about how to treat it and how to distinguish it from other illnesses.

Symptoms
Colds typically cause a scratchy or sore throat, runny or congested nose, cough and fatigue.  There is usually no fever.

Cause
Colds are caused by viruses, typically rhinovirus, coronavirus or respiratory syncitial virus, though many other viruses can be the culprit.

Diagnosis
There is no specific test that is usually done to diagnose a cold.  The diagnosis is usually made by the presence of typical symptoms in the absence of symptoms suggesting another diagnosis.

Treatment
The treatment of colds causes much misunderstanding and grief.  Antibiotics don’t help, and in fact nothing has been found that decreases the duration of symptoms.  The cold always resolves which makes it a prime candidate for quackery, since whatever you take for your cold you’ll definitely improve.  Nevertheless, many of my patients swear by vitamin C and Echinacea despite the consistent evidence for their lack of efficacy.  The best you can do is to treat the symptoms so as to minimize the misery until the cold resolves on its own.

Pseudoephedrine (Sudafed and generic store brands) is fairly effective for treating nasal congestion.  That can also help decrease the sore throat and the cough that are frequently caused by post-nasal drip.  In California, pseudoephedrine is no longer on the shelf.  Patients need to ask for it at the pharmacy counter and show identification.  This has also caused much confusion as patients have mistakenly purchased phenylephrine (Sudafed PE) which is available on the shelf but is less effective.  Pseudoephedrine should be used with caution in patients with high blood pressure and in men over 50.  It also makes some people feel jittery and can cause insomnia.  For patients who can not tolerate pseudoephedrine, there is a safe alternative by prescription.

Over the counter cough suppressants (containing dextromethorphan) can help decrease coughing, though they are usually only modestly effective.  Pain relievers can help with sore throat.  Non-medicinal alternatives like inhaling steam can help loosen mucous and can soothe irritated airways.

Prevention
Colds are very infectious, and no prevention method is perfect.  Frequent hand washing and avoiding people with the cold are probably the most effective steps.

Some other diagnoses that should be excluded

• Streptococcal pharyngitis, or Strep throat, is usually marked by a severe sore throat, fever and swollen lymph nodes in the neck.  Nasal symptoms and cough are usually absent.  Viruses frequently cause these same symptoms and a rapid Strep test or throat culture should be done to confirm the presence of Strep.  Strep throat requires antibiotic treatment.
• Otitis media (middle ear infection) usually causes pain in one ear.  Fever and nasal congestion may be present.  It is usually diagnosed by the doctor looking at the eardrum.  It is usually treated with antibiotics.
• Influenza (the flu) causes high fevers, chills, cough and diffuse body aches.  It can be diagnosed with a nasal swab and treated with antiviral medicines, ideally in the first 48 hours of symptoms, so call your doctor right away.
• Acute sinusitis (sinus infection) causes pain or pressure in the cheeks or forehead or upper tooth pain, and usually fever.  Antibiotics used to be the standard of care for sinusitis, but current recommendations are to use nasal decongestants and pain medicine for 7 days and to prescribe antibiotics only if symptoms persist after that.
• Acute bronchitis is an infection of the airways marked by a productive cough and usually low-grade temperatures.  It is usually caused by viruses and resolves without antibiotics.
• Pneumonia is a lung infection, usually marked by high fever, shaking chills, a productive cough and sometimes shortness of breath.  It requires medical attention and usually is treated with antibiotics.

Now that you’re an expert at managing the common cold, your medical education is well on its way.  Next week you’ll be performing organ transplants.

Learn more:

WebMD Guide to the Common Cold

My review of acute bronchitis

My review of vitamin C in prevention and treatment of the common cold

I’ve written before of the perverse incentives created by the price-fixed healthcare insurance model which reimburses every doctor the same fee for each service provided, promoting quantity rather than quality.  Recently, policy makers and insurance companies have noticed this problem too (over 30 years after they caused it).  They are slowly realizing that they are paying doctors to treat as many patients as they can, but not to treat them well.

There is now a major drive by policy makers for state and federal health systems and by private insurers do develop criteria by which to measure the quality of care that is delivered and to base payments to physicians and to hospitals on these measurements.  The various plans are called “pay for performance”.

Wednesday’s Wall Street Journal featured an op-ed by Dr. Jerome Groopman and Dr. Pamela Hartzband, faculty members of Harvard Medical School, who explain the terrible consequences of Massachusetts’s “pay for performance” programs.  Doctors are publicly scolded for failing to meet arcane criteria.  Rigid guidelines are inappropriately applied to complex patients.  Recommendations that are out-of-date are used to measure physician performance and to determine reimbursement.  The op-ed argues powerfully that these efforts are harmful to patients.  I urge you to read the op-ed (link below) for a frightening look at the growing medical bureaucracy.

The underlying assumption that prompts these misguided efforts to measure medical quality is that healthcare is too complex a field for the patient to figure out.  How can someone with no medical training possibly be a sophisticated healthcare consumer?  And if she can’t, shouldn’t we have policy makers define and demand quality for her?

But this assumption is false.  Savvy consumers shop for products and services all the time despite the fact that they don’t have specialized training in that field, and some of these products are far more complex than healthcare.  Customers with no technical knowledge can be very discriminating shoppers.  We buy cars, video game consoles and computers and hire architects and lawyers without a detailed understanding of the product or service we’re receiving.  How?  By using well-established markers of quality that don’t rely on expertise.  We read reviews; we look for businesses with long traditions in the same location and widespread positive reputations; we look for objective certifications of high quality.

Similarly, in healthcare, savvy patients insist on a physician who is board certified.  They check for complaints against a doctor’s license.  They ask for hospital and university affiliations, knowing that elite institutions will exercise some scrutiny over their staff.  Since patients have no way to test a doctor’s training directly, they expect ongoing education (and preferably teaching) as evidence of current knowledge.

In every other marketplace it’s the customer who pays for performance.  Excellence and affordability will be restored to healthcare when patients are allowed to keep and spend their own healthcare dollars and shop around.

Learn more:

Wall Street Journal opinion article: Why ‘Quality’ Care Is Dangerous

or, Malaria Makes a Bad Souvenir
or, I Went on Safari and all I Got Was Hepatitis A

We Americans take for granted much of what keeps us healthy.  We expect our food and water to be uncontaminated.  We expect the neighbor’s dog to have had all his shots.  We expect that if we get sick we will receive prompt and excellent care.  Then, when we travel to the developing world, we forget that none of our expectations apply.  We plan our itinerary, our meals, even our web access, but we forget to plan for our health.

But staying healthy abroad requires planning.  Some of the required vaccines take a month to be effective.  So see your doctor at least a month before you travel.  Before the visit review the Centers for Disease Control recommendations at their Traveler’s Health website (link below).  The website allows you to enter your destination and then gives you up-to-date recommendations for vaccinations, preventive medications and other precautions for that part of the world.  Besides recommendations for your physician, the website has very important recommendation for you, such as how to avoid mosquito bites, reminders to avoid pets (that cute puppy may have rabies!), and advice for avoiding contaminated food and water.

If you take prescription medications, make sure you have enough with you for the whole trip.  (I’m happy to fax a prescription to Tanzania for you, but I’m not sure where the great pharmacies are.  By “great”, I mean pharmacies with a fax machine.)  Since travelers and their checked luggage occasionally get separated, essential medications should be in your carry-on luggage.

So please remember, jaundice and fever do not make for happy leisure time.  Plan ahead to make your vacation memorable and healthy.

Learn more:

The Centers for Disease Control and Prevention Traveler’s Health website