Re: Managing H1N1 in the trenches

[Guest guest]

Pedro,

I am in the midst of quite a little epidemic here in Virginia.

Lots of cases although only one school has shut down (so far). Although some

people do get really sick, most do just fine. I am just telling parents (as

this is really hitting school aged kids hard) to use motrin and Tylenol and

keep the child quarantined until 24 hours after the fever breaks. I am no

longer giving Tamiflu unless there is potential exposure to a high risk

individual. Most of the time, the fever breaks in 2-3 days and the kids are

back out playing quickly. I have had one patient who needed zithromax (X-ray

confirmation of pneumonia 24 hours after the rapid flu test was positive), but

that was unusual and the kid did not respond as quickly as I wanted him to so

it was obvious we needed to do more. With all my patients, I give good access

and encourage them to call if anything is not improving as it should. Parents

know and I trust their judgement.

I would not give steroids or albuterol unless there was wheezing

and a history of asthma. I would not worry about the rest thing as most will

automatically rest until they feel better. Perhaps I am missing the boat, but I

am concerned that intervening (beyond giving the vaccine) may do more harm than

good.

From:

[mailto: ] On Behalf Of Pedro

Ballester

Sent: Monday, October 19, 2009 8:06 PM

To: Clinical Procedures; practiceimprovement1

Subject: Managing H1N1 in the trenches

I have decided that I will treat aggressively all my patients with flu

diagnosis:

Medrol Pak

antibiotic Rx appropriate for outpatient CAP treatment

albuterol MDI

Tamiflu only if within the first 48 hours of onset of Sx

rest for a week

Contemplating phoning in Rxs to a pharmacy that will deliver to the patient's

home if I can't see the patient or he/she sounds too ill to come in (advise to

call 911 if they sound really bad?).

Admit earlier rather than later if there are any concerns

I found some contradictions in the steroid recommendations, I suspect there are

cytokines involved in the cases of young people that have become ill quickly,

maybe early steroids can help prevent the ARDS.

Comments?

tangential link: http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

Pedro Ballester, M.D.

Warren, OH

[Guest guest]

Thanks, I may be panicking...I am trying to figure out what is the safest, most aggressive course of treatment.Pedro Ballester, M.D.Warren, OH

[Guest guest]

It doesn't look like there is sufficient data in this area to suggest the routine administration of corticosteroids.Steroids are indicated in those patients who also suffer HPA suppression as a result of the infection, but this type of testing is time consuming.  Rat studies suggest a dose of 70 mg prednisone daily might be sufficient to reduce pulmonary lesions caused by the hypercytokinemia, but too much steroid also suppresses the immune system.  A period of 7 - 10 days of treatment may be required combined with antiviral therapy.

People have also looked at adjuvant treatment using macrolides ( presumably as pulmonary anti-inflammatory agents ).http://jmm.sgmjournals.org/cgi/reprint/56/7/875

 

Pedro,

I am in the midst of quite a little epidemic here in Virginia.

Lots of cases although only one school has shut down (so far). Although some

people do get really sick, most do just fine. I am just telling parents (as

this is really hitting school aged kids hard) to use motrin and Tylenol and

keep the child quarantined until 24 hours after the fever breaks. I am no

longer giving Tamiflu unless there is potential exposure to a high risk

individual. Most of the time, the fever breaks in 2-3 days and the kids are

back out playing quickly. I have had one patient who needed zithromax (X-ray

confirmation of pneumonia 24 hours after the rapid flu test was positive), but

that was unusual and the kid did not respond as quickly as I wanted him to so

it was obvious we needed to do more. With all my patients, I give good access

and encourage them to call if anything is not improving as it should. Parents

know and I trust their judgement.

I would not give steroids or albuterol unless there was wheezing

and a history of asthma. I would not worry about the rest thing as most will

automatically rest until they feel better. Perhaps I am missing the boat, but I

am concerned that intervening (beyond giving the vaccine) may do more harm than

good.

 

From:

[mailto: ] On Behalf Of Pedro

Ballester

Sent: Monday, October 19, 2009 8:06 PM

To: Clinical Procedures; practiceimprovement1

Subject: Managing H1N1 in the trenches

 

 

I have decided that I will treat aggressively all my patients with flu

diagnosis:

Medrol Pak

antibiotic Rx appropriate for outpatient CAP treatment

albuterol MDI

Tamiflu only if within the first 48 hours of onset of Sx

rest for a week

Contemplating phoning in Rxs to a pharmacy that will deliver to the patient's

home if I can't see the patient or he/she sounds too ill to come in (advise to

call 911 if they sound really bad?).

Admit earlier rather than later if there are any concerns

I found some contradictions in the steroid recommendations, I suspect there are

cytokines involved in the cases of young people that have become ill quickly,

maybe early steroids can help prevent the ARDS.

Comments?

tangential link: http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

Pedro Ballester, M.D.

Warren, OH

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

Wow. I, too, am seeing a lot of this. In general, I send them home and they get

better in 3-7 days. I know of no need for any of these other treatments for an

uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

>

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

[Guest guest]

Here is the latest in recommendations from the CDC.Couple interesting algorithms attached from CDC, too.See below. Locke, MD===================================http://www.cdc.gov/h1n1flu/recommendations_pediatric_supplement.htm

Recommendations for Use of Antiviral Medications for the Management

of Influenza in Children and Adolescent for the 2009-2010 Season --

Pediatric Supplement for Health Care Providers

October 16, 2009 5:00 PM ET===============================http://www.cdc.gov/h1n1flu/recommendations.htm

H1N1 Flu Clinical and Public Health Guidance

On this Page

Vaccination Guidance for State, Local, Tribal & Territorial Health OfficialsClinician Guidance

Clinician Guidance for Specific AudiencesInfection ControlLaboratory Testing

Guidance for PatientsGuidance for Pregnant and Breastfeeding WomenBusiness and Employer Guidance

Emergency Personnel GuidanceGuidance for Schools, Colleges and UniversitiesTravel and Travel Industry Guidance

For additional guidance, see Flu.gov.

Vaccination Guidance for State, Local,

Tribal and Territorial Health Officials

Information for Vaccine Planners Jul 24Template Letter for Healthcare Providers about the Vaccine Adverse Event Reporting System (VAERS) Oct 6

Epidemiology and Surveillance

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season Sep 29

Interim Guidance for Influenza Surveillance: Prioritizing RT-PCR Testing in Laboratories Oct 9Interim Guidance for Reporting Influenza-Associated Hospitalizations and Deaths Sept 8

Clinician Guidance

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season Sep 29

Antiviral Recommendations Oct 16Pediatric Supplement Recommendations Oct 16

Updated

Interim Recommendations for Obstetric Health Care Providers Related to

Use of Antiviral Medications in the Treatment and Prevention of

Influenza for the 2009-2010 Season Sep 22Interim Guidance for the Detection of Novel Influenza A Virus Using Rapid Influenza Diagnostic Tests Aug 10

10 Actions Steps for Medical Offices and Outpatient Facilities July 142009-2010 Influenza Season Triage Algorithm for Adults (>18 Years) With Influenza-Like Illness  Oct 2

2009-2010 Influenza Season Triage Algorithm for Children (≤18 years) With Influenza-Like Illness  Oct 16

Identifying and Caring For Patients May 4Emergency Use Authorization (EUA): Medical Products May 7

Clinical Data Collection Forms and Templates May 12Interim guidance for use of 23-valent pneumococcal polysaccharide vaccine during novel influenza A (H1N1) outbreak Jun 9

2009 H1N1 Flu and Seasonal Flu Information for Rheumatology Health Professionals Oct 15

Clinician Guidance for Specific Audiences

Updated

Interim Recommendations for Obstetric Health Care Providers Related to

Use of Antiviral Medications in the Treatment and Prevention of

Influenza for the 2009-2010 Season Sep 17Considerations Regarding Novel H1N1 Flu Virus in Obstetric Settings Jul 6

Patients With Cardiovascular Disease May 2HIV-Infected Adults and Adolescents Jun 5

Pregnant Women Jun 30Infants and Young Children May 13

Patients with Asthma Oct 2Patients with Arthritis Oct 15

Infection Control

Interim

Guidance on Infection Control Measures for 2009 H1N1 Influenza in

Healthcare Settings, Including Protection of Healthcare Personnel

Oct 14Q & A:

CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1

Influenza in Healthcare Settings, Including Protection of Healthcare

Personnel Oct 14Q & A: Respiratory Protection For Preventing 2009 H1N1 Influenza Among Healthcare Personnel Oct 14Considerations Regarding Novel H1N1 Flu Virus in Obstetric Settings

Jul 6Interim Guidance for Homeless and Emergency Shelters on the Novel Influenza A (H1N1) Virus Jun 16

Post-mortem Care and Safe Autopsy Procedures for Novel H1N1 Influenza May 28Interim Guidance for Correctional and Detention Facilities on Novel Influenza A (H1N1) Virus May 24

Interim

Biosafety Guidance for All Individuals handling Clinical Specimens or

Isolates containing 2009-H1N1 Influenza A Virus (Novel H1N1), including

Vaccine Strains Aug 15Infection Control in Outpatient Hemodialysis Centers May 8

Questions

and Answers about CDC’s Interim Guidance on Infection Control Measures

for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of

Healthcare Personnel Oct 14

 

Laboratory Testing

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season Sep 29

Interim Guidance for the Detection of Novel Influenza A Virus Using Rapid Influenza Diagnostic Tests Jul 29Specimen Collection, Processing, and Testing for Suspected Infection May 13

Submission of Tissue Specimens for Pathologic Evaluation May 23Protocol for Antiviral Susceptibility Testing by Pyrosequencing

Sequencing Primers and Protocol

CDC Protocol of Realtime RTPCR for Swine Influenza A(H1N1)

DSAT Guidance on CDC Import Permits for Swine-Originated Flu May 26

Guidance for Patients

Patients With Cardiovascular Disease May 2Caring for a Sick Person in Your Home Aug 5

Home Care Guidance: Physician Directions to Patient/Parent Aug 5

Guidance for Pregnant and Breastfeeding Women

What Should Pregnant Women Know About 2009 H1N1 Flu (Swine Flu)? Oct 6Feeding your Baby: What Parents Should Know Jul 6

Info for Pregnant Women in Education, Child Care, and Health Care May 3 Business and Employer Guidance

CDC Guidance for Businesses and Employers To Plan and Respond to the 2009–2010 Influenza Season Aug 19Planning for 2009 H1N1 Influenza: A Preparedness Guide for Small Business Sept 16

Emergency Personnel Guidance

Managing Calls and Call Centers during a Large-Scale Influenza Outbreak: Implementation Tool Jul 30EMS and 9-1-1 Personnel:  Managing Confirmed or Suspected Infections May 11

Guidance for Community Settings

CDC Recommendations for the Amount of Time Persons with Influenza-Like Illness Should be Away from Others Aug 5

Public Gatherings September 23 Facemask and Respirator Use Aug 5

Guidance for Child Care Programs, Schools, Colleges and Universities

Interim CDC Guidance on Day and Residential Camps Jun 14Guidance on Helping Child Care & Early Childhood Programs Respond to Flu during 2009–2010 Flu Season Sep 4

Guidance for State & Local Health Officials & School Administrators for 2009-2010 School Year Aug 7

Guidance for Institutions of Higher Education for 2009-2010 Academic Year Aug 26 Travel & Travel Industry Guidance

Guidance for Cruise Ships Aug 5Flight Crews Arriving from Affected Areas Aug 5

2 of 2 File(s)

ILI-childalgorithm.pdf

ILI-adultalgorithm.pdf

[Guest guest]

,

Just as an FYI, I have stopped using the rapid flu tests. I used

it in this kid as he was on the front end of the epidemic and I wasn’t

initially sure if that was what was going on. Now I know how the H1N1 is

presenting and agree the flu test adds nothing to clinical judgment.

B

From:

[mailto: ]

On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AM

To:

Subject: Re: Managing H1N1 in the trenches

Wow. I, too, am seeing a lot of this. In

general, I send them home and they get better in 3-7 days. I know of no need

for any of these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

[Guest guest]

Because my full time job is in urgent care, I have a different clinical viewpoint than most on this list.I practice an hour west of B and am seeing the same epidemic. We are seeing record volumes, yesterday, 175 patients in 30 provider hours - that's 5.8 patients/provider hour. Our typical flu season volume is about 130 visits/day. We are seeing these volumes partially because the typical PCP office is limited to 24 to 30 visits/provider day and they don't seem willing to free up slots for same day visits of flu patients. One elderly patient I saw last night was told by her geriatricians office that they were referring all possible flu cases to the ER. This type of PCP scheduling leaves me about 10 minutes per patient, even staying an hour past our usual closing time.I find the flu test, strept test, and CXR to be quite helpful, though I do not live by the results and place them within the patients individual clinical situation. This swine flu epidemic is occurring on top of the usual fall illness of strept, bronchitis, pneumonia, and the rare case of meningitis, etc. The tests allow me to rapidly distinguish which patients I need to look at more closely. I'm rather liberal in my use of CXR (we have it available inhouse) as a cough, fever, malaise, etc can be the presenting sxs of pneumonia. I have diagnosed several over the past couple of weeks in patients both with and without the flu. You may not agree that this is the most cost effective evaluation, but it is time effective and I believe it needs to be done to handle these volumes of sick people.I treat aggressively with Tamiflu. All those with test confirmed flu < 48 hours out, patients who fit the clinical scenario with no other evident cause < 48 hours out, those who may be > 48 hours out but with severe illness, and prophylactically those in the household with risk factors for bad outcomes. I'm beginning to consider prophylaxis for family members as the epidemic seems to be widening. I'm also not timid to add Abx for those with possible pneumonia on CXR. I think parents have a legitimate concern to ask for and receive Tamiflu for their flu infected children of any age. If anyone out there can guarantee, looking at a patient in the first 24 hours of flu (when Tamiflu is most effective), whether they will have a benign or fulminant case, please tell me your secret. You can play the odds game, i.e that only 1 out of 100,000 infected patients will have a difficult course, so if you only see 200 or 500 or 1000 cases, it's unlikely 1 of them will have a severe course. But, you're just gambling; and I'd rather be on the side of doing the most for my patients. Check out these links to MSNBC. msnbc.com:Misdiagnosis leads to swine flu fatality msnbc.com:Father: I begged for Tamiflu for daughter Though I acknowledge the forces of propaganda are hard at work, it's not hard to empathize with the family.Personally, I feel the CDC and the public health officials have handled this situation poorly. The CDCs recommendations are based more on what ifs, i.e.suppose the virus becomes resistant to Tamiflu, than what is actually happening in my office. I acknowledge the real concern, but the result seems to be that people die on the fear that some future event may occur that may not occur. I think I can rationally make the opposite argument. One way to stop the spread of any disease is to treat all affected patients and their contacts aggressively to curtail transmission of the disease, e.g. the current recommendations for handling cases of menigitis. This may not work quite as well for a pathogen as infectious as influenza, but would work to some degree. We also agree that there is a certain incidence within those infected with flu of severe complications. As the total # of bad outcomes is therefore dependent of the total # of flu cases, we can reduce mortality and morbidity by decreasing the total # of flu cases. This is the rationale behind an aggressive immunization campaign. It could also be the rationale for aggressive active and prophylactic treatment with Tamiflu. As you treat everyone with Tamiflu you likely decrease the quality of their infectiousness, by treating their families prophactically you reduce the number of illnesses and the number of people who become infectious to others. There would likely be subclinical cases of flu that would confer immunity to the recipient of the Tamiflu. I admit that this increases the risk for Tamiflu resistence, but let's deal with what's happening and not what may happen. By the way, does anyway know if the CDC will change it's recommendations for prophylaxing seasonal flu. If not, they are certainly being two faced.Best Wishes to everyone; it's going to be a long, hard winter.Straz

,Just as an FYI, I have stopped using the rapid flu tests. I used

it in this kid as he was on the front end of the epidemic and I wasn’t

initially sure if that was what was going on. Now I know how the H1N1 is

presenting and agree the flu test adds nothing to clinical judgment. B

From:

[mailto: ]

On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AM

To:

Subject: Re: Managing H1N1 in the trenches

Wow. I, too, am seeing a lot of this. In

general, I send them home and they get better in 3-7 days. I know of no need

for any of these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

[Guest guest]

Good thoughts, .Yes, it will be an interesting winter.Just yesterday, my colleague down the hall had a patient who was seen 10 days ago and had (+) type A quick test - likely H1N1.Was getting better, then suddenly got worse with Influenza Like Illness symptoms.

Flu Quick Test showed she now has type B flu.I feel bad for those patients hit hard by H1N1 and will be hit again by the garden variety flu that hasn't much started in our neck of the mountains yet. Locke, MD

 

Because my full time job is in urgent care, I have a different clinical viewpoint than most on this list.I practice an hour west of B and am seeing the same epidemic. We are seeing record volumes, yesterday, 175 patients in 30 provider hours - that's 5.8 patients/provider hour.  Our typical flu season volume is about 130 visits/day.  We are seeing these volumes partially because the typical PCP office is limited to 24 to 30 visits/provider day and they don't seem willing to free up slots for same day visits of flu patients.  One elderly patient I saw last night was told by her geriatricians office that they were referring all possible flu cases to the ER.  This type of PCP scheduling leaves me about 10 minutes per patient, even staying an hour past our usual closing time.

I find the flu test, strept test, and CXR to be quite helpful, though I do not live by the results and place them within the patients individual clinical situation.  This swine flu epidemic is occurring on top of the usual fall illness of strept, bronchitis, pneumonia, and the rare case of meningitis, etc.  The tests allow me to rapidly distinguish which patients I need to look at more closely.  I'm rather liberal in my use of CXR (we have it available inhouse) as a cough, fever, malaise, etc can be the presenting sxs of pneumonia.  I have diagnosed several over the past couple of weeks in patients both with and without the flu.  You may not agree that this is the most cost effective evaluation, but it is time effective and I believe it needs to be done to handle these volumes of sick people.

I treat aggressively with Tamiflu.  All those with test confirmed flu < 48 hours out, patients who fit the clinical scenario with no other evident cause < 48 hours out, those who may be > 48 hours out but with severe illness, and prophylactically those in the household with risk factors for bad outcomes.  I'm beginning to consider prophylaxis for family members as the epidemic seems to be widening.  I'm also not timid to add Abx for those with possible pneumonia on CXR.  I think parents have a legitimate concern to ask for and receive Tamiflu for their flu infected children of any age.  If anyone out there can guarantee, looking at a patient in the first 24 hours of flu (when Tamiflu is most effective), whether they will have a benign or fulminant case, please tell me your secret.  You can play the odds game, i.e that only 1 out of 100,000 infected patients will have a difficult course, so if you only see 200 or 500 or 1000 cases, it's unlikely 1 of them will have a severe course.  But, you're just gambling; and I'd rather be on the side of doing the most for my patients.  Check out these links to MSNBC.   msnbc.com:Misdiagnosis leads to swine flu fatality   msnbc.com:Father: I begged for Tamiflu for daughter     Though I acknowledge the forces of propaganda are hard at work, it's not hard to empathize with the family.

Personally, I feel the CDC and the public health officials have handled this situation poorly.  The CDCs recommendations are based more on what ifs, i.e.suppose the virus becomes resistant to Tamiflu, than what is actually happening in my office.  I acknowledge the real concern, but the result seems to be that people die on the fear that some future event may occur that may not occur.  I think I can rationally make the opposite argument.  One way to stop the spread of any disease is to treat all affected patients and their contacts aggressively to curtail transmission of the disease, e.g. the current recommendations for handling cases of menigitis.  This may not work quite as well for a pathogen as infectious as influenza, but would work to some degree.  We also agree that there is a certain incidence within those infected with flu of severe complications.  As the total # of bad outcomes is therefore dependent of the total  # of flu cases, we can reduce mortality and morbidity by decreasing the total # of flu cases.  This is the rationale behind an aggressive immunization campaign.  It could also be the rationale for aggressive active and prophylactic treatment with Tamiflu.  As you treat everyone with Tamiflu you likely decrease the quality of their infectiousness, by treating their families prophactically you reduce the number of illnesses and the number of people who become infectious to others.  There would likely be subclinical cases of flu that would confer immunity to the recipient of the Tamiflu.  I admit that this increases the risk for Tamiflu resistence, but let's deal with what's happening and not what may happen.  By the way, does anyway know if the CDC will change it's recommendations for prophylaxing seasonal flu.  If not, they are certainly being two faced.

Best Wishes to everyone; it's going to be a long, hard winter.Straz

 

,Just as an FYI, I have stopped using the rapid flu tests. I used

it in this kid as he was on the front end of the epidemic and I wasn’t

initially sure if that was what was going on. Now I know how the H1N1 is

presenting and agree the flu test adds nothing to clinical judgment. B 

From:

[mailto: ]

On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AM

To:

Subject: Re: Managing H1N1 in the trenches

  

Wow. I, too, am seeing a lot of this. In

general, I send them home and they get better in 3-7 days. I know of no need

for any of these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

[Guest guest]

,

You have excellent points. The most concerning phrase to me is " One elderly

patient I saw last night was told by her geriatricians office that they were

referring all possible flu cases to the ER. " This is exactly what's wrong with

the system. I suspect the geriatrician doesn't want to contaminate her waiting

room or can't handle the patient flow. So instead, the geriatrician would

rather contaminate an ER or UC waiting room or overwhelm the ER/UC. And that's

a better solution???

There is no reason primary care physicians shouldn't be caring for their

patients with flu. There are precautions one can take to prevent spread in the

office (e.g. pt enters via back door, respiratory precautions etc). If you have

access, continuity of care, long term relationship, and coordinated care, you

can practice by CDC guidelines and improve care and outcomes (Duh!). 's

description is the exact care that UCs and ERs should be giving. You don't know

the patient and won't have easy f/u. Perfect UC given by , in my opinion.

And if you go to a barber, you'll get your hair cut with barber clippers.

Craig

> > >

> > > I have decided that I will treat aggressively all my patients with

> > flu

> > > diagnosis:

> > >

> > > Medrol Pak

> > >

> > > antibiotic Rx appropriate for outpatient CAP treatment

> > >

> > > albuterol MDI

> > >

> > > Tamiflu only if within the first 48 hours of onset of Sx

> > >

> > > rest for a week

> > >

> > > Contemplating phoning in Rxs to a pharmacy that will deliver to the

> > > patient's home if I can't see the patient or he/she sounds too ill

> > to come

> > > in (advise to call 911 if they sound really bad?).

> > >

> > > Admit earlier rather than later if there are any concerns

> > >

> > > I found some contradictions in the steroid recommendations, I

> > suspect there

> > > are cytokines involved in the cases of young people that have

> > become ill

> > > quickly, maybe early steroids can help prevent the ARDS.

> > >

> > > Comments?

> > >

> > > tangential link:

> > >

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

> > >

> > > Pedro Ballester, M.D.

> > > Warren, OH

> > >

> >

> >

> >

> >

>

[Guest guest]

Looks like I'll have to be the dissenting voice here.I read that H1N1 is no more lethal than the usual seasonal flu.It is however now pandemic so it is unlikely that anything an individual clinic does to try and stop the spread is going to do much.  

There are already 23 cases of H1N1 where their strain was resistant to tamiflu, and they were all cases given the drug prophylactically.  So, you might as well quarantine the family at home as opposed to treating all the family members with tamiflu.

Citing a single case where a pregnant mother died in ICU from H1N1, and where the docs treating her got the diagnosis wrong, is bad medicine if you want to use that as a reason for giving everyone tamiflu.

If you're struggling to treat all the patients coming to be seen in urgent care, and can't assess them properly, then tamiflu is not a substitute for getting some locums in to help.

Sending patients with flu symptoms to UC is just making the situation worse as you are exposing already sick patients to the virus.  I would tell these docs doing that they should not do so without first assessing these patients.  That might reduce your workload. 

Ok, got my flak jacket on now....

 

Because my full time job is in urgent care, I have a different clinical viewpoint than most on this list.I practice an hour west of B and am seeing the same epidemic. We are seeing record volumes, yesterday, 175 patients in 30 provider hours - that's 5.8 patients/provider hour.  Our typical flu season volume is about 130 visits/day.  We are seeing these volumes partially because the typical PCP office is limited to 24 to 30 visits/provider day and they don't seem willing to free up slots for same day visits of flu patients.  One elderly patient I saw last night was told by her geriatricians office that they were referring all possible flu cases to the ER.  This type of PCP scheduling leaves me about 10 minutes per patient, even staying an hour past our usual closing time.

I find the flu test, strept test, and CXR to be quite helpful, though I do not live by the results and place them within the patients individual clinical situation.  This swine flu epidemic is occurring on top of the usual fall illness of strept, bronchitis, pneumonia, and the rare case of meningitis, etc.  The tests allow me to rapidly distinguish which patients I need to look at more closely.  I'm rather liberal in my use of CXR (we have it available inhouse) as a cough, fever, malaise, etc can be the presenting sxs of pneumonia.  I have diagnosed several over the past couple of weeks in patients both with and without the flu.  You may not agree that this is the most cost effective evaluation, but it is time effective and I believe it needs to be done to handle these volumes of sick people.

I treat aggressively with Tamiflu.  All those with test confirmed flu < 48 hours out, patients who fit the clinical scenario with no other evident cause < 48 hours out, those who may be > 48 hours out but with severe illness, and prophylactically those in the household with risk factors for bad outcomes.  I'm beginning to consider prophylaxis for family members as the epidemic seems to be widening.  I'm also not timid to add Abx for those with possible pneumonia on CXR.  I think parents have a legitimate concern to ask for and receive Tamiflu for their flu infected children of any age.  If anyone out there can guarantee, looking at a patient in the first 24 hours of flu (when Tamiflu is most effective), whether they will have a benign or fulminant case, please tell me your secret.  You can play the odds game, i.e that only 1 out of 100,000 infected patients will have a difficult course, so if you only see 200 or 500 or 1000 cases, it's unlikely 1 of them will have a severe course.  But, you're just gambling; and I'd rather be on the side of doing the most for my patients.  Check out these links to MSNBC.   msnbc.com:Misdiagnosis leads to swine flu fatality   msnbc.com:Father: I begged for Tamiflu for daughter     Though I acknowledge the forces of propaganda are hard at work, it's not hard to empathize with the family.

Personally, I feel the CDC and the public health officials have handled this situation poorly.  The CDCs recommendations are based more on what ifs, i.e.suppose the virus becomes resistant to Tamiflu, than what is actually happening in my office.  I acknowledge the real concern, but the result seems to be that people die on the fear that some future event may occur that may not occur.  I think I can rationally make the opposite argument.  One way to stop the spread of any disease is to treat all affected patients and their contacts aggressively to curtail transmission of the disease, e.g. the current recommendations for handling cases of menigitis.  This may not work quite as well for a pathogen as infectious as influenza, but would work to some degree.  We also agree that there is a certain incidence within those infected with flu of severe complications.  As the total # of bad outcomes is therefore dependent of the total  # of flu cases, we can reduce mortality and morbidity by decreasing the total # of flu cases.  This is the rationale behind an aggressive immunization campaign.  It could also be the rationale for aggressive active and prophylactic treatment with Tamiflu.  As you treat everyone with Tamiflu you likely decrease the quality of their infectiousness, by treating their families prophactically you reduce the number of illnesses and the number of people who become infectious to others.  There would likely be subclinical cases of flu that would confer immunity to the recipient of the Tamiflu.  I admit that this increases the risk for Tamiflu resistence, but let's deal with what's happening and not what may happen.  By the way, does anyway know if the CDC will change it's recommendations for prophylaxing seasonal flu.  If not, they are certainly being two faced.

Best Wishes to everyone; it's going to be a long, hard winter.Straz

 

,Just as an FYI, I have stopped using the rapid flu tests. I used

it in this kid as he was on the front end of the epidemic and I wasn’t

initially sure if that was what was going on. Now I know how the H1N1 is

presenting and agree the flu test adds nothing to clinical judgment. B 

From:

[mailto: ]

On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AM

To:

Subject: Re: Managing H1N1 in the trenches

  

Wow. I, too, am seeing a lot of this. In

general, I send them home and they get better in 3-7 days. I know of no need

for any of these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

Fully agree.

From:

[mailto: ] On Behalf Of Graham Chiu

Sent: Tuesday, October 20, 2009 3:16 PM

To:

Subject: Re: Re: Managing H1N1 in the trenches

Looks like I'll have to be the dissenting voice here.

I read that H1N1 is no more lethal than the usual seasonal

flu.

It is however now pandemic so it is unlikely that anything

an individual clinic does to try and stop the spread is going to do much.

There are already 23 cases of H1N1 where their strain was

resistant to tamiflu, and they were all cases given the drug prophylactically.

So, you might as well quarantine the family at home as

opposed to treating all the family members with tamiflu.

Citing a single case where a pregnant mother died in ICU from

H1N1, and where the docs treating her got the diagnosis wrong, is bad medicine

if you want to use that as a reason for giving everyone tamiflu.

If you're struggling to treat all the patients coming to be

seen in urgent care, and can't assess them properly, then tamiflu is not a

substitute for getting some locums in to help.

Sending patients with flu symptoms to UC is just making the

situation worse as you are exposing already sick patients to the virus. I

would tell these docs doing that they should not do so without first assessing

these patients. That might reduce your workload.

Ok, got my flak jacket on now....

Because my full time job is in urgent care, I have

a different clinical viewpoint than most on this list.

I practice an hour west of B

and am seeing the same epidemic. We are seeing record volumes, yesterday, 175

patients in 30 provider hours - that's 5.8 patients/provider hour. Our

typical flu season volume is about 130 visits/day. We are seeing these

volumes partially because the typical PCP office is limited to 24 to 30

visits/provider day and they don't seem willing to free up slots for same day

visits of flu patients. One elderly patient I saw last night was told by

her geriatricians office that they were referring all possible flu cases to the

ER. This type of PCP scheduling leaves me about 10 minutes per patient,

even staying an hour past our usual closing time.

I find the flu test, strept test,

and CXR to be quite helpful, though I do not live by the results and place them

within the patients individual clinical situation. This swine flu

epidemic is occurring on top of the usual fall illness of strept, bronchitis,

pneumonia, and the rare case of meningitis, etc. The tests allow me to

rapidly distinguish which patients I need to look at more closely. I'm

rather liberal in my use of CXR (we have it available inhouse) as a cough,

fever, malaise, etc can be the presenting sxs of pneumonia. I have

diagnosed several over the past couple of weeks in patients both with and

without the flu. You may not agree that this is the most cost effective

evaluation, but it is time effective and I believe it needs to be done to

handle these volumes of sick people.

I treat aggressively with Tamiflu.

All those with test confirmed flu < 48 hours out, patients who fit the

clinical scenario with no other evident cause < 48 hours out, those who may

be > 48 hours out but with severe illness, and prophylactically those in the

household with risk factors for bad outcomes. I'm beginning to consider

prophylaxis for family members as the epidemic seems to be widening. I'm

also not timid to add Abx for those with possible pneumonia on CXR. I

think parents have a legitimate concern to ask for and receive Tamiflu for

their flu infected children of any age. If anyone out there can guarantee,

looking at a patient in the first 24 hours of flu (when Tamiflu is most

effective), whether they will have a benign or fulminant case, please tell me

your secret. You can play the odds game, i.e that only 1 out of 100,000

infected patients will have a difficult course, so if you only see 200 or 500

or 1000 cases, it's unlikely 1 of them will have a severe course. But,

you're just gambling; and I'd rather be on the side of doing the most for my

patients. Check out these links to MSNBC. msnbc.com:Misdiagnosis

leads to swine flu fatality msnbc.com:Father:

I begged for Tamiflu for daughter Though I acknowledge

the forces of propaganda are hard at work, it's not hard to empathize with the

family.

Personally, I feel the CDC and the

public health officials have handled this situation poorly. The CDCs

recommendations are based more on what ifs, i.e.suppose the virus becomes

resistant to Tamiflu, than what is actually happening in my office. I

acknowledge the real concern, but the result seems to be that people die on the

fear that some future event may occur that may not occur. I think I can

rationally make the opposite argument. One way to stop the spread of any

disease is to treat all affected patients and their contacts aggressively to

curtail transmission of the disease, e.g. the current recommendations for

handling cases of menigitis. This may not work quite as well for a

pathogen as infectious as influenza, but would work to some degree. We

also agree that there is a certain incidence within those infected with flu of

severe complications. As the total # of bad outcomes is therefore

dependent of the total # of flu cases, we can reduce mortality and

morbidity by decreasing the total # of flu cases. This is the rationale behind

an aggressive immunization campaign. It could also be the rationale for

aggressive active and prophylactic treatment with Tamiflu. As you treat

everyone with Tamiflu you likely decrease the quality of their infectiousness,

by treating their families prophactically you reduce the number of illnesses

and the number of people who become infectious to others. There would

likely be subclinical cases of flu that would confer immunity to the recipient

of the Tamiflu. I admit that this increases the risk for Tamiflu

resistence, but let's deal with what's happening and not what may happen.

By the way, does anyway know if the CDC will change it's recommendations

for prophylaxing seasonal flu. If not, they are certainly being two

faced.

Best Wishes to everyone; it's going

to be a long, hard winter.

Straz

On Oct 20, 2009, at 7:31 AM, Dr.

Brady wrote:

,

Just as an FYI,

I have stopped using the rapid flu tests. I used it in this kid as he was on

the front end of the epidemic and I wasn’t initially sure if that was

what was going on. Now I know how the H1N1 is presenting and agree the flu test

adds nothing to clinical judgment.

B

From: [mailto: ]

On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AM

To:

Subject: Re: Managing H1N1 in the trenches

Wow. I, too, am seeing a lot of this. In general, I

send them home and they get better in 3-7 days. I know of no need for any of

these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

--

Graham Chiu

http://www.synapsedirect.com

Synapse - the use from anywhere EMR.

[Guest guest]

Me too.

,

Just as an FYI, I have stopped using the rapid flu tests. I used it in this kid as he was on the front end of the epidemic and I wasn’t initially sure if that was what was going on. Now I know how the H1N1 is presenting and agree the flu test adds nothing to clinical judgment.

B

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of newflocSent: Tuesday, October 20, 2009 1:52 AMTo: Practiceimprovement 1yahoogroups (DOT) comSubject: [Practiceimprovemen t1] Re: Managing H1N1 in the

trenches

Wow. I, too, am seeing a lot of this. In general, I send them home and they get better in 3-7 days. I know of no need for any of these other treatments for an uncomplicated viral illness.A lot of providers in my area are giving everyone Tamiflu, so I'm having some difficulty getting it for my high risk cases. I wish they would stop that and stop using rapid flu tests that are of no use that I can discern. Haresch>> I have decided that I will treat aggressively all my patients with flu> diagnosis:> > Medrol Pak> > antibiotic Rx appropriate for outpatient CAP treatment>

> albuterol MDI> > Tamiflu only if within the first 48 hours of onset of Sx> > rest for a week> > Contemplating phoning in Rxs to a pharmacy that will deliver to the> patient's home if I can't see the patient or he/she sounds too ill to come> in (advise to call 911 if they sound really bad?).> > Admit earlier rather than later if there are any concerns> > I found some contradictions in the steroid recommendations, I suspect there> are cytokines involved in the cases of young people that have become ill> quickly, maybe early steroids can help prevent the ARDS.> > Comments?> > tangential link:> http://www.propubli ca.org/feature/ in-flu-pandemic- states-hospitals -may-exclude-

certain-patients -1016> > Pedro Ballester, M.D.> Warren, OH>

-- Graham Chiuhttp://www.synapsed irect.comSynapse - the use from anywhere EMR.

[Guest guest]

Here are some guidelines if you have pregnant patientshttp://wiki.medpedia.com/Clinical:H1N1_in_Pregnancy:_Practical_Considerations

 

Me too.

 

 

,

Just as an FYI, I have stopped using the rapid flu tests. I used it in this kid as he was on the front end of the epidemic and I wasn’t initially sure if that was what was going on. Now I know how the H1N1 is presenting and agree the flu test adds nothing to clinical judgment.

B

 

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of newfloc

Sent: Tuesday, October 20, 2009 1:52 AMTo: Practiceimprovement 1yahoogroups (DOT) com

Subject: [Practiceimprovemen t1] Re: Managing H1N1 in the

trenches

 

 

Wow. I, too, am seeing a lot of this. In general, I send them home and they get better in 3-7 days. I know of no need for any of these other treatments for an uncomplicated viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some difficulty getting it for my high risk cases. I wish they would stop that and stop using rapid flu tests that are of no use that I can discern.

Haresch

>> I have decided that I will treat aggressively all my patients with flu> diagnosis:> > Medrol Pak> > antibiotic Rx appropriate for outpatient CAP treatment>

> albuterol MDI> > Tamiflu only if within the first 48 hours of onset of Sx> > rest for a week> > Contemplating phoning in Rxs to a pharmacy that will deliver to the> patient's home if I can't see the patient or he/she sounds too ill to come

> in (advise to call 911 if they sound really bad?).> > Admit earlier rather than later if there are any concerns> > I found some contradictions in the steroid recommendations, I suspect there

> are cytokines involved in the cases of young people that have become ill> quickly, maybe early steroids can help prevent the ARDS.> > Comments?> > tangential link:> http://www.propubli ca.org/feature/ in-flu-pandemic- states-hospitals -may-exclude-

certain-patients -1016> > Pedro Ballester, M.D.> Warren, OH>

 

 

-- Graham Chiuhttp://www.synapsed irect.comSynapse - the use from anywhere EMR.

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

I already tipped my hand in agreement with Graham et al.

All of this emphasizes the IMP message of the importance of having a doctor who

knows you and is accessible, not just for the individual patient, but for public

health and economics. If we're (the system, not IMPs) really going to manage

most simple illnesses at high speed, primarily with tests of limited usefulness

and then use any medication that might possibly be indicated, then I'm

frightened to even live in these communities.

I don't even know how to use a test that's as likely to be wrong as right. If I

were going to treat every case of flu with Tamiflu, I wouldn't feel good about

denying treatment based on a negative test that is very likely to be wrong.

I'm not aware of any data showing treatment with Tamiflu is an effective

transmission prevention method.

We see a lot of people with cough that is almost certainly viral but could

progress to a deadly pneumonia. I'm not placing them all on Levaquin.

While our primary responsibility is to the patient in front of us, I also

believe that we are entrusted with the public health. These interests compete at

times, but ignoring the health of the many entirely is dangerously

short-sighted, IMO.

Straz et al, I applaud your working to do the best you can for patients given

the system and situations you're handed. I'm just asking that we all keep

thinking and working toward making it all better.

Haresch

www.onefamilydoctor.com

> >

> > I have decided that I will treat aggressively all my patients with flu

> > diagnosis:

> >

> > Medrol Pak

> >

> > antibiotic Rx appropriate for outpatient CAP treatment

> >

> > albuterol MDI

> >

> > Tamiflu only if within the first 48 hours of onset of Sx

> >

> > rest for a week

> >

> > Contemplating phoning in Rxs to a pharmacy that will deliver to the

> > patient's home if I can't see the patient or he/she sounds too ill to come

> > in (advise to call 911 if they sound really bad?).

> >

> > Admit earlier rather than later if there are any concerns

> >

> > I found some contradictions in the steroid recommendations, I suspect

> there

> > are cytokines involved in the cases of young people that have become ill

> > quickly, maybe early steroids can help prevent the ARDS.

> >

> > Comments?

> >

> > tangential link:

>

> > http://www.propubli ca.org/feature/ in-flu-pandemic-

> <http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-excl

> ude-certain-patients-1016> states-hospitals -may-exclude- certain-patients

> -1016

>

>

> >

> > Pedro Ballester, M.D.

> > Warren, OH

> >

>

>

>

>

>

>

>

>

> --

> Graham Chiu

> http://www.synapsed <http://www.synapsedirect.com/> irect.com

>

>

> Synapse - the use from anywhere EMR.

>

>

>

>

>

>

> --

> Graham Chiu

> http://www.synapsed <http://www.synapsedirect.com> irect.com

> Synapse - the use from anywhere EMR.

>

[Guest guest]

Anyone getting tamiflu and keeping it with them? I have already had some cases

of H1N1 and I am wondering how to keep myself healthy so I don't have to dip

into my disability policy!?! ;-)

Needless to say, I am planning on getting the vax...whenever my hospital FINALLY

gets it! What are the hospitals near you doing?

[Guest guest]

just to add fuel to the cytokine fires, we have thishttp://jama.ama-assn.org/cgi/content/full/2009.1496v1 "  we have demonstrated that 2009 influenza A(H1N1) infection–related critical illness predominantly affects young patients with few major comorbidities and is associated with severe hypoxemic respiratory failure, often requiring prolonged mechanical ventilation and rescue therapies. With such therapy, we found that most patients can be supported through their critical illness. "

 

Anyone getting tamiflu and keeping it with them? I have already had some cases of H1N1 and I am wondering how to keep myself healthy so I don't have to dip into my disability policy!?! ;-)

Needless to say, I am planning on getting the vax...whenever my hospital FINALLY gets it! What are the hospitals near you doing?

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

What are the recommendations re: Tamiflu for family members with sick

kids? An MD I work with had a sick teen with H1N1---

had her other teens, hubbie and self take Tamiflu for 10 days. 2d kid

came home with T101-102 a wk after they had finished Rx.

He was fine within 24 hrs--so did he have flu or not?? Unclear. She

wonders if she should vacc the other two kids and she & spouse.

Any thoughts?

Ellen

Pedro Ballester wrote:

>

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

> come in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

> there are cytokines involved in the cases of young people that have

> become ill quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

>

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

>

<http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-\

certain-patients-1016>

>

> Pedro Ballester, M.D.

> Warren, OH

>

>

Attachment: vcard [not shown]

[Guest guest]

I'm not FP or Peds but Medrol and AB seem overkill as first line. I

would check with your local ID person about this.

Pedro Ballester wrote:

>

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

> come in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

> there are cytokines involved in the cases of young people that have

> become ill quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

>

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

>

<http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-\

certain-patients-1016>

>

> Pedro Ballester, M.D.

> Warren, OH

>

>

Attachment: vcard [not shown]

[Guest guest]

Agree with all you've said.

Dr. Brady wrote:

>

>

> Pedro,

>

> I am in the midst of quite a little epidemic here in Virginia. Lots of

> cases although only one school has shut down (so far). Although some

> people do get really sick, most do just fine. I am just telling

> parents (as this is really hitting school aged kids hard) to use

> motrin and Tylenol and keep the child quarantined until 24 hours after

> the fever breaks. I am no longer giving Tamiflu unless there is

> potential exposure to a high risk individual. Most of the time, the

> fever breaks in 2-3 days and the kids are back out playing quickly. I

> have had one patient who needed zithromax (X-ray confirmation of

> pneumonia 24 hours after the rapid flu test was positive), but that

> was unusual and the kid did not respond as quickly as I wanted him to

> so it was obvious we needed to do more. With all my patients, I give

> good access and encourage them to call if anything is not improving as

> it should. Parents know and I trust their judgement.

>

> I would not give steroids or albuterol unless there was wheezing and a

> history of asthma. I would not worry about the rest thing as most will

> automatically rest until they feel better. Perhaps I am missing the

> boat, but I am concerned that intervening (beyond giving the vaccine)

> may do more harm than good.

>

>

>

>

>

> *From:*

> [mailto: ] *On Behalf Of *Pedro

> Ballester

> *Sent:* Monday, October 19, 2009 8:06 PM

> *To:* Clinical Procedures; practiceimprovement1

> *Subject:* Managing H1N1 in the trenches

>

>

>

>

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

> come in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

> there are cytokines involved in the cases of young people that have

> become ill quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

>

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

>

<http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-\

certain-patients-1016>

>

> Pedro Ballester, M.D.

> Warren, OH

>

>

Attachment: vcard [not shown]

[Guest guest]

Rapid test is not very specific or sensitive and is not recommended from

what I have read.

Dr. Brady wrote:

>

> ,

>

> Just as an FYI, I have stopped using the rapid flu tests. I used it in

> this kid as he was on the front end of the epidemic and I wasn’t

> initially sure if that was what was going on. Now I know how the H1N1

> is presenting and agree the flu test adds nothing to clinical judgment.

>

> B

>

> *From:*

> [mailto: ] *On Behalf Of *newfloc

> *Sent:* Tuesday, October 20, 2009 1:52 AM

> *To:*

> *Subject:* Re: Managing H1N1 in the trenches

>

> Wow. I, too, am seeing a lot of this. In general, I send them home and

> they get better in 3-7 days. I know of no need for any of these other

> treatments for an uncomplicated viral illness.

>

> A lot of providers in my area are giving everyone Tamiflu, so I'm

> having some difficulty getting it for my high risk cases. I wish they

> would stop that and stop using rapid flu tests that are of no use that

> I can discern.

>

> Haresch

>

>

> >

> > I have decided that I will treat aggressively all my patients with flu

> > diagnosis:

> >

> > Medrol Pak

> >

> > antibiotic Rx appropriate for outpatient CAP treatment

> >

> > albuterol MDI

> >

> > Tamiflu only if within the first 48 hours of onset of Sx

> >

> > rest for a week

> >

> > Contemplating phoning in Rxs to a pharmacy that will deliver to the

> > patient's home if I can't see the patient or he/she sounds too ill

> to come

> > in (advise to call 911 if they sound really bad?).

> >

> > Admit earlier rather than later if there are any concerns

> >

> > I found some contradictions in the steroid recommendations, I

> suspect there

> > are cytokines involved in the cases of young people that have become ill

> > quickly, maybe early steroids can help prevent the ARDS.

> >

> > Comments?

> >

> > tangential link:

> >

>

http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-c\

ertain-patients-1016

>

<http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-\

certain-patients-1016>

> >

> > Pedro Ballester, M.D.

> > Warren, OH

> >

>

>

Attachment: vcard [not shown]

[Guest guest]

these are the current recommendationshttp://www.cdc.gov/h1n1flu/recommendations.htmSo, in this case, the sick child should have been " isolated " as much as possible.  The other family members, if not in an at risk group, should have been counselled to seek early assessment if they developed symptoms.  It doesn't mention quarantine, but I  think that's a reasonable thing to do .. quarantine the whole family.

 

What are the recommendations re: Tamiflu for family members with sick

kids? An MD I work with had a sick teen with H1N1---

had her other teens, hubbie and self take Tamiflu for 10 days. 2d kid

came home with T101-102 a wk after they had finished Rx.

He was fine within 24 hrs--so did he have flu or not?? Unclear. She

wonders if she should vacc the other two kids and she & spouse.

Any thoughts?

Ellen

Pedro Ballester wrote:

>

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

> come in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

> there are cytokines involved in the cases of young people that have

> become ill quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

> <http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016>

>

> Pedro Ballester, M.D.

> Warren, OH

>

>

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

My understanding pretty specific, not so sensitive, therefore helpful in a clinical situation with a high likelihood of true flu.Straz

Rapid test is not very specific or sensitive and is not recommended from

what I have read.

Dr. Brady wrote:

>

> ,

>

> Just as an FYI, I have stopped using the rapid flu tests. I used it in

> this kid as he was on the front end of the epidemic and I wasn’t

> initially sure if that was what was going on. Now I know how the H1N1

> is presenting and agree the flu test adds nothing to clinical judgment.

>

> B

>

> *From:*

> [mailto: ] *On Behalf Of *newfloc

> *Sent:* Tuesday, October 20, 2009 1:52 AM

> *To:*

> *Subject:* Re: Managing H1N1 in the trenches

>

> Wow. I, too, am seeing a lot of this. In general, I send them home and

> they get better in 3-7 days. I know of no need for any of these other

> treatments for an uncomplicated viral illness.

>

> A lot of providers in my area are giving everyone Tamiflu, so I'm

> having some difficulty getting it for my high risk cases. I wish they

> would stop that and stop using rapid flu tests that are of no use that

> I can discern.

>

> Haresch

>

>

> >

> > I have decided that I will treat aggressively all my patients with flu

> > diagnosis:

> >

> > Medrol Pak

> >

> > antibiotic Rx appropriate for outpatient CAP treatment

> >

> > albuterol MDI

> >

> > Tamiflu only if within the first 48 hours of onset of Sx

> >

> > rest for a week

> >

> > Contemplating phoning in Rxs to a pharmacy that will deliver to the

> > patient's home if I can't see the patient or he/she sounds too ill

> to come

> > in (advise to call 911 if they sound really bad?).

> >

> > Admit earlier rather than later if there are any concerns

> >

> > I found some contradictions in the steroid recommendations, I

> suspect there

> > are cytokines involved in the cases of young people that have become ill

> > quickly, maybe early steroids can help prevent the ARDS.

> >

> > Comments?

> >

> > tangential link:

> >

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

> <http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016>

> >

> > Pedro Ballester, M.D.

> > Warren, OH

> >

>

>

<nellegreen.vcf>

[Guest guest]

Part of my point was that ER and UC docs may be experiencing the flu epidemic differently than family docs, pediatricians and internists, so their/my behavior is different. Don't assume that UC and ER docs are pushovers for med seekers; I'm certainly not, and I have the patient complaints to prove it. To quote Joe South, "Walk a Mile In My Shoes."Straz

We already have run into two pharmacies

this week that have NO tamiflu in stock; on back order!I have seen/spoke with a number of

families who headed to the local urgent care and ALL have received tamiflu. NOW, what will we do for those high risk

patients (pregnant women, asthmatics, diabetics, etc) when the Tamiflu supply

has been exhausted due to overzealous prescribing practices at the urgent

cares?? I have been judiciously prescribing, per

guidelines and clinical picture. Some of my patients appreciate that;

others are not too happy b.c. “everyone else” (who went to the

urgent care) is on it!R (Have seen tow clinical secondary pneumonia

cases, after 1-3 fever free days and typical flu symptoms preceding.

First did well, second just today, so waiting on verdict!)

Ramona G. Seidel, MDwww.baycrossingfamilymedicine.comYour Bridge to Health NOTE NEW ADDRESS AND PHONE NUMBER: 269 Peninsula Farm Road

Suite FArnold, MD 21012 410 518-9808

From: [mailto: ] On Behalf Of Graham Chiu

Sent: Tuesday, October 20, 2009

5:52 PM

To:

Subject: Re:

Re: Managing H1N1 in the trenches

Here are

some guidelines if you have pregnant patients

http://wiki.medpedia.com/Clinical:H1N1_in_Pregnancy:_Practical_Considerations

On Wed, Oct 21, 2009 at 10:01 AM, Lonna Larsh <larshlonna> wrote:

Me too.

,

Just as an FYI, I have stopped using

the rapid flu tests. I used it in this kid as he was on the front end of the

epidemic and I wasn’t initially sure if that was what was going on. Now

I know how the H1N1 is presenting and agree the flu test adds nothing to

clinical judgment.

B

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of newfloc

Sent: Tuesday, October 20, 2009

1:52 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject:

[Practiceimprovemen t1] Re: Managing H1N1 in the trenches

Wow. I, too, am seeing

a lot of this. In general, I send them home and they get better in 3-7 days.

I know of no need for any of these other treatments for an uncomplicated

viral illness.

A lot of providers in my area are giving everyone Tamiflu, so I'm having some

difficulty getting it for my high risk cases. I wish they would stop that and

stop using rapid flu tests that are of no use that I can discern.

Haresch

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

come

> in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

there

> are cytokines involved in the cases of young people that have become ill

> quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propubli ca.org/feature/ in-flu-pandemic-

states-hospitals -may-exclude- certain-patients -1016

>

> Pedro Ballester, M.D.

> Warren, OH

>

--

Graham Chiu

http://www.synapsed

irect.com

Synapse - the use from anywhere EMR.

--

Graham Chiu

http://www.synapsedirect.com

Synapse - the use from anywhere EMR.

[Guest guest]

I found this 2006 article from ConsultantLive journal called "Rapid Diagnostic Testing for Influenza:When Does It Make Sense?". While it seems to be two experts' opinions, their logic sounds reasonable.Rapid antigen detection tests for influenza typically have a sensitivity of 70% or greater and a specificity of 90% or greater. These numbers sound fairly reassuring, but clinicians are typically more concerned with a test's predictive values. The positive predictive value is the proportion of patients with a positive result on a rapid test who actually have influenza, and the negative predictive value is the proportion of patients with a negative result on a rapid test who do not have influenza. The predictive values depend on the test's sensitivity and specificity, but also on the frequency of disease in the community. For this reason, the positive and negative predictive values of rapid influenza tests depend on the time during influenza season when the testing is done.The calculated positive and negative predictive values for the rapid influenza test with a sensitivity of 70% and a specificity of 90% are displayed in Table 1. During periods of less influenza activity, the positive predictive value of the test is modest. Only at the peak of the season does the positive predictive value exceed 70%. http://www.consultantlive.com/display/article/10162/11056?verify=0So it sounds like they are saying that the best time to use these rapid tests are during the peak of an epidemic, like now (depending on where you are). SetoSouth Pasadena, CAMy understanding pretty specific, not so sensitive, therefore helpful in a clinical situation with a high likelihood of true flu.Straz Rapid test is not very specific or sensitive and is not recommended from what I have read.Dr. Brady wrote:>> ,>> Just as an FYI, I have stopped using the rapid flu tests. I used it in > this kid as he was on the front end of the epidemic and I wasn’t > initially sure if that was what was going on. Now I know how the H1N1 > is presenting and agree the flu test adds nothing to clinical judgment.>> B>> *From:* > [mailto: ] *On Behalf Of *newfloc> *Sent:* Tuesday, October 20, 2009 1:52 AM> *To:* > *Subject:* Re: Managing H1N1 in the trenches>> Wow. I, too, am seeing a lot of this. In general, I send them home and > they get better in 3-7 days. I know of no need for any of these other > treatments for an uncomplicated viral illness.>> A lot of providers in my area are giving everyone Tamiflu, so I'm > having some difficulty getting it for my high risk cases. I wish they > would stop that and stop using rapid flu tests that are of no use that > I can discern.>> Haresch>> > >> > I have decided that I will treat aggressively all my patients with flu> > diagnosis:> >> > Medrol Pak> >> > antibiotic Rx appropriate for outpatient CAP treatment> >> > albuterol MDI> >> > Tamiflu only if within the first 48 hours of onset of Sx> >> > rest for a week> >> > Contemplating phoning in Rxs to a pharmacy that will deliver to the> > patient's home if I can't see the patient or he/she sounds too ill > to come> > in (advise to call 911 if they sound really bad?).> >> > Admit earlier rather than later if there are any concerns> >> > I found some contradictions in the steroid recommendations, I > suspect there> > are cytokines involved in the cases of young people that have become ill> > quickly, maybe early steroids can help prevent the ARDS.> >> > Comments?> >> > tangential link:> > > http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016 > <http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016>> >> > Pedro Ballester, M.D.> > Warren, OH> >>> <nellegreen.vcf>

[Guest guest]

Recommendations are to vaccinate all children.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Ellen

son

Sent: Wednesday, October 21, 2009 12:49 AM

To:

Subject: Re: Managing H1N1 in the trenches

What are the recommendations re: Tamiflu for family members with sick

kids? An MD I work with had a sick teen with H1N1---

had her other teens, hubbie and self take Tamiflu for 10 days. 2d kid

came home with T101-102 a wk after they had finished Rx.

He was fine within 24 hrs--so did he have flu or not?? Unclear. She

wonders if she should vacc the other two kids and she & spouse.

Any thoughts?

Ellen

Pedro Ballester wrote:

>

>

> I have decided that I will treat aggressively all my patients with flu

> diagnosis:

>

> Medrol Pak

>

> antibiotic Rx appropriate for outpatient CAP treatment

>

> albuterol MDI

>

> Tamiflu only if within the first 48 hours of onset of Sx

>

> rest for a week

>

> Contemplating phoning in Rxs to a pharmacy that will deliver to the

> patient's home if I can't see the patient or he/she sounds too ill to

> come in (advise to call 911 if they sound really bad?).

>

> Admit earlier rather than later if there are any concerns

>

> I found some contradictions in the steroid recommendations, I suspect

> there are cytokines involved in the cases of young people that have

> become ill quickly, maybe early steroids can help prevent the ARDS.

>

> Comments?

>

> tangential link:

> http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016

> <http://www.propublica.org/feature/in-flu-pandemic-states-hospitals-may-exclude-certain-patients-1016>

>

> Pedro Ballester, M.D.

> Warren, OH

>

>