No Evidence of Ebola Exposure in Akron or Cleveland as of October 15, 2014

Questions on Ebola Exposure in Akron or Cleveland

[NOTE: This is an update from our original post earlier on 10.15.14]

Many of you have contacted our office with questions and concerns regarding the recent Ebola news. We appreciate that you have reached out to us for information and support during this time. 

It was reported on Wednesday, October 15, 2014, that the second health care worker in Dallas to come up positive for Ebola virus infection was in the Cleveland area a few days ago.

At this time, there is no evidence that this person exposed anyone to her Ebola infection in the NE Ohio region.

Here is what we know.

September 28, 2014

The second health care worker, who I will refer to as Ms. SW (second worker), was exposed to a contagious patient with Ebola virus infection on September 28, while caring for the patient in the Dallas hospital.

September 28 -October 12, 2014

Ms. SW felt perfectly well and had no fever or sense of being ill.

Ms. SW was in the Akron/Cleveland area during some of this time.

October 13, 2014

Ms. SW flew from Cleveland to Dallas on Frontier AIrlines #1143 which landed in Dallas at 8:16 PM.

She is now known to have had a fever while on this flight.

October 15, 2014

It was reported that after getting ill, Ms. SW was tested for Ebola infection and found to be positive.

KEY POINTS

1.  Ebola, to the best of our knowledge, is not contagious until symptoms such as fever appear.  That means if you spend time with someone with Ebola virus infection before they get sick, you cannot catch Ebola virus from them.

2.  Since Ms. SW had a fever on October 13, she was possibly contagious during her flight.   Anytime prior to her getting symptoms, such as fever, she was not contagious, and contact with her prior to onset of symptoms should not lead to catching the Ebola virus.

3.  All the passengers on Flight #1143 of Frontier AIrlines Ms. SW was on are being evaluated, since they were in the airplane with while she had symptoms.

4.  Ebola virus is contagious only by contact, NOT by breath.  So one would have to be touching Ms. SW in some way, have actual physical contact sometime after she got symptoms, that is, sometime October 13 or later, to be at risk.

4.  ANYONE who is concerned that they may have been in contact with Ms. SW on the flight on October 13 or later, should call the CDC HOTLINE at 1-800-232-4636.

My impression, at this time, is that this second health care worker from Dallas, who spent time in Akron/Cleveland, is likely not to have spread her Ebola virus infection while in Akron/Cleveland, unless someone was actually in physical contact with her around October 13.    To be clear, if someone did have physical contact and did so while she was contagious, they may have been infected with Ebola virus, but that person could not spread it until they developed symptoms.

We will keep you updated as more information becomes available.  We understand the anxiety and fear that this Ebola outbreak is causing here in Northeast Ohio, as well as nationwide. We endeavor to be a voice of knowledge and reason and will keep you updated on the most recent facts and concerns as they become available. We appreciate your trust in our opinions regarding this issue. 

Again, any questions on worries about exposure to this person should be directed to the CDC at 1-800-232-4636.

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Enterovirus D68- What is it, What to Do?

Enterovirus D68- What is it, What to Do?

This summer a new outbreak, an unusual outbreak, from a virus called Enterovirus D68.  This virus is causing some very serious trouble, and so we thought it would be helpful to explain what we know about it, and what to do.

What is a Virus?

As the name makes clear, all enteroviruses are types of virus.  

Viruses are very strange sort of thing, they are packages of information wrapped in a coating that forces cells to make more copies of themselves.  The information comes in the form of genetic material, either DNA or RNA and in every virus known these genes always code for instructions that force a host cell to activate the viral genes and then create a huge number of copies of the genes and new protective coats.

The protective coats of viruses are always made of a set of proteins that shield the virus from attack from an immune system, and contain properties that allow the virus to spread from person to person, find the right cell to infect, enter the cell, and deliver the viral genes to that cell to make copies.

What is an Enterovirus?

An Enterovirus refers to a very large number of viruses that cause a large number of viral illnesses in people.  One subset of the Enterovirus family is the common cold virus, or Rhinovirus, but most Enteoviruses are described as belonging to a several subsets designated by letters, such as Enterovirus A, Enterovirus B, Enterovirus C, etc.

The prefix entero-, means having to do with the intestines, so the word enterovirus really minus, a gut or intestinal virus.

This makes sense since the typical Enterovirus causes a range of illnesses that include most of the stomach flus that happen in the summer, hand-foot-mouth disease, a high fever/stiff neck illness, and a simple bout of very high fever without any other symptoms.

One curious property of these, the typical Enterovirus illnesses, is that they only happen in the summer months, or close to them.  This is a very important point and quite striking.   The usual enterovirus is nowhere in the US in the winter.  Almost no city in the US in the winter has the typical enteroviruses that cause stomach flu around in January.  But come July, suddenly every city in the country is loaded with these viruses, in every neighborhood.  No one knows why they disappear in cold weather and how they so suddenly erupt in the summer everywhere.

Another key property of Enteroviruses is that each subset or type has its own character, and some subtypes appear in clusters of cases over discrete periods of time.  So there can be an outbreak of one particular Enterovirus subtype that creates a large number of cases over a few months, or even a few seasons, then disappears for many years, perhaps to never return, or to return in a few or many years hence.

We have seen years in which an Enterovirus creates a large number of cases of high fever, stiff neck, and very severe headache, for example.  There have been stretches of 4-5 years of many such cases, followed by 10-20 years of far fewer.

So a particular subtype of Enterovirus can appear suddenly, then disappear as quickly, causing a stretch of time in which a striking illness occurs across the nation, followed by a stretch of time when such an illness disappears or becomes far less frequent.

What is Entervirus D68?

Remember that there are groups of Enteroviruses grouped by letters, like Enterovirus A and Enterovirus B?  Well, this Enterovirus D68 is part of the Enterovirus D species of Enterovirus.

And it happens to be the 68th one in the group, hence Enterovirus D68.  (There really are hundreds of all the different subtypes, or serotypes, of Enteroviruses, and five known Enterovirus D's.)

Enterovirus D68 is one of the subtypes of Enterovirus that come in clusters.  There have been prior outbreaks of infection with Enterovirus D68, but none as large or concerning as the current one.

We do not know yet, but the hope is that with winter, this Enterovirus D68 will act like prior outbreaks, and like most Enteroviruses and stop causing illness during the winter.

Even more importantly, the hope is that this outburst of Enterovirus D68 is only this season, or if more, just a few years.  This is a real hope, as noted such striking subtypes as Enterovirus D68 often drop off over time.

What Illnesses Does Enterovirus D68 Cause?

The Enterovirus D68 is different than most classical Enteroviruses in that it infects the lungs more than the guts, so it causes more breathing problems than vomiting and diarrhea.  But sadly, it also seems to attack the nervous system, although not as commonly as the lungs.

Here are the key symptoms seen.  That means, if one gets an infection with Enterovirus D68, it causes these symptoms most commonly.  It does not mean if you have these symptoms you have Enterovirus D68:

• Nose symptoms:  runny nose, sore nose, sneezing, headache
• Throat symptoms:  sore throat, hoarseness
• Lung symptoms:  cough, wheeze, real trouble breathing
• Nerve and Muscle symptoms:  less commonly than the above- weakness, inability to move limbs (paralysis).  These symptoms are not yet proven to be caused by Enterovirus D68, in one outbreak in Colorado, nine children developed loss of movement function (paralysis) and have Enterovirus D68 infection, but none of the virus was found in their cerebrospinal fluid, so we need further study to know if this symptom is indeed possible with this infection.
• Some gut symptoms:  mildly loose stools, stomach aches
• Skin symptoms:  various rashes

What to DO!

The answer to what to do is the same for Enterovirus D68 as it is for every virus:  if symptoms are mild, just keep your child comfortable.  If symptoms are worrisome, call us for help, and we will arrange for care to reduce the danger the infection presents.

Why do all viral illnesses have the same advice?  Because for nearly all viral infections, there is no drug or treatment that kills the virus or heals its inflammations. 

When to Worry

Even if one is infected with Enterovirus D68, if the only symptom is a mild runny nose, there is no cause for any concern.

And of course, even if the virus is not Enterovirus D68, if someone is struggling to breathe, you should call for help right away.

So, for Enterovirus D68, we are less concerned and there is very little to do, if symptoms are limited to this list:

• runny nose, sore throat, cough, mild stomach aches, mild rash, and/or slightly soft stools;  but, breathing fine when not coughing.

If any of the following symptoms appear, call for help right away:

• Severe difficulty breathing, meaning your child has to work very hard to get air in and out of his or her chest
• Muscle weakness beyond the mild tiredness of being ill.  Your child seems very weak, and of course, if they cannot move an arm or leg

If we see your child and they have the mild symptoms, the treatment will be to keep your child comfortable at home without any specific testing.  As long as the symptoms remain mild, it makes no difference what the virus is, the treatments and care remain the same.

If we speak to you or see your child and they have the more severe troubles of struggling to breathe or having significant changes in muscle strength, then the treatment is quite different.  In this situation we would arrange for evaluation and care at the hospital.  Tests for Enterovirus D68 and other viruses and germs would be done, and specific therapies to help a person breathe and to help a person who is getting weak, would all be started.

Bottom Line

1. The Enteroviruses are a very common and large number of viruses that typically cause the summer stomach flu, hand-foot-mouth disease, and other mild summertime illnesses.
2. Now and then subtypes of the Enterovirus family show up in outburts that bring unusual and severe disease.  This is what is happening with Enterovirus D68, a strain causing quite severe and unusual breathing problems.
3. As with nearly every virus, there are no drugs to cure or heal the infection.  
4. When it comes to knowing when to worry, when your child gets a cold or respiratory infection, it does not matter so much what the name of the virus is, even if it is Enterovirus D68.  What does matter is how sick your child is.  If the cold or respiratory infection is mild, no worries.  If the infection is causing your child to struggle to breathe or become severely weak, then it is time to worry, to call us for help.   Again, this is true no matter the name of the infecting germ.
5. Lastly, this outbreak of Enterovirus D68, which has caused so many cases of severe trouble breathing, will hopefully go away.  Time will tell.  Enteroviral outbreaks of severe illness typically appear mainly in the summer for several years, then seem to stop happening.  Our hope is that this round of Enterovirus D68 is limited solely to the summer of 2014, goes away this winter, and does not return.  We will watch to see how it goes.

To your health!

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Ebola- What we Need to Know

The Ebola Virus- Some Helpful Information

The Ebola virus has been a frightening danger for some time, and for good reason.  It is a serious infection and cause real harm.  So let's start with the bottom line: although there is a case of Ebola infection in the United States, it is one case, it is easily contained, there should be no spread.  No one in Ohio is at risk.

As we all know there is a case that appears to have developed in the United States, although it was not likely caught in the United States.  This raises the concern about Ebola coming to the US, but we are very far from a situation where catching this illness in this country becomes a risk of significance.

Here are some basics that should help understand what Ebola is all about.

The Germ

With any infection, the disease is caused by a micro-organism, either a parasite, a bacteria, or virus.  And all such micro-organisms that cause infections are called germs.

What's a virus?

The germ that causes Ebola is, as the name indicates, a virus.  Viruses are the smallest of germs.  They actually are bits of genetic material wrapped in a protein coat.  The genetic material has one purpose: to instruct a living cell to make more viruses.  The protein coat has one purpose:  to allow the virus to gain access to the living cell so that the genetic material it contains can do its job- force the cell to make more virus.

All viruses work this way.  They are simply copying machines.  But in the process of forcing a cell to make more virus, the cell is usually damaged or destroyed.

Although every virus works the same way, each infects its own special set of cells.  It is the pattern of cells infected that defines the nature of the illness.

Cold viruses only attack the cells lining our airways, so they cause colds which are infections of the airways.

Stomach flu viruses only attack the cells lining our gut, so they cause stomach flus which are infections of the gut.

The Ebola virus.

The Ebola virus is named for a river that flows into the Congo River, the Ebola River, where it was first discovered in 1976.  Our current approach to categorizing viruses places five different species of virus in the category of Ebolavirus.  Four of these all cause an illness that is called Ebola virus disease.  One of these four species was named the Zaire ebolavirus, and recently had its name changed to the Ebola virus.

As with many emerging infectious diseases, infections that have only recently begun to infect people, the Ebola virus mainly infects another animal rather than humans, and for the Ebola virus, the original source of the virus was fruit bats.  In some way that is not yet known, the virus happened to contact humans, somewhere on the banks of the Ebola River, and infections in humans began.

The Disease

The Ebola virus infects mainly the cells that create blood vessels, liver cells, and several cells of the immune system.  This means when the infection occurs, these systems are the ones that suffer. 

When the blood vessels get infected, they get leaky, and this causes one of the key symptoms of Ebola virus disease: bleeding.   The bleeding occurs anywhere in the body, including reddened eyes, bleeding into the skin, vomiting blood, coughing blood, severe nosebleeds, and many other sites.

The infection of the immune system cells leads to symptoms such as fever, severe muscle pains and stomach pain, headaches, severe tiredness.

The infection of the liver,, makes it harder for the blood to clot, making bleeding even worse.

As you will note, the general symptoms of fever, severe pains, and tiredness are seen in many, many viruses, including harmless flus.  And, in perhaps as many as half of cases of Ebola virus disease, these may be the only symptoms, with no bleeding occurring. 

This means that one cannot rely on symptoms to know who has Ebola instead of some other viral illness, Ebola is best found if the contacts that cause it can be shown to have occurred.

How Ebola virus disease is caught, and how it is not caught

The Ebola virus does not enter breath.  And so it cannot be caught by air or breathing near an infected person, or in the same building or room as someone through the air.

The Ebola virus is spread by direct contact with an  infected person's body fluids.   The virus can live for sometime on objects so it can be spread via contact with objects that have touched an infected person's body's fluids- for example, needles.

This is perhaps the best news about Ebola virus, if one can avoid direct contact with an infected person's body fluids, you can be protected from infection.  It does not spread easily.  Infections can be contained.  One can avoid infection.

The incubation period

The incubation period for any infection is the time that usually occurs between the virus entering one's body and the first symptoms appearing.   During the incubation period, one is infected, but since there are no symptoms during this period, it is very hard to know your are infected.

The incubation period for Ebola virus disease is usually about 8-10 days, but some people have developed symptoms as soon as 2 days after catching the virus, and as long as 22 days later.

Note that the person who showed up with Ebola virus infection in the United States on the last day of September of 2014, was infected in Liberia, but had no symptoms, he was still incubating the infection.  This is why he was able to fly to the US. He did not know he was sick and no one at the airport would know to be concerned.  So he caught the virus in Liberia, came to the US while having no symptoms, and ended the incubation period in the US revealing he had an infection.

The Risk of an Ebola Epidemic in the United States, and our Risk here in Ohio
As stated at the start of this discussion, it is very, very unlikely Ebola would ever take hold in the US, or ever develop into an epidemic here.

Why is that?  Fortunately, for several reasons:

1. There have never been more than one or so cases of Ebola virus disease in the United States.  To get an epidemic going, you need more than one case at a time.  This also means that at any point in time, the United States is Ebola-free but for that one place the one person with the infection is present.
2. Since the infection can only be spread by direct contact with an infected person's body fluids, then a medical system that can limit that contact can very well end any further spread.  This is not just a theoretical advantage, it has taken place in prior outbreaks, and is happening now in Nigeria.  The American medical system can stop the spread of this virus from any known infected person.
3. The CDC is very alert to the dangers Ebola can present, and how those dangers can be contained.  The current outbreak is limited to a small number of countries in Western Africa.  As horrific as this outbreak has been, any large epidemics have only occurred in these three countries.  And so the CDC is in an excellent position to monitor the emergence of any symptoms in anyone visiting or returning to the US from these active countries.
4. There are no natural reservoirs of Ebola virus infection in the United States.  The virus mainly lives in fruit bats in Africa, human infections are far less frequent.  And so outbreaks erupt in areas of the world 

As far as Ohio occurs, the outlook is very good.  There are no cases of Ebola virus disease in Ohio, there have never been any cases in Ohio.  Given that the entire US is alert to this danger, any case that occurs in the US is very tightly contained.  Even though several people with Ebola virus disease have been in the US, not once has the disease spread to someone in the US.  This makes it essentially impossible that a spreading outbreak would take place in Ohio.

Current Limits and Future Prospects for Treatment
As a new infection there are no vaccines to protect anyone from getting Ebola virus disease.

Like other viruses, with very few exceptions, there are no medications that can cure or even slow down the course of the illness.

This means that there is no way other than avoiding contact to prevent infection with Ebola virus.

And, no treatments for Ebola virus disease now exist, beyond basic supportive therapies.

But a worldwide initiative is underway to create a vaccine and to create actual therapies that kill the virus and cure the infected person.

Bottom Line

Ebola virus is a virus that lives very peacefully in bats, but when that virus crossed paths with humans, it caused a very dangerous illness in people.  Such crossing of paths is most likely to occur where the bats live, so far in Africa.

It does not spread from person to person without direct contact of body fluids, and so it can be contained.

There have been isolated, individual cases of Ebola virus disease in the US, but every single case has been one where the infection began in Africa, and in every instance the medical center they have been treated at has been able to keep even one case from spreading.

Ebola virus disease is a very dangerous illness, but there is every reason to expect it will not become a threat to people living in the US.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Boosting the Immune System

Boosting the Immune System- Can it be done?

A common questions we are asked is, "What can I do to boost my child's immune system?"

It turns out to be an important and challenging question.

To answer it, first we should talk about two key items:

1.  What does boosting mean?

2.  What is the immune system?

Boosting

Boosting means making stronger, and likely what we all seek when we talk about boosting the immune system is getting stronger in 3 ways:

1.  A boosted immune system will decrease the number of infections and illnesses our child will get.

2.  A boosted immune system will make any infection our child has much milder- last many fewer days,cause fewer symptoms, and what symptoms occur will be far milder.

3.  And, hopefully, a boosted immune system will somehow make one much healthier over all- stronger, better rested, live longer, etc.

The Immune System

For many of us, the immune system is the most mysterious of all the systems in the body.   Most systems are easy to think about.  The digestive system is the stomach and gut, the circulatory system is the heart and its vessels, the skeletal system is the bones.

But what is the immune system?  There is no structure that makes it easy to point to and say, yes, there it is.

So to understand how to boost it, we need to start with knowing what it is.

The immune system are all the cells in the body that respond to dangerous cells and viruses by destroying them. Most of the time these dangers are things that cause infections: parasites, bacteria, and viruses.  But more often that we like to think, the immune system also eliminates our own cells that are dangerous- these would be cells that could go on to become cancers.  But the main point here is that the immune system are all the cells that destroy cells and viruses that could harm us.

Those cells are in every part of our body, and also organized in 4 key structures:  the lymph nodes, the spleen, the bone marrow, and a relatively unknown structure, the thymus.

The bone marrow is where all the cells of the immune system are made.

The spleen is where all circulating cells, like our blood cells, pass through an inspection looking for signs of dangerous cells and viruses.  

The lymph nodes are little lumps of immune system tissue that ramp up production of immune system cells and antibodies in response to a need.  There are literally thousands of them across our body, and they get big when activated.   Some are very near the surface, especially in the neck and groin, and when they get activated and get big we call them swollen glands.

And, the thymus is an organ in the chest that matures a special set of immune system cells, the T-cells.  The T-cells are the brains of the operation.  They decide whether to attack any item in our body, or not.  And if an attack is made, it is the T-cell that orchestrates it.  Curiously, the thymus shrinks dramatically during puberty, most adults have almost no thymus.

Can you Boost the Immune System?

Now that we know a little about boosting and the immune system, we can talk about how, or even whether it can be done.

The American marketplace has a very loud answer to this question- YES!

Manufacturers make, and we buy, billions of dollars worth of stuff to boost our immune system.

There are vitamins, and nutritional supplements, and oils.  There are special exercises and manipulations.

So how would one know if you took one of these items, or participated in one of these activities, that your immune system actually got boosted or not?

It's a much harder question to answer than asking if an intervention works to lose weight.  For that, all you need to do is step on a scale.  

It turns out that the way to know is to see, do you actually see any of the promised boosting effects, the ones listed at the top of this article.

That is, if you take the eat a certain diet, take a particular pill, or do a prescribed exercise, do you actually experience:

• Fewer infections
• Milder infections
• Longer life

So far, there are no proven immune boosting pills or strategies that have proven to do any of these three things.

Again, many products promise that your immune system will be boosted.   Why not?   The law in the United States specifically releases a whole category of products from ever having to show they work.

The category the law in the US has created is called "Dietary Supplements."  So if anyone creates a food, nutrient, pill, or herbal preparation that can be categorized as a dietary supplement, it is released from having to do any work to see if it does anything, by law.

And as for exercise, or other activities, there has never been any requirement that such activities prove any impact or effect.

And so, we have very little evidence that anything people have created to take, eat, or do, actually boosts the immune system.

There is no evidence that the industry that creates products that boost the immune system have in fact prevented infections, made infections milder, or extended life times.

What to Do

It should be said that we are all for boosting the immune system.  If something, safely, could eliminate infections, reduce the severity of infections, and help us live healthier and longer lives by boosting the immune system, we would love to see it happen.

But for now, until such remedies are actually invented, we recommend staying away from false claims, and not take pills and supplements that claim to boost the immune system.

No need to despair, though.   There are a few things that can indeed lead to be better health.

They are all things our grandmothers have been telling to do for many centuries:

• Eat fruits and vegetables.  Those who eat at least 5 servings of 2 ounces a day live about 7 years longer than those who do not.
• Exercise.  This makes every organ in the body work better and reduces the chance of a huge range of illnesses.
• Sleep.  Sleep actually has a big impact on physical and mental health.
• Socialize.  People who have social experiences, that is friends and family, live longer than those who do not.

And, when it comes to infections, nothing prevents them more dramatically than immunization.  Diseases for which we have immunizations are essentially eliminated from our world when we immunize- polio is an excellent example.   Immunizations do not boost the immune system overall, but they do block one from having whatever illness the immunization is for.

BOTTOM LINE It's a great idea to boost the immune system.  But when you think about what that really is about, it turns out nothing has yet been created that does this.

Meanwhile, there are very real steps one can take to improve the chance of living a longer, and healthier, life.

To a good and long life!

Dr. Arthur Lavin 

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Who's the Best? Comments on Magazine Ratings and Other Approaches

Who's the Best?  

Comments on Magazine Ratings and Other Approaches

One of the most pressing challenges in any medical system, and certainly ours in the United States, is finding who does the best job for any particular medical challenge.

The need for help from the medical world can be described as splitting into two major categories:  the need for a trusting, effective relationship with a guide who can help across a wide variety of challenges, and the need for a person who can perform a procedure well and successfully.

The approach to finding the right person for a trusting, effective relationship that can deliver guidance across a very wide range of medical needs is very difficult to measure, and there are few reports on how people  compare in this realm of medical care.

When it comes to judging how procedures are performed, there are emerging a large number of rating reports.

This is not a trivial challenge.  Certainly for minor procedures the challenge is less important, but for major procedures there are often large differences in the chance of surviving without complication, what could be more important?

Perhaps the dominant rating report available to the public comes from a magazine, US News & World Report (USNWR).   USNWR is not a medical journal, but a curious alliance has sprung up across the country.   The alliance is amongst major medical centers, we the public, and USNWR. Three needs bring these three parties to alliance.  For medical centers, there is the need to announce they really are the best place for medical care, for we the public there is the need to find out who does a good job (or better yet, the best job), and for USNWR there is the need to sell magazines.  

So, if USNWR can report that a large number of medical centers are the "best," at least in some way, then banners proclaiming they made the list of best is USNWR can appear on their streets.  This satisfies the need of medical centers to announce they should be the preferred place people go for care.   We the public see a banner on the medical center we use and are reassured we are at the best place.  And everyone looks to USNWR as the definitive judge of who is best, selling lots of magazines.

There are two major flaws with the USNWR reports.  One is that so many medical centers get at least some listing that there are precious few medical centers of any size that can't sport a USNWR banner proclaiming they are the best.  As we all know, however, not everyone can be the best.

The second major flaw is that the ratings in USNWR are based on votes of peers.  This approach has its value, but ultimately, what I want to know when I have a serious disease, is outcome.  I want to know, will I have a better outcome at medical center A or medical center B.  USNWR uses four criteria to pick who is the best:  reputation, chance of survival, patient safety, other care-related indicators.  These are each important indicators of quality, but they avoid the most important, and always the most elusive indicator- not just will one live, but how will the overall outcome be?  Will one survive with excellent health, or impairments, for example.

Beyond that, however, lurks a more important problem with rating institutions.   I know of no serious medical condition that is really treated by an institution.  Yes, all manner of medical conditions are treated at institutions, and by teams at institutions, but in my experience, the real differences are seen by the level of expertise and success of outstanding individuals.  

I have seen, countless times, that there are very real differences in outcomes, especially for very complex challenges, that are entirely the result of exactly which doctor is doing the care.  The name of the medical center is nearly irrelevant to this consideration.

What this means is that in a particular instance, it turns out the best person to achieve success in a serious medical challenge is at a medical center that may not be #1 when it comes to institutional ratings.

Sadly, it turns out to be very, very hard to discover who really does excel in especially complex procedures.  The American medical system is unfortunately very secretive and misleading on this point.  Most medical centers promote their staff, and like to blur distinctions.  But recently, a new approach to finding particular and specific doctors of excellence, it has to do with families, not publications.   Families are beginning to report their actual experiences and outcomes in social media networks, and for the first time in American medical history, we are getting the first glimmerings of an understanding of who really excels, again in very complex medical challenges.

A word on that last point.   As a medical procedure gets simpler, the range of ability narrows, that is there is less and less difference between doctors.  At the simplest levels, it really doesn't matter who does the procedure, nearly every doctor of basic competence does it about equally well, with outstanding outcomes for nearly everyone.   So, for example, placing tubes in the ears for ear infections is an extremely simple procedure, I know of no difference in outcome amongst a wide range of pediatric ENT surgeons for this simple procedure.

Thankfully, the vast, vast majority of procedures children may require fall into this category, and thus it makes little difference whether any of  the major medical centers in NE Ohio perform the procedure, the outcome will nearly always be excellent at all of them.

But, now and then, very rarely, a problem comes along that is very complex, and it may turn out only a handful, or even just one doctor in the country actually has the expertise and ability to deliver a successful outcome reliably.   This is where my concern with publication-based ratings of quality sits, since their methods cannot tell us who that doctor is.

We at Advanced Pediatrics have spent many years listening carefully to families, observing outcomes, speaking to experts around the country.  We have tried in each instance when a rare and complex condition presents, to keep our focus on the child.  And, to that end, look nationally to determine which doctor(s) can actually deliver the expertise and outcome that put them ahead of the rest.

A last comment on judging the quality of the relationship-based medical care.  How does one determine who can deliver, not specific procedures, but good guidance across a wide range of medical challenges, across many years?  Who will be there when you need them, who can be relied upon to give good, well-thought out advice on approaches to complex, and simple, challenges?

As noted above, I know of no methodology that can reliably report on such important distinctions amongst doctors who provide general medical care.

That leaves all of us, I would advise, to keeping our eyes open and judging for ourselves.  Does your doctor respond to your concerns, deliver good guidance across a wide range of issues?  At this point, each of our own experiences are the best guide for this search for high quality medical care.

I hope these comments are of interest, and better yet, of some help.

We wish everyone much health and happiness.

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Advanced Pediatrics Accepts the ALS Ice Bucket Challenge

Advanced Pediatrics Accepts 

the ALS Ice Bucket Challenge

At 5PM on August 20, 2014, Advanced Pediatrics accepts the ALS Ice Bucket Challenge.

There is much excitement at Advanced Pediatrics, as the staff will drop a bucket of icy cold water onto the providers.

Tune in to our Facebook page at Advanced Pediatrics, #APIceBucket, and enjoy the sight of Sue, Samantha, and Lavonda, dumping the ice on Dr. Lavin, Dr. Hertzer, and Nurse Kelley.

When the Challenge is met, the Advanced Pediatrics team will be calling out to our friends and colleagues, Dr. Laura and staff, and Dr. Laura Adelman's dental office.

Beyond the fun, we also thought it would be good for everyone to know what ALS is and what the Ice Bucket Challenge achieves.

ALS stands for Amyotrophic Lateral Sclerosis and is also known as Lou Gehrig's disease, since the great baseball player, Lou Gehrig had ALS.

At the heart of ALS is the destruction of nerves that control the movement of muscles of the body.  The normal way a muscle moves in the body is that a nerve from the brain signals a nerve from the spinal cord to make the muscle contract.  The nerve from the brain is called an upper motor neuron, the nerve from the spinal cord to the muscle is called a lower muscle neuron.  In ALS material accumulates in both upper and lower motor neurons, leading to their death.  Once enough of these nerves die, their muscles stop moving.

This leads to trouble walking, swallowing, and eventually all muscle movements.  Once ALS begins it tends to lead to more and more loss of muscle function, and eventually, death.

The Ice Bucket Challenge is essentially a crowdsourcing fundraising event that has gone viral, to support research to prevent and treat ALS.  To date, this event has raised $22 Million.

Tomorrow Advanced Pediatrics will have some fun, and will be proud to make a donation to the ALS Association, and we encourage all of us to do the same as alsa.com.

Enjoy the rest of your summer,
Advanced Pediatrics

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The Summer Bug- Hand-Foot-Mouth, Sleepy Fever, Stomach Flu- All from the Enterovirus

The Summer Bug- 

Hand-Foot-Mouth, Sleepy Fever, Stomach Flu- 

All from the Enterovirus
We are all familiar with the influenza or flu epidemic that happens every winter, but many of us are not so familiar with a virus that causes a tremendous number of fevers and infections every summer, the enterovirus.

What is an Enterovirus and What Illnesses Do they Cause?

Entero- means intestinal in Greek and so enterovirus means, virus of the intestine, and it frequently is.

The enteroviruses cause many epidemics typically only seen in the summer through early fall- June to October- with major flares in July and August.

We are right now (July 17, 2014), experiencing a major outburst of enterovirus infections in our community.

The enteroviruses can cause a very wide range of infections, but the most common are the following:

1. Stomach flu- fever, vomiting, and diarrhea
2. Hand-foot-mouth disease- small very uncomfortable red, small-fluid filled bumps on the palms and soles and many tiny cold-sore like lesions in the mouth, usually with fever.
3. Viremia- just fever, no other symptoms except at times a rash at the end of the fever
4. Colds and pink eye- runny nose, cough, fever, red eyes with or without discharge
5. Mild CNS [central nervous system] infections- these can cause pronounced tiredness or even sleepiness, fever, at times with severe headache and even stiff neck.   They are mild because complete recovery is the rule.

If you look up Enteroviruses, you will find they come in various families of viruses.  The two main categories of Enteroviruses are the Coxsackie and ECHO viruses.  Coxsackie viruses are named after a town in New Jersey, Coxsackie, where the first strains were found.   ECHO comes from an outdated acronym that implies this is a virus found in the stools of children with no illness, but we now know that the ECHO viruses can cause the enteroviral illnesses.

There is one, perhaps most famous enterovirus, that no longer causes infections in the United States, the polio virus.  It turns out that when polio was rampant, most people who got this enterovirus got a stomach flu, like other enteroviral infections.  But occasionally this virus would also cause a CNS infection, but in the case of polio virus, the infection of the central nervous system is far more severe and actually does cause damage, the dangerous infection of polio.  

How do they Spread, Incubation Periods, How Long are You Contagious?

Interestingly, one enterovirus can cause several of these infections, so you could catch an enterovirus from someone with hand-foot-mouth disease and experience a viremia.

With the exception of colds, most enteroviral infections are spread not by breath but by hand contact.  Handwashing should block contagion.

If you are exposed to a person with an enteroviral infection, and catch the illness, it typically takes 3-6 days to develop symptoms, so the incubation period is 3-6 days.

Children and adults with enteroviral infections are contagious, otherwise they wouldn't have caught the illness.

Someone remains contagious as long as their body sheds live virus.  This typically goes on for some time after fully recovering, which explains why the period for being contagious can seem surprisingly quite long.

For those with mainly respiratory infections like colds and pink eyes, they remain contagious for 1-3 weeks.  But for those with stomach flu, one can remain contagious for months.

Right now we are seeing a very large number of cases of hand-foot-mouth diseases, viremias, and mild CNS infections, as well as some stomach flu, all likely due to the enteroviruses.

What to Do

When it comes to what to do if your child gets infected with an enterovirus, there are several key points:

• Like nearly all viral infections, medical science has not yet developed any medication to rid us of the infection, so antibiotics do nothing to help a person with enteroviral infections
• These infections, as uncomfortable as they are, are typically harmless.  Given that we cannot cure them, our job is to make our children comfortable.  Comfort varies according to the problem.  For viremias where the only symptom is fever, ibuprofen is often sufficient.  For the painful sores of hand-foot-mouth there are a variety of soothing measures for the sore throat- cold liquids, ice cream, comfort foods, etc.
• All these infections go away in a few days to a week or two and typically leave your child as healthy as before the illness.
• As for contagion, we all spread virus long after we get well, especially for stomach flu where you can remain contagious for months.  Further, these viruses are rampant now, so even if you isolated your child completely while she or he is contagious, the viruses would spread exactly to the same extent.  So we do not recommend isolation for contagiousness.

BOTTOM LINES

This summer is no exception, we are experiencing our annual summer epidemics of enterovirus infection right now.

• These viruses cause a wide range of illnesses, nearly all of which are quite harmless.   The one variant that is harmful is the one we immunize against and no longer is in North America.
• There are no medications to get rid of these viruses, to care is limited to keeping your child comfy.
• The most common forms of infection with the enteroviruses are hand-foot-mouth disease, stomach flus, simple fevers with and without rash, and fever and severe lethargy with and without headache.
• No need to isolate, once your child feels better, back in action.

Here is to a safe and healthy summer,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.