In May of 2010, I wrote an article regarding my opinion of the validity of certain indicators insurance companies use to evaluate performance — given the fact that according to their records I write 71% generic prescriptions, and my nephrology specialty rank is eight out of 14 for writing generic medication. My conclusion at the time: "I recommend you be very careful interpreting performance numbers. Until the system is better able to capture quality, you may be doing yourself a disservice relying on data such as what I showed you."

I am not the only physician concerned with organizations publishing this kind of misleading data. Why? The data submitted to the insurance company does not capture my true prescribing because it is based on what they see. They do not have access to all of my data!

People realized that the only way to fairly evaluate health care system performance was to create an "optional" system that would enable analysis of all of the data. ("Optional" is in quotes because if physicians choose not to play, there is no way they can pay their bills.) In my opinion, this need to evaluate is what gave birth to the Electronic Medical Record (EMR) movement.

The next step, once the raw data is made "digestible," is to incentivize clinical outcomes. In other words, if everyone hospitalized for a heart attack (myocardial infarction) is started on a statin as suggested by guidelines, we will pay you more than those places who do not achieve the same result. However, everyone gets the bonus if the goal is achieved. But because this is a true bonus, the goal must be ambitious, yet achievable. In my opinion, achieving payment for goal-based performance is reasonable and a wonderful motivator for action.

Therefore, what we need is criteria for meaningful use of electronic medical records. Meaningful use is really a fancy term for using computer data in a way that proves to the government and other payers of healthcare that evidence based medicine is practiced by clinicians, and that data is acted upon through clinical decision making "rules."

The above thinking is quite brilliant. The theory is quite sound. The current problem is the expense of initiating an electronic medical record. Many physicians struggle to make ends meet. Medical practice managers are dealing with rising operating costs and have identified this as their biggest challenge of 2010 (which supports my thinking that there is a health care bubble, and it is going to burst unless we enact change). Hence, one of the reasons for the American Recovery and Reinvestment Act. The act is a way for the government to make available approximately 27 billion dollars in incentive payments for doctors (or health systems that employ physicians) who adopt electronic medical record technology over the next ten years ($44,000 through Medicare and $63,750 through Medicaid per clinician).

Some in the community opine this is "easy money" for systems. Do the math: 200 providers times $44,000 equals 8.8 million dollars. What these skeptics don't realize is that in order to qualify for the up to $44,000 in incentives, physicians must use certified electronic medical records in a meaningful way. Dr. David Blumenthal, MD, MPP, and other wrote a phenomenal perspective on the meaningful use regulation in the July 13th, 2010 edition of The New England Journal of Medicine. The challenge we physicians face, in addition to paying for the system, is meeting the requirements of meaningful use.

After reviewing the stipulations of the proposal, the "transformational opportunity to break through the barriers to progress" may not be enough. With no disrespect meant, the skeptics need to understand the concept of cash flow. When I was studying accounting, I learned a lot from the Bean Counter. Bottom line, many providers don't have available capital to purchase the "auditing equipment" that will be used to truly evaluate a provider's performance. The changes in work-flow, the lost productivity, and the added time it takes to navigate the system all contribute to decreased earning potential. I haven't even mentioned the cost of the systems, the required data storage capacity requirements, the number of people needed to train...

When you review the objectives of meaningful use in detail, you will see what I mean. There are two types of objectives: a core set and a menu set. Core is consider essential and must occur. Menu of options allows for provider choice and allows for some flexibility.

Core requirements include:

• Physicians will have to maintain an active medication list for their patients.
  
• Please consider reviewing The Synchronized Prescription Refill Service: A Patient Centric Model for the ideal synchronizing system that can be used to keep track of different providers prescribing medication for you.
  
• Physicians will have to implement one clinical decision support rule and the ability to track compliance with the rule [likely based on evidence based medicine].
  
• Upon request, physicians will have to provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies).
  
• Please consider reviewing Getting Value from Your Medical Appointments to help you navigate the quagmire that can occur if you don't follow these helpful tips to make the most of your medical appointments.
  
• Smoking status must be recorded for patients over 13 years of age. The American Academy of Family Physicians has developed a tobacco cessation program called the ASK and ACT program. The program helps providers integrate tobacco cessation into electronic health records.
  
• The template prompts clinicians to collect information about tobacco use, secondhand smoke exposure, cessation interest and past quit attempts.
• The electronic health record should also include automatic prompts that remind clinicians to encourage quitting, advise about smoke-free environments, and connect patients and families to appropriate cessation resources and materials [including the use of medication when appropriate].
  
• The template should be automated to appear when patients present with complaints such as cough, upper respiratory problems, diabetes, ear infections, hypertension (think me as in nephrology!), depression, anxiety and asthma, as well as for well-patient exams.

Moreover, clinicians will have to report data on 3 core quality measures in 2011 and 2012: blood-pressure level, tobacco status, and adult weight screening and follow up.

Let it be known that these "goals" are just a starting point. Therefore, physicians should make sure their choice of EMR is based on sound principles because "pigs get fat and hogs get slaughtered." Some medblogs have suggested independent providers partner with large hospital systems to help utilize the economy of scale to negotiate a return on "the independent provider's" investment (or said another way: the government's incentive) because the initial seed money may not be enough to meet all of the meaningful use criteria -- the doctor may get stuck with a bad program without help (if the software company goes out of business or starts price gouging).

There will be some hiccups in adapting the meaningful use criteria. In fact, CPOE.org notes 9 types of unintended consequences of computerized physician order entry:

1. More/New Work for Clinicians
   
2. Work flow Issues
   
3. Never Ending System Demands
   
4. Problems Related to Paper Persistence
   
5. Changes in Communication Patterns and Practices
   
6. Negative Emotions
   
7. Generation of New Kinds of Errors
   
8. Unexpected and Unintended Changes in Institutional Power Structure
   
9. Over-dependence on Technology

That said, a paradigm shift is happening in medicine today. We need to embrace the changes that are coming and realize that meaningful use is a work in progress. With perseverance, "we will progress toward electronically connected, information-driven medical care."

Once a committee has decided on a plan of action, the next step is implementation — the rate-limiting factor that must occur after equipment or process has been approved! In my opinion, this step is the hardest to execute. And that's why systems look for champions (persons) to serve as catalysts to help "get things going."

Therefore, provider "buy in" must occur early. The only way for that to occur is to use physician-driven committees. The Physician Drivers should not be chosen based on seniority, but on an established record of excellence to get a particular job done. These people must have education in the field, be willing to learn new things, have up to date credentials, and must be great communicators to successfully get the word out.

I have learned that physicians with education in a field need to have a role in advancing new technologies or processes in the hospital system. That said, control of conflict of interest with appropriate checks and balances needs to occur so that stewardship takes place. The goal is high quality, low cost, and an exceptional patient experience. The sum of these 3 parts is VALUE!

Let me clarify. If there is an expensive product that I want to purchase because it is cool and will help give value to patients, there needs to be someone there to "check" my thinking and provide balance, so that my conflict of interest (wanting the product) doesn't get in the way of doing what is best for the system and the patient. Maybe, for example, cardiology does it better than nephrology, so I'll let them do it because its the right thing to do.

Remember, its now about the 3 P's (in addition to the 3 A's*): Person, Process, and Product.

1. Person: who is the best person or the most appropriate speciality for the job?
2. Process: what is the best process for the job? Should we use lean or Six Sigma?
3. Product: what is the best product defined as the one that is the most cost effective, the best manufactured, and the one that gets the job done. There should be high sensitivity, specificity, positive predictive value, and negative predictive value associated with any diagnostic product. Therapeutic machines should have outcomes data that prove efficacy to provide patient value.

Many hospitals have interest in creating a "virtual hospital." A virtual hospital is a system which has the ability to utilize "cutting edge" technology through top-notch manufacturing to detect disease onset earlier so that disease can be prevented. Moreover, a good virtual hospital should also have the ability to monitor hospital ward patients (the lowest level of care in the hospital) in real time, avoiding catastrophic events.

Please don't misunderstand. You CAN have it both ways. The only time a person, product, or process should replace what is currently in practice is when the math suggests that quality will improve while cost will ultimately decrease. Did you know that Toyota lost money on every Prius it sold initially? Now, they make the premier product for a profit and own the market. So the product may initially cost money, but if the system benefits in a positive way, then the money is well spent.

I'll clarify with an example:  I had the honor to work with the Alegent Hypothermia Group to develop a 5-hospital, system-wide protocol to cool out-of-hospital cardiac arrest patients -- therapeutic hypothermia after cardiac arrest. The evidence in favor of using hypothermia after cardiac arrest is phenomenal: for every 7 patients cooled, one life is saved (assuming an absolute risk reduction of 14%). Today's numbers, using Dr. Kern's protocol (the one in use at Alegent Health), are even more impressive. Please note: Dr Karl Kern from the University of Arizona will be one of the keynote speakers at the Annual Cardiology Update on September 24th at the Omaha Marriott Regency.

My understanding is that Alegent Health is the first and only hospital system in the region to offer the service at more than one hospital. During the discussions to bring the concept to fruition, we noted that infection during this process is a real concern. If a person is cold, how can we detect if there is an infection? In other words, how does fever present itself in a patient we are trying to cool? People have used "time to cooling" or "difficulty maintaining cooling" as a marker for infection. My opinion is we currently have no good options.

There is a product for continuous temperature monitoring (braintunnelgenix.com) not yet available in the United States. Their system uses continuous non-invasive temperature monitoring:

"The Brain Temperature Tunnel (BTT™) is a direct and undisturbed connection between the thermal storage area in the brain and the surface of the skin at the inner corner of the eye.

This "tunnel of light" enables humanity — for the first time in history — to have noninvasive, continuous temperature measurement."

Perhaps early knowledge of an increase in temperature will allow for earlier detection and management of infection in therapeutic hypothermia. The early warning may indicate the need for broader spectrum antibiotics in this setting.

So although the theory is good, the company needs to prove to the hospital system that the temperature sensor is better than what we have now in terms of length of stay, cost, and patient outcome -- survival.

Also, we have to watch out for lead-time bias. Wiki defines lead-time bias as the bias that occurs when two tests for a disease are compared, and one test (the new, experimental one) diagnoses the disease earlier, but there is no effect on the outcome of the disease—it may appear that the test prolongs survival, when in fact it only results in earlier diagnosis when compared to traditional methods. The time of death in lead time bias is the same. This concept is an important factor when evaluating the effectiveness of a specific test.

Here's the point: the product may be worth adopting in practice if there is a true benefit with earlier detection. However, once disease is detected by the product, there must be a system in place for the physician to act on the data. Because if a tree falls in the forest, it only makes a sound if someone is there to hear it.

In conclusion, I believe in using technology appropriately. In order to be adopted, the plan of action that is developed must be shown to be "better" than what is currently used. We need to consider using real measures of outcomes. The right people should perform the studies, using the right products and processes. In order to survive the current health care environment, our goal should be to improve quality while lowering costs thereby providing value to our patients.

*The 3 A's: Availability, Affability, Ability

Wiki defines jargon as a term that descrcibes the language used by people who work or live in a particular area (such as doctors or Nebraskans respectively). Jargon words are also used by people with a common interest (such as cribbage).

There are benefits to the use of jargon: a standard term may be given a more precise or unique usage among practitioners of a field. This allows for better communication among the members of group.

The major problem with using jargon is that in many cases this causes a barrier to communication with those not familiar with the language of the field (such as patients).

Let's use the term "snow" to develop this concept further. There is a relationship between the geographic area where people live and the need for knowing snow-jargon. For example, in order to survive the harsh Nebraska winter, people must have the ability to effectively communicate around the different terms for snow.

I have lived in the northern Midwest for a good portion of my adult life. I've had to learn these terms in order to be able to survive the winter, stay safe, and prepare for my workday -- nephrologists such as myself have to travel to many hospitals, kidney dialysis clinics, and outpatient clinics in order to provide service -- regardless of the weather. Also, I need to understand these terms in order to make sense of the weather report 6 months a year.

Compare Nebraska to Texas. I spent 2 months in Austin, Texas when I was in high school. I had the opportunity to take AP biology at the University. Its hot! Snow is rare and there is no need to know the 18 Nebraska snow words -- unless you plan to vacation up north!

Here is a short list of the words for snow used in Nebraska:

1. powder snow: frozen precipitation in the form of white or translucent hexagonal ice crystals that fall in soft, white flakes. People who ski prefer powder snow. I think of powder snow as "Rudolph the Red Nosed Reindeer" snow. Same thing as "snowfall" except used in the setting of skiing.
2. sleet: a mixture of rain and snow
3. slush: partially melted snow or ice
4. snowfall: frozen precipitation in the form of white or translucent hexagonal ice crystals that fall in soft, white flakes.
5. whiteout: the failure to maintain visibility in heavy snow. Very unsafe weather in which to drive.
6. hail: snow in the form of pellets of ice larger than 5 millimeters (0.2 inches) in diameter. I have seen softball sized hail. Imagine what a car looks like after being pounded by softball sized hail!
7. crust: this type of snow has a harder crust on top of softer powder snow. We see crust on the road after cars have been driving for a few hours after a snowfall.
8. blizzard: a very heavy snowstorm with high winds. Heavy winds are usually defined as at least 35 miles per hour.
9. ice: water frozen in the solid state.
10. icicle: ice resembling a pendent spear, formed by the freezing of dripping water.
11. dusting: a light sprinkling of snow.
12.  flurry: a light, brief snowfall. Not sure, but I think flurries have more snow than a dusting.
13. snowbank: a heap of snow. Snowbanks are created as a result of shoveling snow.
14. snowdrift: a heap of snow as a result of the wind.
15. snowstorm: a storm with heavy snowfall.
16. freezing rain: supercooled droplets that freeze on impact.
17. yellow snow: snow given a golden or yellow appearance by the presence in it of pine, cypress pollen, or anthropogenic material or animal-produced material (such as squirrel potty as my son would say).
18. black ice: a thin, nearly invisible coating of ice that forms on paved surfaces. People can lose control of their vehicles. Four wheel drive vehicles don't help you on ice. Black ice formation is a very difficult situation. Cruise control should not be used when driving on black ice.

People living in Texas have one word for snow:

1. snow: that white stuff we get every few years that our kids find cool, is impossible to drive in, and melts in a day.

So how does this discussion justify the need for medical jargon, and why does this important article fall under the heading of a medical blog? I speak a foreign language called "medicalese" -- the specialized terminology of the medical system. Latin is easier to learn than Medicalise! Medicalise is derived from Latin, Greek, English, and more. The standard medical dictionary has over 45,000 words. In order to communicate effectively, we need to use the jargon we spent 7-10 years initially learning, as well as all the new words that keep popping up.

Another language spoken all over the world that is similar to medicalese is Yiddish. Yiddish is spoken in the United States, Israel, Poland, Argentina, Brazil, United Kingdom, Russia, Canada, Ukraine, Belarus, Hungary, Mexico, Moldova, Lithuania, Belgium, Germany, Australia, France and elsewhere. Someone with knowledge of Yiddish and German in Germany can speak Yiddish to a person in Mexico who can speak Yiddish and Spanish. The German in this case can effectively communicate with the Mexican without having to learn another language.

Let's get back to medicalese. An example of using medicalese is heart failure. There are many terms associated with the condition, and the words we use can get quite complex. Consider the following example:

The patient has New York Heart Association Class IV heart failure with an estimated ejection fraction of 20 percent. He has SOB. He denies chest pain. Moreover, long term sleep apnea has led to pulmonary hypertension, cor pulmonale, and bilateral lower extremity edema. Aquapheresis is an option for this patient, but I think we need to make sure the patient has diuretic resistance first by checking a 24 hour urine collection for creatinine clearance and sodium. I will ask cardiology to calculate the caval index. A greater than 50% variation in inspiration, especially in this setting would suggest decreased effective circulating volume in the setting of total body hypervolemia -- a situation where aquapheresis can do wonders by safely removing water through ultrafiltration while decreasing the risk of acute kidney injury, especially if inline hematocrit monitoring is utilized. In addition, we should consider placement of an implantable defibrillator. Although the patient has chronic kidney disease IIIA, the benefits outweigh the risks because only 10 cc of contrast will be used. We can prophylax with mucomyst....

Still with me? The terms that are understandable may be taken as an insult to the patient without knowledge of how the language is spoken.  SOB is a term to describe "shortness of breath." Also, "denies" is a strong term. A patient reading this chart may misconstrue what doctors mean when this term is used. Using "denies" is a simple term we doctors use to rule out a diagnosis. There is nothing personal here!

Another, better way to say it: the patient's heart is not pumping correctly. A pacemaker might help prevent sudden death. The kidneys are working at 50% of normal so we need to be careful placing the pacemaker. Fluid removal using a machine may be helpful as well. If a person still has swelling in the legs on a high dose of water pills, we can go forward.

In my opinion, the best doctors are the ones who have the ability to communicate in a way that both their colleagues and their patients understand (such as the ability to speak both German and Yiddish). Did you know that "doctor" is from the Latin word "teacher"? That is what the best providers do -- they teach. Both descriptions above are necessary. The cardiologist needs to hear the first explanation; the patient needs to hear the second.

A patient with high blood pressure presented to my office with a severe headache. She has a history of seasonal allergies. The patient is adherent to her medication regimen. In the office, her blood pressure was 210/120. Normally, her blood pressure on therapy is 125/78. What is happening and what should we do?

It turns out the patient was outside with her family watching fireworks. Her allergies to pollen acted up, and she took pseudoephedrine to help control her symptoms. A side effect of this medication is hypertension.

I see a referral population which can be very different from the general population that sees a primary care practitioner. That said, I have seen many high blood pressure patients on allergy medications that have had bad outcomes: stroke, heart attack, kidney problems, and malignant (life-threatening) hypertension.

Both perennial and seasonal allergies can be annoying for a person. Its usually easy to tell an untreated patient with allergies because they give you the "allergic salute" (people with allergic rhinitis often rubs their noses using the index finger).

Many over the counter therapies for allergic rhinitis can worsen a patient's hypertension. For instance, phenylephrine, the active ingredient in Sudafed, can also increase a person's blood pressure. In fact, most decongestants (drugs that shrink the swollen membranes in the nose) may cause hypertension.

The best therapy for allergies in a patient with high blood pressure is an intra-nasal steroid. Avoidance of the allergens, if possible, also helps.

A cost-effective, generic nasal steroid that is not absorbed by the body is called fluticasone propionate which is currently $60 dollars a month at drugstore.com. Other steroid inhalers are available, but these can get very pricey.

There are other medication options for those on an extremely tight budget. The Walmart $4 list includes loratadine, which you can obtain via a prescription from your doctor. The medicine is generic and is the same thing as over the counter Claritin. This medicine is extremely effective and is a great second-line or add on therapy to the intranasal corticosteroid.

For those of you with hypertension and allergies who wish to try an over the counter nasal inhaler option, cromolyn sodium is available. Cromolyn stabilizes inflammatory cells which are involved in the allergy process. This medicine works. It is cost effective (around 12 dollars per inhaler), but the big downside here is that a person has to use it 4 times daily. I have found that many people are non-adherent to more than twice a day medication regimens. And if you don't take the medication it won't work. Therefore, Cromolyn is my third line therapy.

For those who do not like to take medication, nasal irrigation and saline sprays can be effective. Many of my patients find this form of therapy to be unappealing and give up on it quickly.

For the patient described here in the clinical vignette, I referred her back to her primary care physician for an allergy therapy assessment. I asked the patient to stop taking the pseudoephedrine and continue her current blood pressure medication therapy. Her blood pressure quickly returned to normal and with the help of her PCP (primary care physician), her allergies got better!

Every day, delivery of medical care becomes more streamlined and transparent. Alegent Nephrology is always making procedural adjustments to improve care and give you, a consumer of health care, the greatest return on your investment. As a center of excellence, where the highest standard of health care delivery and the highest quality of care in the region is, we want to make your visit as productive as possible.

Doctors, both generalists and specialists, have constraints on their time. New practices and new approaches need to happen in order to maximize everyone's time. In addition to bringing your co-payment, you should "invest" in the visit and do your part, so that by the time the visit has ended, a SUCCESSFUL plan of care is developed.

Here are some helpful tips to make the most of your medical appointments:

1. Ask questions. The relationship between you and your doctor is a special one based on trust and mutual respect. It is important to ask questions that concern you -- up front. It is normal to feel uncomfortable about discussing certain topics such as antibiotics after sexual intercourse. However, if you don't tell me, I can't help you.
2. Successful planning begins at home. Bring important records with you which should include your recent laboratory test results, a current list of your present and past diagnoses, and a current medication list based on the medicines you are presently taking and how often you take your pills. Every piece of information is a clue to making a diagnosis. For instance, as a kidney specialist, it makes a difference to me if you are taking Lasix once or twice a day.
3. Repetition is a good thing. Sometimes patients get annoyed that they have to repeat information. For clarity, I like it. Although the nurse may take your current medication list for the chart, I like to see what you are taking. Bringing an up to date list saves both you and me valuable time because I can read quickly.
4. Bring your records to the appointment. What if the electronic medical record is down? What if we can't find your chart? What if you see a doctor in a different system? Although exceedingly rare, problems do occur. Google Health, a flash drive with records, or paper speeds up the process. Then you don't have to wait for "old records" to be faxed to the clinic. Not infrequently I hear, "They told me they were going to send the records." Although people's intentions are good, sometimes records do not get sent by the time of the appointment.
5. Keep a list of your over the counter medications, alternative therapies, and vitamins. Some of these medicines interact with prescription medication, and these interactions can adversely affect therapy. For example, there is a known interaction between warfarin (coumadin) and cranberry juice that can affect INR (blood thinning) levels. Your doctor needs to know how you are treating particular conditions such as the prevention of urinary tract infection.
6. Know the physicians you see and why you see them. "Dr. Aaronson, the nephrologist, treats my blood pressure. Dr. Van De Graaff, the cardiologist, treats my heart failure and put in my pacemaker. Dr. Schwartz, the internist, treats my high cholesterol." Why is this tip so important? Dr. Schwartz may assume that Dr. Van De Graaf is treating high cholesterol. Dr. Van De Graaf may assume that Dr. Schwartz is treating high cholesterol. And the end result is nobody is treating the high cholesterol! By defining who takes care of which problem, nothing inadvertently gets missed.  Also, please remember to ask for a business card. Consider bringing these cards with you to every visit.
7. If you think it will be helpful, bring along a family member. Friends are also welcome. Accompanied by friends and family, you can have advocates present to help you understand what the doctor said or write down key points learned at the visit.
8. Make sure you understand what happens next. When will you see the doctor next? When does a blood draw need to happen? Also, make sure there is a mechanism in place so that if your symptoms worsen or don't improve you can get help. Emergency room visits or hospitalizations can be prevented!
9. Understand the language. "Doctor-speak" is foreign to most consumers of healthcare. These words are important however because that's how providers communicate with one another. You need to know the words and what they mean. I'm not asking you to memorize a medical dictionary, just the words used to describe the conditions you have. My job is to help explain what those words mean. I frequently write the patient's diagnosis on a piece of paper and provide a description of what that means. Feel free to look up the terms on the internet to learn more or ask me if you don't understand what I'm talking about! In the event you can't remember your diagnoses, make sure you always have an updated list with you so that your provider can take great care of you.

Remember, we all must work as a team to help make the medical visit productive and valuable. Communication is the key to getting value from your medical appointment. Mutual understanding and shared decision making helps you adhere to the medical plan and helps me give you world class care.

Over the years, I have helped scores of women with frequent, recurring urinary tract infections (UTIs). Since many recommendations have changed over the last decade, I decided to answer the question right away. Because some common practices have turned out to be unhelpful, an update is timely and warranted.

First, involvement of your primary care provider is critical. "Must not miss" disorders need to be considered prior to going forward with the recommendations given below.

Second, how do you define recurrent urinary tract infection? Most define recurrent UTI as when a woman has two or more symptomatic urinary tract infections in six months or three or more symptomatic UTIs over 12 months. What makes this definition less precise is the fact that the degree of discomfort in the woman usually is the determining factor that leads her to present to her primary care provider. Frustration usually motivates the woman to act.

Once your primary provider has determined you have recurring UTI's, the following recommendations may be made for young, healthy, non-pregnant women:

For sexually active women:

• If spermicides or diphragms are used, an alternative form of contraception may be recommended.
• Drinking fluid and urinating after sexual intercourse: studies have not proven the effectiveness of this strategy. Although some providers opine that this "doesn't hurt," my opinion is that if it doesn't help, why do it?
• Antibiotics are highly effective. There are many ways to effectively use antibiotics to prevent recurrent urinary tract infections (see below).
• Cranberry juice and concentrated cranberry extract tablets have not been proven to be effective. In my opinion, the cost, the calories, and the unpalatable taste make other alternatives desirable.

Antibiotic regimens:

• Low dose antibiotics daily
• Low dose antibiotics three times a week
• Antibiotics after sexual intercourse
• Alternatively, at the first sign of a urinary tract infection, when you first notice symptoms, an antibiotic is taken.
  

Studies have suggested these methods are efficacious for six months up to several years of therapy.

Questions:

1. Does the type of antibiotic prescribed make a difference? It turns out that all antibiotics are equally effective. Some antibiotics have to be dosed for kidney disease. Antibiotics can have side effects including diarrhea and yeast infections. That's why your primary provider is there to give you advice.
2. Do I have to worry about drug resistance? Yes, however it turns out that drug resistance is rare in this setting. Sometimes a urine culture is needed to see if the antibiotics are treating the organism causing the infection.

So that is the latest information on the treatment of recurrent urinary tract infections. If you have a follow up question or comment, please feel free to ask.

Dr. Eric Van De Graaff, Cardiologist at Alegent Health Clinic Heart and Vascular Specialists, wrote a very poignant article in defense of statins. His timing was perfect. It's almost as if he knew the Archives of Internal Medicine's June 28th article was going to be published.

You will be hearing a lot about this article: Statins and All-Cause Mortality in High-Risk Primary Prevention. The argument the study makes is that there may be little benefit in primary prevention patients to justify using statin medicines to lower your cholesterol level. (Primary prevention is defined as avoiding the development of a disease. Most population-based health promotion activities are primary preventive measures.) Before you stop your Lipitor, please consider Professor Van De Graaff's article in addition to mine where I "ditto" his argument.

Although diet and exercise are paramount, one can argue that protection through medication should be considered in patients at risk for dying from heart disease — if medication is indeed effective.

It takes time for atherosclerosis (plaque build-up) in the coronary arteries to become clinically evident heart disease. Trials that are stopped after only 4 years may not show a benefit because it may take many more years for the plaque build-up to result in a cardiac event (a heart attack). This is the definition of a false negative study: failure to detect a difference when a difference does in fact exist.

Let's use a simple country nephrology analogy. Take 2 cars in good condition. Drive up to Northern Minnesota. Rust-proof one car but leave the other alone. Drive the 2 cars during the winter, allowing the salty roads to attempt to rust the cars. After the first few years, we may be unable to detect a difference. However, after 5-10 years, the rust proofing shows a benefit whereas the other did not. People are not cars; however, a high salt, fatty diet resulting in obesity can lead to heart disease over time. Perhaps we didn't perform due diligence and give enough time to allow a difference to happen because it takes many years for fatty material to deposit in a vessel wall:

The problem with primary prevention trials is that they require too much time and are extremely expensive. Pharmaceutical companies don't want to pay because of drug patent-life issues and decreased return on investment. Therefore, the National Institute of Health needs to fund this study. The problem however, is who wants to wait a generation to find out the results when you could be benefiting right now?

Fortunately we have many good 4 dollar a month medicines. For now, in a high risk population, I would opine that we should consider using cost effective statin drugs. This may be a leap of faith, but until proven otherwise, the mechanism of action makes sense. Given the billions of dollars Americans waste on vitamins, it could be argued they would be willing to pay for the proposed benefit. Moreover, if a generic statin is not powerful enough, you might want to consider a more powerful statin, like Lipitor. That choice is between you and your clinician.

Finally, there is no question that patients who already have established heart disease should be on a statin because these cholesterol lowering medications prevent death from heart disease and complications related to heart disease. This is called secondary prevention.

So let's say that you are a purest and want to wait until you have absolute evidence of cardiovascular disease. The question now becomes when to intervene. When does a stable heart plaque become unstable? Are our current markers adequate to know when to start statins? Do you want to wait until you have a heart attack prior to starting the medication? Determining whether you have heart disease or not is a challenge, one I will defer to Alegent Health Clinic Heart and Vascular Specialists and the primary care docs. However, in my opinion, once there is evidence of plaque, I think a statin (or other risk factor modifier such as blood pressure pills) should be started.

Ask your doctor if you are on a statin for primary prevention or secondary prevention. This will help you determine whether or not you should consider continuing, or starting, a cholesterol lowering statin or not. The decision should be an individual choice, free from algorithms, so that you are comfortable with your doctor, your care, and are taking control of your health.

The question keeps getting asked: Water pills (diuretics) do not take care of my water weight problem. Why is this when aquapheresis works great?

The figure represents the water distribution of a 70 kilogram male (150 pounds) with no extra fluid. You are mostly water. If you have swelling in the legs (edema), the EXTRA fluid is located in the intersititial space. Of interest, patients with 30 pounds of edema have all that extra water weight located in the intersitial space.

According to the figure, only a tiny amount of fluid is located on the arterial side (0.7 liters or about 2 cans of Pepsi), the place where diuretics (water pills) have an effect. Too much stress placed on that system from water pills can lead to sudden kidney failure.

Since the venous compartment contains much more fluid (3.9 liters), the process of aquapheresis can pull fluid from the venous side without really affecting the arterial side -- sparing the kidneys. During aquapheresis, we take off pounds of fluid over the 3 day process because the interstitial fluid (9.4 liters or more in a patient with pitting edema in the lower extremities) replaces the removed fluid from the venous side.

We have actually seen some patient's kidney function improve during the procedure!

Lasix is a water pill used in heart failure patients and as a treatment for high blood-pressure. Many people are prescribed Lasix. In fact, I'm willing to bet you a penny that you know at least one person who is on it. Unfortunately, many people are incorrectly using Lasix.

When I was in medical school at the University of Connecticut, one of my favorite rotations was my surgery experience. At night, on call, and waiting for admissions, I sometimes watched television with the residents — usually if we were not in the mood to study. The television show "ER" was very popular at that time. I remember a question asked on the show: "Is Lasix (furosemide) a once a day medication?" The answer is no. Lasix is a twice a day medication.

Fast forward to today. I'm currently studying for my Kidney recertification exam. One of the study questions asks how to dose Lasix. Surprisingly, most physicians get this one wrong. Most providers prescribe Lasix once a day.

I frequently get consulted for resistant high blood-pressure. The patients I see tend to be on multiple blood pressure medications. One of the first things I do is recommend to my patients that they take their Lasix twice a day. Why is this recommendation necessary? The kidneys are extremely smart organs. When a water pill is given that only lasts for 6 to 12 hours, the kidneys will spend the remaining 12 hours of the day recovering the lost fluid resulting in net zero fluid loss.

The secret to tolerating Lasix is to know what to expect. Be prepared to urinate a lot both during the day and night when you first start Lasix twice daily, or when the dose is increased. After about 4-5 days of using this diuretic, your body will adjust, and you will be less likely to wake up at night to urinate.

So remember, Lasix (furosemide) lasts 6-12 hours and needs to be taken TWICE DAILY in order to work correctly. Ask your doctor if you have any questions regarding Lasix (furosemide).

Another week, another question from an email subscriber: I had eclampsia in July 2008, I would have loved a kidney consult! Can there be any long term consequences of protein in the urine in pregnancy?

Dr. Aaronson: Thank you so much for your question! I appreciate the fact that you value my opinion.

Pre-eclampsia refers to high blood pressure and protein spillage in the urine after 20 weeks of pregnancy in a woman who had a normal blood pressure prior to getting pregnant. When the preeclampsia gets bad enough, a person may have a seizure. When this occurs the woman is said to have eclampsia. Normally, delivery of the baby is the treatment of choice to protect both the mother and the infant.

Mothers are at risk for recurrence of pre-eclampsia/eclampsia during their next pregnancy. Those who were diagnosed early on in the pregnancy and were noted to have been in critical condition have a 25-65% risk of reoccurrence. OB-Gyn doctors will watch you very closely and try to help prevent a recurrence.

Unfortunately, women diagnosed with preeclampsia are at greater risk than their counterparts for heart disease and stroke and should be treated aggressively by their provider for any risks they might have. Also, these women have an increased risk of kidney disease, including the need for dialysis. You may want to find out how much protein you currently are spilling in your urine. That helps the doctor make decisions regarding your care.

My recommendation: make sure you see your doctor and focus on preventive care and goal rate attainment. If you note that you have a GFR of 60 or less, have residual protein in your urine, or have any concern regarding your kidney function, please feel free to make an appointment with a kidney specialist.

A question from one of our email subscribers: "I have a friend with childhood onset sugar diabetes. She is 40 years old. She takes great care of herself. She recently got an insulin pump and her sugars have been great. She exercises every day. After seeing her primary care provider, she was told her GFR (her level of kidney function) was down to 50 (normal is 100) — this was 2 weeks ago. Six months prior it was 56. They said they'd recheck it in 3 months. Well, this week she got short of breath and was concerned that she was having a heart attack. She had a stress test today that went well. They rechecked her GFR though and it was 43. Her primary doctor told her if it goes below 40 she's going to have her see a nephrologist / kidney specialist. A kidney U/S showed that her kidneys were slightly smaller than normal but had good blood flow. They are rechecking her kidney function in one week. Any thoughts? I wonder if the worsened kidney function is a fluke or something we should be concerned about? Thanks!"

Dr. Aaronson: Thank you for asking this question. Understanding kidney function can be complex. Let me simplify. Even though we normally have about 2 million kidney filters, kidney doctors say that a person with no kidney problems has 100 filters. These 100 filters perform the job of removing toxins and fluid from the body every day. In doctor-speak, this person has a "GFR" or filter rate of 100 per cent function.

Over time, people with diabetes and high blood pressure can damage some of the filters. The woman in our case study has 50 out of 100 filters to do the job (50 per cent function). These filters have a lot of work to do, but they can get it done and a person doesn't have to get kidney dialysis. As more and more filters get damaged, the remaining ones start to get overworked. Eventually when there are 10 to 15 filters left, the filters are unable to remove the toxins and fluid from the body, and the patient requires an external filter (a kidney dialysis) to get the job done.

Primary care physicians have different cutoffs in terms of GFR the patient has to have before they are willing to consult a kidney specialist. Of course, I am happy to see the patient at any level of kidney dysfunction for any reason. However, I would much rather have 60 filters to work with than 40. When there are only 20 to 30 filters left, my job gets harder and the chances of preventing kidney dialysis is even worse. Many nephrologists or kidney doctors would recommend consultation when the kidney function, the GFR drops below 60. This is the magic number.

A lot of things change in the body when the GFR is around 60 or below. People can become anemic, tired and fatigued. People can have major bone problems. People can have potassium and other electrolyte problems. Kidney specialists can help the primary care physician with these kidney specific issues. What's more, targets for blood pressure and cholesterol are lowered. So control becomes harder to obtain. Kidney consultants can help the primary care doctor and the patient achieve these new goal targets.

In this case, I do agree with checking a blood test in one week. However, whether or not the lower number was a fluke doesn't change the fact that this woman needs to see a kidney doctor. In addition to what was just mentioned, I would like to know if the patient has any protein or blood in her urine. If she has protein, she would be a candidate for a medications such as benazepril to help prolong the life of her kidneys — even if her blood pressure is normal! Iron studies to evaluate for iron deficiency anemia would also be indicated. Target blood pressure should be 130/80, and I would argue that the patient should have an LDL (bad) cholesterol of 70 or below, triglyceride level of 150 or below, and HDL (good cholesterol) of 40 or above. If there is any evidence of secondary hyperparathyroidism, the person needs to be treated.

Make sure your physician tells you your GFR. Terms like "creatinine" have less meaning and is not enough information, because your creatinine level is only a rough estimate of your kidney function.

Now you know if the number is below 60 you should see me. If the number is trending down quickly, even if it is above 60, you should see me. If you are concerned, you should see me. My goal at that time would be to prevent further worsening of kidney function so that you never see the kidney dialysis machine. However, it is important to note that if you do need kidney dialysis, I can help you with that.

Kidney doctors are frequently asked to give their opinion on whether a patient should continue taking a nonsteroidal medication (Advil, Motrin) or switch to an alternative such as Tylenol or a scheduled narcotic.

Chronic pain is very common. After over-the-counter medication has been tried and has failed, patients come to their family doctor for help.

 There are two broad categories of non-narcotic pain medication:

1) Nonsteroidal anti-inflammatory medication: Motrin, Advil, and many others. This class of medication treats pain, fever, and inflammation (swelling). Ibuprofen is a type of non-steroidal that is processed in the liver.

2) Tylenol: this medication treats pain and fever but NOT inflammation. Tylenol is excreted in the urine but in some circumstances affects the liver.

Patients who have arthritis are usually prescribed nonsteroidal anti-inflammatory medication. NSAIDS are very powerful pain control medicines and frequently do the trick. Not only do they control pain, but they also to help decrease swelling in people's joints.

"So, if ibuprofen is processed in the liver and Tylenol is excreted in the urine, why is Tylenol "safer" for the kidneys than ibuprofen?"

Patients with chronic kidney disease can be very sensitive to non-steroidals. Their kidney function can get worse, and their blood pressure can go up. So even though a medicine such as ibuprofen is processed in the liver and is meant to control pain, it can have untoward effects on the rest of the system -- in this case the kidneys and the blood pressure through complex mechanisms. When this happens Tylenol is usually recommended because it doesn't adversely affect the kidneys. The big downside here is that Tylenol doesn't help decrease the swelling of inflammation.

It is important to note that the kidney doctor doesn't write for the pain medicine. The kidney doctor performs a risk/benefit analysis with the patient so that the patient can make informed decisions regarding what to do. Some people are willing to risk worsening kidney function and hypertension in order to have their pain and inflammation treated. In that case the nephrologist will try to help prevent worsening kidney function and high blood pressure at all costs. On the other hand, some people may want to avoid blood pressure and kidney problems and choose Tylenol (and possibly a narcotic with the help of a pain specialist). When I was training, we were taught to avoid nonsteroidal medication at all costs when the blood pressure or the kidneys were affected. However, my problem with this is that a life of severe pain may be so intolerable that the risk of kidney decline may be something to consider if a patient can get some relief.

A fellowship is the period of medical training in the United States that a physician may undertake after completing a specialty training program.

It can also be defined as "companionship of persons on equal and friendly terms."

When I was in training to become a kidney doctor at the University of Minnesota, the fellows would often partake in fellowship. Whether it was getting together for pizza or playing board games, the social time we spent helped us learn about one another outside the setting of nephrology and work. Unfortunately, as people nowadays get busier and busier, fellowship rarely happens because there is no time. Other priorities take over.

As Alegent Health continues to build a culture of excellence, fellowship is becoming a priority. Building bonds of friendship improve patient care because people work better together. Last Saturday night, my wife and I spent some quality time with our Alegent Cardiology friends and their spouses. I appreciated this opportunity, because even though I graduated 14 years ago, I'm relatively new to Omaha. Time spent playing Family Feud, Are You Smarter Than a Fifth Grader and Trivial Pursuit translated to fun, laughs and relationship building. I was thrilled my wife could get to know some of the people I work with.

I learned some interesting tidbits as well. Tara Whitmire is an advanced practice nurse who recently got accepted to the University of Iowa DNP program. The Doctor of Nursing Practice (DNP) is an advanced-level practice degree that focuses on the clinical aspects of nursing rather than academic research. The curriculum for the DNP degree generally includes advanced practice, leadership, and application of clinical research related to nursing. She starts in June and is going to get her doctorate degree. She is also really good at Family Feud. Jill Ogg-Gress has already completed her training and is a doctor of nursing practice. Dr. Joseph Thibodeau, in addition to his impressive bio, used to moonlight as an e-Focus physician while he was in training.

I am just so impressed with this group of people. They are down to earth, extremely modest, yet so well educated. There is no pomp and circumstance. And perhaps this is why they are such phenomenal clinicians with great rapport with their patients.

Did they learn anything about me? You betcha! While I was defining CPR, it came up that I set up two successful pancreas transplant programs in the Dakotas, a legacy I am quite proud of but don't usually mention.

Bottom line: Make time for fellowship. Whether it is with your co-workers, your family, or your friends, I'm sure you'll have a lot of fun!

Alegent Nephrology is happy to report a 95% success rate upon review of their 1st quality performance indicator!

This is phenomenal news! And there is more to this story. Here at Alegent Nephrology, we want to provide you with the best care in the nation. Our patients expect that. We expect that of ourselves. So how can we achieve that goal in an objective fashion? We need to compare how well (or how poorly) we are doing compared with the nation, and the way to do that is by reporting quality metrics.

Quality metrics is one of the latest buzzwords in healthcare. What is it, and why is it important? Quality metrics is a way for an organization to measure how well they are doing on a certain performance indicator. The reports are important because it gives you, the consumer, an objective way to evaluate our performance as kidney doctors. We decided that our goal for '09-'10 was to identify diabetic patients with protein in their urine (a risk factor for heart disease death) and make sure that those patients are taking an ACE inhibitor such as benazepril. An ACE inhibitor is a blood pressure medication that is available in a generic formulation that decreases protein in the urine and significantly decreases heart disease risk when taken.

The literature suggests that despite all of the evidence in favor of this form of treatment, only 43% of older diabetics with protein in their urine receive an ACE inhibitor (J Gen Intern Med. 2006 April; 21(4): 315–319). This suggests a major quality problem -- there is a cheap, effective, beneficial therapy for patients that 57% of the population is not taking! Therefore, if we can increase the number of people getting treated, we can save lives.

So the results are in: Alegent Nephrology has 95% of our population on appropriate treatment, which represents a whopping 52% higher score than the national average!

After the high-fives, the "hip, hip, horrah!" and the pats on the back, I was asked how I felt about scoring 95% when the average goal rate attainment is 43%. I replied, "why didn't we get 100%"?... And I am serious! We are in the top percentile of the country in terms of goal rate attainment, and in general, I'm a "glass is half full" kind of guy. So why was I unhappy with our results?

I was shocked that some our patients were "missed." I eat, drink, breathe, and sleep ACE inhibitors in diabetic kidney patients with protein in their urine. I strongly believe the therapy is the right thing to do for our patients. I have the Alegent Pharmacy $4.99 drug list framed on my wall next to a picture of my beautiful wife and children. During every patient encounter, I review whether an ACE inhibitor is indicated. In fact, I write so much benazepril that I can spell it backwards (lirpezaneb) while chewing a piece of gum and hopping up and down on one leg. So why didn't we get 100%?

To err is human. Things can get overlooked. And that is why I embrace these performance measures/quality metrics because a person can't be perfect all the time. The beauty of the Alegent Health system is that we are encouraged to constantly strive for perfection. The PROCESS of reviewing our population in an attempt to improve quality alerted us to the few patients that we missed. And instead of crying over spilt milk and using the cliched term "it is what it is," we decided to find out WHY the few patients weren't getting the therapy they were supposed to. By the end of the week, everyone was either getting the appropriate therapy or had documentation why they were not able to receive it. The result = zero patients missed. Now I am happy!

Here is a take-home pearl for you: if you happen to be a diabetic with protein in your urine and you are not taking one of the "prils," please ask your doctor why. And as always, if there are any concerns from a nephrology standpoint, we are here to help facilitate.

I hope you enjoyed our latest blog. We plan to continue to report our quality metrics in the future with the goal of giving you, our patients, "world class" care.

*UPDATE* I am happy to report that I have passed the internal medicine recertification! Next step in my life long learning plan: nephrology recert in 2011...

Click here to view my CNE Certificate

Dr. Michael L. Aaronson (Kidney Doctor / Nephrologist): Today I have the pleasure of interviewing Dr. Pierre Lavedan, M.D. Medical Director for palliative care and also a hospice physician for Alegent Health Hospice. Thank you Doctor for joining us today.

Dr. Lavedan: My pleasure.

Dr. Aaronson: What did you do prior to becoming medical director of the palliative care service?

Dr. Lavedan: I was a family medicine doctor for 12 years. I delivered babies for 10 years. I started with hospice care about five years ago.

Dr. Aaronson: Can you define palliative care for us in layman's terms?

Dr. Lavedan: Palliative care is attention to the patient and attention to symptoms a patient might have as the patient approaches the end of their life: We coordinate with social workers. We address the patient's spiritual needs and work with the chaplain. We focus on treating a patient's pain. We also take care of symptoms that take away from a patient's comfort such as shortness of breath, nausea, vomiting, diarrhea, constipation and other issues related to pain.

But also, palliative care is meant to be given in some circumstances alongside aggressive medical therapy. So if the goal is curative, that does not exclude the use of palliative care medicine.

Dr. Aaronson: I think that's a key take home message. To reiterate: I, as a kidney doctor, can perform dialysis, treat a patient with an intent to cure, and still use your services. The reason why I like to have palliative care involved, is that in the setting of a sick patient, sometimes curative therapy is futile, and the palliative care service can facilitate the transition from cure-focused, which may be uncomfortable, to comfort-focused which enables the patient to have dignity when they pass. You are there to help them with that transition.

Dr. Lavedan: We can also help the transition to hospice care, so a patient can be transferred out of the intensive care unit to their home or another facility.

Appropriate consultation to palliative care is the following: the diagnosis of chronic obstructive pulmonary disease or emphysema when the patient is requiring oxygen; the diagnosis of congestive heart failure; the diagnosis of kidney failure including the possible need for kidney dialysis...

Dr. Aaronson: I like to use you in this setting very often. Sometimes the decision of whether or not to perform kidney dialysis is quite complicated. I like to think of your service as a third-party independent team of people that helps the patient decide what to do. Just because dialysis is available doesn't mean a patient has to go on it.

Dr. Lavedan: My pleasure. We can also help patients who have diabetes and are approaching end-stage. End-stage means when the diabetes is starting to affect multiple organs: heart problems, eye problems, and kidney problems. In other words, everything taken together. Sometimes, despite what we do the patient is gets worse and not better.

Dr. Aaronson: Why did you decide that palliative care was your calling?

Dr. Lavedan: I was a part of the ethics committee prior to making the change. I felt that there was a lot of misunderstanding in terms of what can or what cannot be done.

Dr. Aaronson: That's a good point. The ethics committee is a group of people who may not be directly involved with the patient. Palliative care enables you the opportunity to discuss the situation with the patient or their proxy/durable power of health care directly.

Dr. Aaronson: I just wanted to let the public know that palliative care at Alegent health is growing at a rapid pace. Palliative care medicine is widely available.

Next question: For those who do not believe, here's a tough one for you. Why can't I do what you do? Why can't the primary care provider, who has known the patient for possibly 20 or 30 years, do what you do? What makes it worthwhile to have you on board?

Dr. Lavedan: Let me give you my perspective. As a family medicine physician, I look at life from beginning to end. As a palliative care physician, I look at life from the end to where we are currently at. I do this full-time, and I look at life backwards. I have totally reoriented the way that I view life. I think about how the patient is going to progress naturally, and I do everything I can to help anticipate and control symptoms so that the patient has comfort. In order to do this, it does takes special expertise. Just like you have special skills and expertise taking care of patients with kidney problems, hypertension, and critical care issues, my expertise is palliative care and hospice care. In fact there is a board certification in palliative care that is available and that I have passed.

Our team focuses on how much time is left, how can we help the patient and the patient's family. We also want to make sure that the patient and family address issues early so that a smooth transition can be had. This approach is much preferable to a series of emergencies.

For example, if the patient is living at home alone, is the patient doing that successfully? If you are driving, should you stop driving? If you are not living alone, if you are now living with your family because you need extra support and care, how are they doing and are they adequately planning for the time when more care is needed? If the patient's family is not able to perform a higher level of care, then what's the plan? Should the patient go to assisted living at this point? What about nursing home care?

Dr. Aaronson: I think that's a great explanation. I would add that you are also a specialist in pain control. I sometimes feel a patient's pain is under-treated, and I'm glad that you are there to take over that part of the patient's care.

Dr. Lavedan: We also are very helpful in the setting of when a patient wants something done and the patient's family wants something else done. We can help facilitate coming to a conclusion so that everyone is on the same page. We can help the family decide what should be done. The key here is to come at it from the point of view of what the patient wants, not what the family wants, not what the doctor wants. The focus is on what the patient wants or would want. Our goal is to try to help it all make sense.

Dr. Aaronson: What to do for fun?

Dr. Lavedan: Not a lot of time for fun. My main hobby for fun right now is sailing.

Dr. Aaronson: What you do in the winter? Do you ice fish?

Dr. Lavedan: No ice fishing. And no ice sailing -- that is when the ice freezes over and people actually sail on ice. Otherwise I spend my time taking care of my family. I have three children. They keep me busy. I have a lot of school and sports activities. We are active in the school church.

Dr. Aaronson: If someone is interested in using your services, what approach should they take to get you involved?

Dr. Lavedan: Since palliative care medicine is a specialty not a primary care practice, it is proper to go through the primary care doctor. Sometimes a specialist with the blessing of the primary care physician will call us directly to let us know about the patient's situation. Of note, we do have an outpatient clinic located at Lakeside.

Dr. Aaronson: Thank you so much for your time today. I think we've all learned quite a bit.

Dr. Lavedan: Thank you for the opportunity.

Dr. Aaronson: Here is the link to the palliative care website at Alegent health. Thanks for listening!

I received the mist version of the H1N1 flu vaccine. Since I received a live virus, I wondered if I kissed my children more than I usually do whether or not I would be able to transmit inactivated virus to them and therefore protect them from obtaining the real Mccoy. Dr. Dave Quimby with Infectious Disease and Epidemiology Associates was gracious enough to grant me an interview to answer this question as well as some others that I had.

Aaronson: H1N1 influenza virus: what’s the latest? Has anything changed?

Quimby: Not really. One new development: If a person contracts this virus, becomes sick and has to be admitted to an intensive care unit and is unable to take medications orally like tamiflu, there are some new antiviral drugs that we can obtain from the centers of disease control that can be given intravenously.

Aaronson: You and I have been involved in taking care of some patients who have been really sick in the hospital with H1N1. Some have done well, others have not. In your opinion, if someone is sick enough to get admitted to the hospital, what predicts whether a patient will do well or not? If Alegent Nephrology gets called because of kidney failure, what is the patient’s prognosis compared with not having kidney disease?

Quimby: The more organs that shut down, the worse off you are. If the kidneys have failed the person is at high risk.

Aaronson: Is the H1N1 influenza vaccination still effective?

Quimby: It is as effective as any flu vaccine.

Aaronson: Have there been any changes or mutations in the H1N1 bug?

Quimby: There have been a handful of cases where the H1N1 flu was resistant to Tamiflu. But those are very, very few and far between.

Aaronson: Why are some people afraid of the vaccine?

Quimby: Because of a lot of incorrect information out there, you’re going to find people afraid of any type of vaccine. There’s no more reason to be afraid of this vaccine than any other vaccine. The vaccine is safe. I got it. You got it. I gave it to my two and half year old who qualifies under the guidelines.

Aaronson: I would like my kids to get it, but availability of the vaccine is hard to find. Alegent does have a phone number people can call (402-717-H1N1) to check availability and to schedule an appointment. My understanding is there will be more vaccine available soon. I encourage all my patients and everyone I know to call that number and get on the list so they can get their vaccine as soon as possible. If a person has a choice between the mist and the shot, which one should they choose?

Quimby: Because of the shortage, I would go with whichever one a person can get their hands on. If a patient has a bad medical condition such as leukemia or is receiving chemotherapy, I would not recommend a live vaccine in general. I would just do a shot.

Aaronson: Let’s talk about the standard flu shot. There are people who opt out of receiving a regular influenza shot, thinking "if I get the flu, I get the flu. I’ll take the risk." Now that we are at risk for contracting swine flu, should this opinion change?

Quimby: In general, people usually mistake the common cold for the flu. Actual influenza even in a healthy person, will knock you down for a week and a half. People I see who get the real flu learn how horrible it is and usually decide to get a flu shot yearly from that point on. The reason why H1N1 is so virulent [infectious] is that people have never seen this new strain, and they have no partial immunity to it. The reason why H1N1 can kill healthy people so easily is that it is different from anything most of us have seen before.

Aaronson: Why can’t a person get both the standard flu mist and the H1N1 mist at the same time?

Quimby: I don’t know. But there such a shortage of both of them that it usually is not a big issue at this time.

Aaronson: As you know, I got the H1N1 flu mist. I was wondering if I kissed my children more than I usually do if I could give them an inactivated form of the virus and protect them from the real thing. Is that crazy?

Quimby: It’s not crazy, but it’s not likely to work. The mist is a live virus that has been weakened. Therefore the chance of spreading it person to person is exceedingly low. Since the virus is so weak, it’s very unlikely that it will make you sick. So although well intentioned, your display of affection most likely was just that.

Aaronson: There is a concept called to herd immunity that infectious disease folks like to talk about. Wiki defines it as "a type of immunity that occurs when the vaccination of a portion of the population (or herd) provides protection to unprotected individuals. Herd immunity theory proposes that, in diseases passed from person to person, it is more difficult to maintain a chain of infection when large numbers of a population are immune. The higher the proportion of individuals who are immune, the lower the likelihood that a susceptible person will come into contact with an infected individual."

So here is my question, if many people in Omaha and its surrounding areas get vaccinated, are the ones that refuse or can’t get vaccinated protected from infection? Does that concept apply here?

Quimby: Not really in this case because the H1N1 flu is so easily spread to others, unless almost all of the people in Omaha get vaccinated, if there’s any flu virus around, those not vaccinated are still at very high risk. These unvaccinated people are at high risk because of the way H1N1 is transmitted person to person. So people need to get their vaccine. Make sure you bold that. Right now, we don’t have enough vaccine to give to everybody, and that’s why we risk stratify – we give it to those who need it the most.

Aaronson: And the Alegent hotline, 717-H1N1, does just that. I would encourage our readers to pick up the phone and give a call so that they can get vaccinated as soon as possible.

Quimby: That is correct. It should be noted that once more vaccine becomes available, anyone who wants it will be able to get it.

Aaronson: I’ve seen in the news the suggestion that now that the first wave of infectious H1N1 has passed through Nebraska the need to get vaccinated has lessened. Since I am a kidney specialist who spends a lot of time in intensive care units helping to take care of very sick patients, I’ve seen some really bad cases of the swine flu. I disagree with the thinking that the unvaccinated population is safer now than before. Is my thinking based on a referral bias, where I think a certain way because I’ve seen the small percentage of people who’ve gotten so sick that they have needed to be admitted to an intensive care unit for support and therapy? Since infectious disease specialists such as yourself are also consulted on these patients, you know what I’m talking about. Are we safer now?

Quimby: No. It is still very important to get vaccinated when you can. Many people still have not been exposed in any fashion to H1N1. So the risk will still be there until H1N1 goes away, you get actual herd immunity from vaccines, or you get actual H1N1. Since most people have not had the flu vaccine or the flu, the risk of getting it is still very high. There are still many people who can get it and that keeps this terrible infection going.

Aaronson: So let’s pretend that I am a patient, and I have cold symptoms. I’m worried that I have H1N1. I go to my primary care Physician and ask the question should I be tested for H1N1? How would you answer?

Quimby: A nose swab can be done in a primary care setting. The problem is that this rapid test for influenza type A is NOT the H1N1 influenza virus. There is a cross reaction, so a positive test implies that there is a possible H1N1 infection. The problem is that a person can test negative and still have H1N1. So in other words, if a person actually has H1N1 influenza, the immediate test done it in a primary care office setting is positive six out of 10 times, which is basically the same as flipping a coin.

Aaronson: That’s why I don’t recommend it unless I’m worried about standard influenza A or B virus. However, I do think it is important for people who are concerned and get sick very quickly to go to their doctor as soon as possible to see if they are a candidate for Tamiflu.

Quimby: I base this diagnosis for the most part on the patient’s clinical picture. How they present.

Aaronson: Thank you professor for your time. We appreciate hearing your expertise on this issue.

In sum, remember to call 717-H1N1 if you have not gotten your H1N1 vaccine yet and get vaccinated as soon as you can! You can also visit the Alegent Health Flu Center for the latest updates. Thanks for reading.

Hi! This is Dr. Michael Aaronson, kidney doctor/ simple country nephrologist. Today I'm speaking with Dr. Alan Parks, general surgeon at Alegent Health. Thank you doctor for taking time out of your busy schedule so that we can get to know you better.

Parks: Thank you.

Aaronson: Tell me a little about yourself: where did you grow up, where did you train, and what you do for fun?

Parks: I grew up all throughout the United States.

Aaronson: Why was that?

Parks: My father worked for the Air Force, civil service. We would move approximately every six years. So I've lived in Virginia, Hawaii, Nebraska and Florida. But Nebraska is home. I went to high school here at Bellevue East. I went to college at the University of Nebraska at Omaha. I went to med school at Des Moines University where I found a passion for anatomy and general surgery. I pursued my general surgery residency in Columbus, Ohio.

Aaronson: You've lived in so many places. Why is Nebraska "home"?

Parks: My family lives here. I have spent the majority of my live here. Omaha and its surrounding towns are a great place to raise a family. It's a great place to live and a very friendly city.

Aaronson: I couldn't agree with you more! After all, if it is good enough for Warren Buffet, it is good enough for me! Let's move on: you are general surgeon.

Parks: That's correct.

Aaronson: What kind of surgeries does a general surgeon perform?

Parks: General surgeons perform operations on the following organs: thyroid, breast, anything within the abdomen -- gallbladder, appendix, colon, and spleen. When highly complex operations are required, a specialist is called in. Hepatobiliary surgery would be an example of this.

Aaronson: Ah, I understand. So the more complex the word, the greater the number of syllables per word, and an increased number of words required to explain the operation, makes it more likely that a specialist will be called in.

Parks: That basically sums it up...

Aaronson: Tell me what you do for fun.

Parks: I'm a father of four. So right now I spent my free time raising my children.

Aaronson: Where is your main office located?

Parks: I'm based out of Papillion. My office is located in the Midlands 1 professional building.

Aaronson: I think the Midlands campus is gorgeous.

Parks: I agree. Alegent did a beautiful job. I would call it a true overhaul. I remember Midlands Hospital from before. It is truly amazing what Midlands has become.

Aaronson: Not only does it look nice, but there's also a lot of substance going on behind the scenes. For example, the radiology department has all of the latest and greatest equipment. The intensive care unit is brand spanking new. In addition to bedside care, patients are monitored electronically by critical care doctors for the majority of the day. Efocus has helped me out on many occasions. For example, I was performing kidney dialysis at Alegent Bergan Mercy hospital and was called by a Midlands bedside critical care nurse for a kidney related emergency. Efocus helped stabilize the patient as I drove to Papillion. Another thing I like is the fact that the Alegent pharmacy is now located in the hospital -- it used to be across the street. The pharmacists there are a tremendous resource patients can use for information, and their accessibility can't be beat.

Parks: A good radiology department is critical to the success of a surgeon's practice. Radiology studies help the surgeon know where to go in the body and what to focus on. The radiologists help me to make for example, an exploratory laparotomy less exploratory.

Aaronson: Of all the surgeries you perform, which one is your favorite?

Parks: I love to take out gallbladders, especially those done laparoscopically.

Aaronson: Is there anything else you would like to say about your practice? Anything in particular that you would like the public to know about you?

Parks: My training has prepared me to take care of a variety of surgical diseases. I've been trained to use the latest surgical techniques to give great care to the patients I see. I'm available at Midlands, Lakeside, and Bergen Mercy. I want people to know that I will do everything in my power to take the best care of you possible.

Aaronson: I have had the opportunity to work with you on a few occasions. And your passion to do a great job translates to great care at the bedside. You have a very good bedside manner. You're there for the patient. You spend time with the patient. In sum, you are a really nice guy.

Parks: Thank you.

Aaronson: My pleasure. Well, I appreciate the time you spent today. Agreeing to an interview on a Saturday is above and beyond the call of duty.

So for everybody out there interested in learning more about Dr. Parks, feel free to click here. Alegent.com allows you to schedule an appointment if you wish. Another option is to go through your primary care provider.

I recently had a patient who presented for a routine kidney follow-up for high blood pressure. This patient travels back and forth with his wife to Arizona and also doctors down there. He was unable to remember the changes that were made for him by one of his providers in Arizona. We were both frustrated, because the patient's blood pressure was elevated, and I felt there was little I could do to help him until I had more information. It led me on a search for any free, easy, secure and easily available system on the Internet that might be able to help this patient and other patients who have trouble remembering what changes have occurred since the last nephrology visit.

Google Health is what I came up with. Check it out at your convenience

If you don't already have an account, you can set one up easily and include your current e-mail address if you wish.

Consider trying this out for yourself. At the very least, you will be able to give your physician your current diagnoses, your current medications, and any pertinent studies that may have been done since the last visit.

Medicinal reconciliation is a hot topic in system based healthcare today. As people transition from hospital to clinic and from the clinic to the hospital, we want to make sure that any medication changes are noted, and you are taking what you are supposed to be taking. Problems can arise when a person travels to another state and receives care or prefers specific providers outside of a health system the currently doctor at. That's why I like this concept recording a health profile online electronically: Google health helps you keep track of the problems you have, what's been done about it, and the medications that you currently are on and have been on. Anything a system's unified record might miss otherwise gets picked up.

I like to think of it as a system that helps you and your family and friends keep track of you! Let us know what you think.

Well, I think I am. But what should we define as "great"? Critical to the doctor patient interaction is a sense of trust. You as the patient should like my bedside manner and feel comfortable with my taking care of you. But what about my competence as a kidney doctor? That question becomes harder to answer. Organizations such as Alegent Health have put in standards that all its providers must follow. That way you know that regardless of the doctor, for certain conditions, you will be treated similarly across the entire system. However, medicine does have an "art" component as well as a diagnostic component that is not easily covered by protocols.

One way to check my competency is to see if I am board-certified in both internal medicine and nephrology (nephrology is the study of kidney disease, high blood pressure, kidney stones, transplant, and critical care medicine). Here's how you can tell my board status: visit the American Board of Internal Medicine web site.

In the lower left-hand corner there is a box that allows you to verify a physicians certification status. Let's use me as an example. Type in my first and last name (Michael Aaronson) and press go. It looks like there are two choices. I'm the second one down with active board certification status in both internal medicine and nephrology. Let's look a little bit closer. It appears that I need to recertify in internal medicine pretty soon because that certificate will expire this year. The good news is that I'm planning to take the test soon and feel ready. Assuming I pass, I'll be certified in internal medicine for 10 more years and will have two more years to prepare for my kidney boards.

I strongly believe in education and lifelong learning. Medicine changes at a rapid clip. The way things were done 5, 6, 7 years ago are done very differently today. I feel that in order to be a great specialist, I need to have a broad knowledge of general internal medicine. So I can treat you in the setting of how other family practice doctors, generalists and specialists practice their trade.

So, my recommendation is to use tools available to you to help you find what you're looking for in a physician.

I've got approximately 1500 flash study cards to go through, so I have to run. Wish me luck!

Today I'm going to talk about a patient I saw in the office who thought he was eating correctly and had successfully changed his eating habits. A quick search at the United States Nutrient Data Laboratory suggested otherwise.

Hear this patient's story and learn how you can improve your eating habits and get that blood pressure under control with less medication. Also, if you need additional help, Alegent weight loss information can be found here.

In part two of the conversation, we are going to take a look at the sheet that is filled out during the monitoring process.

Many people have what's called "white coat hypertension." Their blood pressure goes up when they go to the doctor's office only to return to a normal level when they go home. To help differentiate those with this phenomenon from those with chronic hypertension, Alegent Nephrology has launched 24-hour blood pressure monitoring. There are so many benefits to this procedure. The machine checks your blood pressure at home for a 24-hour period. The process is easy, but I wanted to show you how it's done so you know how it works. This is part one of a two part series. Please make sure to get through the entire lesson so that we can utilize the test to its full potential.

A video is worth 1000 words! Today I will develop the concept that "lower blood pressure is better blood pressure."

The bottom line is, whether you are young or old, you need to think about your blood pressure and getting to your goal. Your life depends on it!

You can view my source here

Hello. My name is Dr. Michael Aaronson, M.D. I'm a kidney doctor. I specialize in kidney problems and high blood pressure. It's a pleasure to be part of the Alegent family. To read more about me (and Alegent Health Nephrology), please feel free to check out my bio page. I am looking forward to providing high quality content in multiple formats including MP3 and video on YouTube. I encourage you all to participate, weighing in at your convenience. So let's get started!

Buy the Apple
I truly appreciate Dr. Van De Graaff's position on generic medications. His points are well taken. However, sometimes the generic co-pays can add up to be prohibitively expensive. So what can we do about that?

One option to consider to help you navigate through the quagmire of options is to utilize a service here in Omaha, Nebraska. The service is called Volunteers Assisting Seniors (VAS). They do legal services, conservators, homestead exemption, and most importantly for the purpose of this discussion: The Nebraska Senior Health Insurance and Information Program (SHIP). The SHIP program specializes in Medicare. It helps seniors enroll in an appropriate plan that fits the person's needs. I like this program because it offers a non-biased approach to help you get the medications and services that you need.

Take the Apple
Now, once you have access to the meds, your next step is to remember to take your medication. If you don't take it, it can't help you.

Case Study
Here is an example of an approach to consider: Fall is approaching ... a 65 year old who has had a heart stent placed and needs significant cholesterol reduction requiring a branded product has just run out of money and is in the donut hole. He can't afford his medication. What can he do?

He can stop taking his medication. Or, he can consider samples – if available. Perhaps switching to a less expensive generic for 2 months – then restarting his original prescription in January – is an option. Maybe he should call VAS to make sure he is in the right plan.

Do you have any other ideas on how we can help this patient? Please comment below.

So think ahead, utilize available services, and stay healthy!