Anyone who thinks that they are too small to make a difference has never tried to fall asleep with a mosquito in the room  – Christine Todd Whitman

Not to confuse, or perhaps to confuse etymology and entomology when you put together the Spanish for fly – mosca and the diminutive suffix –ito together you get mosquito.  A topic, an insect, of great interest in this, the possible summer of Zika.

The mosquito species of interest are the Aedes species – aegypti and albopictus (Asian tiger mosquito).  The former as a known vector of arboviruses in the United States with a limited geographic range and albopictus as a possible, unquantified vector but with a wider range.

The range of the mosquito is limited by winter temperatures – isotherms – but exceptions exist, particularly in urban areas where species can winter in protected environments.

In the vector map below by Gardner, et. al., the solid circles represent the suitable habitat and relative risk for Aedes aegypti and clear circles Aedes albopictus with larger concentric circles representing higher total estimated relative risk.  If you want to be mosquito free, move to Iceland, where both the cold temperatures and weather unpredictability are hostile to establishing a mosquito population.

The life-cycle of the mosquito runs the typical egg-larvae-pupae- adult stages.  The Aedes species can breed in casual puddles such as artificial water containers, cupped leaves, bromeliad axils or notoriously in abandoned spare tires (with the curious physics that have them become upright in marshes).  The eggs are also resistant to drying out and can enter diapause for several months if they dry out.  The male of the species is a nectar feeding insect as is the female, until it is time to breed.  A blood meal is needed to produce eggs.  Different species prefer different hosts such as animals, birds, cold-blooded animals, insects, even fish.

Female mosquitos hunt their hosts by detecting CO2, visual recognition and body chemicals, in particular octenol produced by the host.  Some unfortunate people are just genetically predetermined targets for mosquitos (we all know these people if you are not one of them).  Preferred targets include type O blood, heavy breathers, those with a lot of skin bacteria, body heat and the pregnant.   The antennae of mosquitos have 72 types of odor receptors, 27 are represented by chemicals in sweat.  The male mosquito has bushy auditory receptors to hear the whine of the female (this paraphrase is from Wikipedia- really).

Most mosquitoes are crepuscular hunters – dawn and dusk – ominously the Asian tiger mosquito (a potential Zika vector) is a daytime feeder.   Upon feeding the mosquito injects saliva as an anticoagulant.  This serves as the transmission fluid for arboviruses such as Zika.  The irritating and itchy bite is the result of histamine release in response to the bite.

Next Blog – How to protect yourself from mosquitos

Generic medications play an important role in healthcare cost savings.  For FDA approval, a generic drug must be identical in strength, dosage form, and route of administration and be bioequivalent.  In other words, the generic drug for all intents and purposes must be the same as the brand reference drug.  A biosimilar, on the other hand is approved if it shows that it is highly similar to an FDA-approved biologic product known as a reference product.  In addition, a biosimilar is not labeled as bioequivalent to the reference drug.  Thus, unlike a generic medication, a biosimilar is not interchangeable with the reference drug without the prescriber’s approval.

So how does a biosimilar fit into the healthcare spending equation?  Biosimilar are expected to be 15-30% less expensive than the originator drugs.  However, to benefit fully from this potential cost savings, the biosimilar needs to be interchangeable with its reference drug.   The ability to interchange a biosimilar with its reference drug allows the pharmacist to dispense a biosimilar when the prescription is written for the reference drug, much similar to how generics are dispensed for brand name products.  If a biosimilar is not interchangeable with its reference drug, it will certainly not be as readily dispensed since each request to change to a biosimilar will require the prescriber’s approval.

Currently, there are 2 biosimilars approved in the United States.  Zarxio, a biosimilar version of filgrastim and Inflextra, a biosimilar to Remicade.  Biosimilar for a few other blockbuster drugs such as Enbrel and Humira are expected to be approved by the FDA later this year.  Experts believe biosimilars will lead to a $40 billion dollars savings over the next 10 years.  To see this savings, doctors, patients, payors, and legislators will need to have a better understanding of biosimilars and how best to expand its access to patients.  With the skyrocketing cost of biologic medications, biosimilars may be our knight in shining armor to rescue us from this specialty drug distress.

Submitted by Stan Leung PharmD, PHC Director of Pharmcy

Many of us have questions about the end of life option act and how it may affect our practices.  When the CMA first surveyed this matter last year, about 20% of physicians who answered the survey were supportive of the legislation and 20% were very opposed to the idea.  The law was passed and signed and will take effect on June 9, 2016.  The following is a basic outline of what is required to work within the End of Life Option Act.

For more information, please see the excellent legal brief by the California Medical Association:  CMA ON-CALL document #3459 “The California End of Life Option Act” published in January 2016.

Eligible individuals:

• Adult 18 years of age or older
• Capacity to make medical decisions
• Terminal disease

The following conditions must all be met:

• Individual’s attending physician has diagnosed the individual with a terminal disease
• The individual has voluntarily expressed the wish to receive the aid-in-dying drug
• The individual is a resident of California
• The individual documents his or her request on the Request form specified in the act
• The individual has the physical and mental capacity to self-administer the drug

The request:

• The individual submits two oral requests directly to the attending physician 15 days apart
• The individual submits one written request directly to the physician
• The physician has to document each oral and written request in the medical record
• The form must be signed and dated by the individual and have two witnesses

The witnesses:

• Attest that they know the individual or verify proof of identity
• Attest the individual voluntarily signed the form in their presence
• Attest the individual appears to be of sound mind
• Witnesses cannot be the attending or consulting physician or mental health specialist
• Only one witness can be related to the individual

Medical record documentation:

• The attending physician documents the diagnosis and prognosis and that the individual has capacity and is acting voluntarily
• The consulting physician documents the diagnosis and prognosis and that the individual has capacity and is acting voluntarily
• Mental health specialist’s evaluation if performed
• Attending physician must document informing the patient that he or she can withdraw the request at the time of the second oral request
• Attending physician’s note that all requirements have been met and documentation of the drug prescribed
• All documentation has to be sent to the California Department of Public Health
• There are five forms specified in the Act that have to be filled out

Five specific forms are required (no substitutes):

• Request for an Aid in Dying Drug to End my Life in a Humane and Dignified Manner
• Final Attestation for an Aid-in-Dying Drug to End my Life in a Humane and Dignified Manner
• Attending Physician Checklist and Compliance Form
• Consulting Physician Compliance Form
• Attending Physician Follow-up Form

Who is the attending physician?

The “attending physician” is the physician who has primary responsibility for the health care of the requesting patient and treatment of the patient’s terminal disease.

Who is a consulting physician?

The “consulting physician” must be independent from the attending physician and who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding the patient’s terminal disease. The consulting physician cannot be a witness to the written request.  The consultant must review the medical records and examine the patient.  The consultant must determine that the individual has capacity to make medical decisions and that the individual is acting voluntarily.

Participation:

Physicians are free to choose whether to participate in this Act. The health care provider who diagnoses a patient with a terminal illness must inform the patient about the right to information about the end-of-life option, but the law states: “a person that elects for reasons of conscience, morality, or ethics, not to engage in activities is not required to take any action in support of an individual’s decision under this law.”  The physician does not have to advise or counsel a patient about participation in aid-in-dying activities.  Providing a patient, upon request, with a referral to another provider for purposes of participating in this act is not considered “participation” in the Act.

10 Minute Mini Lesson One is designed to provide a basic understanding of the CBT concept of Cognitive Restructuring.

Help them fill in the CBT Cycle Diagram to show what happened, what they were THINKING, how they FELT emotionally and physically, and how they BEHAVED:

HERE ARE SUGGESTED QUESTIONS TO ASK. Have patient if able write answer next to appropriate label in Diagram:

1. WHAT HAPPENED?

Q:  Tell me about a specific, recent time when your pain increased.

A:  I got upset because I had too much back pain to even do the dishes.

Q:  When?

A: I guess it was 2 days ago

Q:  What time of day? (Or other questions like ‘where were you?’ to increase specificity.)

A:  In the afternoon

2. WHAT WERE THEIR THOUGHTS:

Q:  What was running through your mind when [the event] happened?

A:  I’ll never be able to do anything normal and my husband will leave me.

Typical THOUGHTS of chronic pain patients:

• Catastrophising
• Unhelp beliefs, e.g., I should always rest, I need to get rid of the pain (vs. manage the pain)
• Hypervigilance, e.g., paying too much attention to one’s body
• Self Criticism

3. WHAT WERE THEIR FEELINGS:

Q:  How did that make you feel?

A:  I felt worthless and hopeless.

Q:  Did you have other feelings like [anger, fear, sadness]?

A:  Well, I guess anger because this has been going on so long.

Typical FEELINGS of chronic pain patients

• Low mood
• Anger and frustration
• Anxiety and worry

1. HOW DID THEIR BODY FEEL?

Q: How did your body feel?

A: My back was on fire. I felt like I couldn’t stand up.

Typical BODY FEELINGS of chronic pain patients

• Pain, weakness, and stiffness
• Lethargy and fatigue
• Poor sleep
• Nervous symptoms

2. WHAT DID THEY DO?

Q: What did you do at that point?

A:  I took an extra pain pill but it didn’t help, so I called for an appointment.

Typical BEHAVIORS of chronic pain patients

• Sighing and groaning, talking about pain
• Reduced activity; excessive rest
• Social isolation and withdrawalTHIS IS HOW THE CBT CYCLE DIAGRAM MIGHT NOW LOOK:

  

  HELP PATIENT FIND NEW WAY OF THINKING ABOUT EVENT:

  Explore using yourself as a model. Use the patient’s own words as much as possible. Help the patient make their own connections and discoveries. Your main goal is to get the patient to THINK DIFFERENTLY about their situation. Much of this THINKING may occur at home after the visit.

  OFFER COGNITIVE EMPATHY: If I thought I wasn’t ever going to be normal and my spouse would leave me, I would also feel hopeless and worthless and angry and want the doctor to fix me.

  SUGGEST COGNITIVE RESTRUCTURING or REFRAMING:

  Q: Is there something different you could THINK about [event}?

  THIS IS HOW THE CBT CYCLE DIAGRAM MIGHT NOW LOOK:

  

  HELP PATIENT FIND NEW WAY OF THINKING ABOUT EVENT:

  Explore using yourself as a model. Use the patient’s own words as much as possible. Help the patient make their own connections and discoveries. Your main goal is to get the patient to THINK DIFFERENTLY about their situation. Much of this THINKING may occur at home after the visit.

  OFFER COGNITIVE EMPATHY: If I thought I wasn’t ever going to be normal and my spouse would leave me, I would also feel hopeless and worthless and angry and want the doctor to fix me.

  SUGGEST COGNITIVE RESTRUCTURING or REFRAMING:

  Q: Is there something different you could THINK about [event}?

  A:  I need to find a different way to get this done. Dirty dishes are not the end of the world.

  COACH on possible answers if they don’t come up with any on their own.

  Q: How might you FEEL if you thought that about the dishes?

  A: I’d be happy that I had a good idea. I wouldn’t worry about it as much.

  Q:  How would your BODY FEEL?

  A:  Maybe I wouldn’t feel so tense.

  Q:  What would you DO differently?

  A:  I’d wash five dishes and then go watch my favorite soap for 10 minutes.

  HOMEWORK ASSIGNMENT: Ask patient to fill out a new CBT Cycle Diagram AT HOME with the NEW thoughts, emotional and physical feelings, and behaviors (which might look like this). Encourage patient to use this new skill at least once a day (supply them with blank CBT Cycle Diagram forms). Ensure them that regular practice will lessen their pain, improve their mood and self-confidence, and make them less dependent on medications.

  NEXT CBT Mini Lesson: Mindfulness and Relaxation Exercises

   

   

This is a five part series on integration of cognitive behavioral therapy (CBT) into primary care practice written by Karen Stephens PhD, Continue reading →

Every adult in the U.S. knows what happens on April 15. But do you know the significance of the following day? April 16 is National Healthcare Decisions Day. It is a day designated to highlight the importance of people filling out their own Advance Directive (AD), no matter how young and healthy they are. The theme for 2016 is “It Always Seems Too Early. Until It’s Too Late.” The idea is to let people know that something catastrophic can happen to anyone at any time. That is why filling out an AD is important for everyone.

Physicians understand the importance of ADs. But our profession has not been that successful in getting our patients to make their wishes known and fill out these forms. The time available during appointments is limited and usually filled with other pressing issues. Talking about end-of-life wishes can be uncomfortable for patient and clinician alike. But it is an important issue to address periodically with every adult patient, as important as reviewing standard medical screening tests, updating vaccinations, and talking about healthy lifestyle.

Here are several ideas to make the discussion of Advance Directives a bit easier:

• Have a supply of Advance Directives available in your exam room. Being able to hand your patient the form will make it more likely the patient will fill it out.
• Make use of April 16 as National Healthcare Decisions Day as a way to introduce the subject.
• Make sure you and everyone in your family has filled out an AD. Being able to tell patients you yourself have filled out your own AD, as has your spouse and adult children, can help make the issue less daunting. It can reassure patients that you are not bringing it up because you are worried about their health, but because you are as concerned about them as you are about your own family.
• Identify one or more people on your staff who can be educated on how to talk with patients about the importance of ADs, and build time in to office work flow for them to talk with patients about this issue. The responsibility does not need to rest exclusively on the PCP.

We will never get 100% of our patients to fill out ADs, just like we will never get all our patients fully compliant with all their needed health screenings. But by working to normalize this sensitive subject, we can get more of our patients to make known their wishes for end-of-life care. Even though April 16 is now in the past for this year, the importance of getting our patients to fill out their ADs is a year-round challenge.

Cancer remains one of the most prevalent and deadly diseases in California as they are in the United States. Continue reading →

“If end-of-life discussions were an experimental drug, the FDA would approve it.”  Continue reading →

Well, cosmologically speaking, we are still in the Dawn of the Age of Aquarius – (being an “age” is about 2,160 years).  Sun’s out, guns out.  Perhaps it should be more aptly be named the Age of Cancer.

The CDC Skin Cancer Trends state that from 2002 to 2011 skin cancer among men increased by 1.5% per year and 1.1% per year among women.  Mortality from melanoma increased by 0.7% in men ( data not available for women).

In 2010, according to the CDC Sun-Protective Behavior Rates, 70% of adults said they usually or always practice on of the three sun protective behaviors (sunscreen, sun-protective clothing, or seek shade).  Women outperform men and those 25 years or older outperform those 18-25 years old.  Only about 13% and 7% of teen girls and boys, respectively use an effective sunscreen when they were outside for more than an hour on a sunny day in 2013.  About 1/3 of teens aged 14-17 had a sunburn in the past year.

When UV rays reach the inner layer of skin more melanin is produced that moves to the outer layers and becomes visible as a tan – this indicates injury to the skin, not health.

Risk factors associated with the development of skin cancer include

• A lighter natural skin color
• Family or personal history of skin cancer
• Exposure to the sun through work or play
• A history of sunburns, ESPECIALLY EARLY IN LIFE
• A history of indoor tanning
• Skin that burns, freckles, reddens easily or becomes painful in the sun
• Blue or green eyes
• Blond or red hair
• Certain types and a large number of moles

The six skin types, based on how they tan / burn:

1. Always burns, never tans, sensitive to UV exposure
2. Burns easily, tans minimally

• Burns moderately, tans gradually to a light brown

1. Burns minimally, always tans well to a moderately brown
2. Rarely burns, tans profusely to dark
3. Never burns, deeply pigmented, least sensitive

Types I and II are at the highest risk.  I put myself at a IV.5.

The CDC seeks to dispel the myth that a “Base Tan” is a good thing in the Burning Truth initiative. It also states that tanning beds injure thousands of people each badly enough to go to a hospital and creates risk for aging of the skin and melanoma.

To reduce the risk of skin cancer:

• Stay in the shade – not to be confused with throwing shade
• Wear clothing that covers the arms and legs
• Wear a hat!
• Wear sunglasses – hipster and safe
• Use sunscreen of at least SPF 15 with both UVA and UVB protection– that graduation speech
• Avoid indoor tanning

In 2012, the FDA established regulations for the labeling of sunscreens – as described by FDA scientist Raynold Tan (no kidding!!).

• A labeling maximum SPF value of “50+” Those with an SPF 2-14 can only claim to prevent sunburn not aging or skin cancer
• “Broad Spectrum” means it protects from both UVA and UVB
• Those that are both broad spectrum and SPF of 15 or greater can claim a reduced risk of skin cancer and early aging.
• Two water resistant claim periods of 40 and 80 minutes will be allowed but “waterproof” and “sweat proof” will not.
• Labelling as “instant protection” and protection for greater than two hours will not be allowed without proof to the FDA – read here reapply every two hours.

Finally, is the “Sun Safety for America’s Youth” toolkit available from the CDC.

Protect yourselves this summer and let love steer the stars.

We give our patients lots of drugs. Continue reading →