Chicken Soup by Paul McLeod, M.D., MED3OOO Chief Medical Executive

Everyone knows that chicken soup will speed recovery in patients with a common cold. This is a consensus-based recommendation resulting from the collective experience of an expert panel of mothers and grandmothers passed authoritatively along from generation to generation. The validity of this recommendation is not to be trifled with and nay-sayers should take heed. We also know that increasing fluid intake will improve symptoms of constipation and that we should admonish patients from prolonged use of irritant laxatives to avoid the consequences of dependence. This is information passed from faculty to medical students nationwide each year. Both sets of recommendations have some things in common. Neither is evidence-based. Neither is correct. (See the January issue of The American Journal of Gastroenterology.)

Many of the commonly made recommendations in medicine are not based on good evidence. I still remember the last conversation I had with my family medicine residency director upon completion of the program. “Paul,” he said, “I want you to know that half of what we taught you is wrong… I just don’t know which half.”

Good news! The technology revolution has provided an opportunity for physicians to get good evidence-based answers to their questions quickly and with minimal expense. Better yet, this information is available even to solo physicians, as long as they can access the Internet.

A practicing physician can now search for answers to their clinical questions using:

Evidence-based medicine (EBM) online resources and

Clinical guides

These resources present not only the evidence, but the method used to obtain it—Meta-analysis, Systematic Review, Randomized Controlled Trial, Cohort Studies, Case Control Studies, Case Reports, or Expert Opinion. In addition, your search can be purpose-specific, diagnosis-specific, or symptom-specific. Some sites are geared more toward physicians; others have a more “patient friendly” approach and are useful for patient education.

Some EBM Databases that I recommend are:

Cochrane Library: All the English literature meticulously searched for clinical trials, with conclusions based on evidence from valid randomized trials only. Remember, this only gives you information from clinical trials results. Cost: $235/year. Web site: www.thecochranelibrary.com.

ACP Journal Club: One hundred Journals systematically reviewed; includes structured abstracts and clinical commentary. Cost: $78/year. Web site: www.acpjc.org.

DynaMed: Eighteen primary care journals (e.g., BMJ, JAMA, Lancet, NEJM, Pediatrics), twelve secondary sources (ACP, Cochrane Library), and four drug sources. Cost: $200/year. Web site: www.dynamicmedical.com.

Medical Inforetriever: One hundred four journals surveyed, synopsis of 1300 articles, evidence-based guidelines, drug information, and clinical calculators. Web-based, desktop, and PDA versions. This is a great resource. It is very robust and easy to use at the point of care. Since it comes in a PDA version you can “take it with you” to the hospital or nursing home. Cost: $249/year. Web site: www.infopoems.com.

First Consult: Differential diagnosis, disease state information, and patient education—another one of my favorites. The information is condensed and to the point. Cost: $149/year. Web site: www.firstconsult.com.

© Copyright 2005. MED3000 Group, Inc. All Rights Reserved

The Clinical Advisory Newsletter for Physicians and Clinical Staff March 2005 Edition

Planning Ahead . . .

Immunization Awareness

FREE POSTERS INCLUDED

Clinical Background.

Vaccines are one of the most successful and cost-effective public health tools for preventing serious disease and death. Diseases that were once commonplace a generation ago are now relatively rare. Disease such as polio, measles, mumps, whooping cough, diphtheria, and rubella are a distant memory for most Americans.

However, the success of vaccines has given rise to a phenomenon whereby many people don’t understand the importance of childhood immunizations and what diseases can be prevented. Precisely because many parents today have not seen some of these diseases and the devastation they can cause, they are less concerned about immunizations as a parental priority. However, these diseases have not been completely eradicated. Many are still around and still circulating around the world.

Each day 11,000 babies are born who will need to be immunized against twelve diseases before age two. Despite recent gains in childhood immunization coverage, over 1 million of our nation’s two-year-olds are still missing one or more of the recommended immunizations.

Vaccines aren't just for kids. Far too many adults become ill, are disabled, and die each year from diseases that could easily have been prevented by vaccines. Thus everyone from young adults to senior citizens can benefit from immunizations.

Tools and Recall Information on the following page.

Chicken Soup . . . continued by Paul McLeod, M.D., MED3OOO Chief Medical Executive

Practice guidelines can be obtained from:

National Guideline Clearinghouse: Web site: www.guideline.gov.

Primary Care Clinical Practice Guidelines: Web site: http://medicine.ucsf.edu/resources/guidelines.

American Academy of Pediatrics: Web site: www.aap.org.

American Academy of Family Physicians: Web site: www.aafp.org.

All are good sources and tend to be evidence based.

These are plenty of resources to get you started. I think you will find them a great asset to your practice. So the next time someone asks “Do topical solutions of NSAIDs help the pain of osteoarthritis?”. . . . Look it up!

FREE Immunization Awareness Posters to display in Patient Rooms are attached.

© Copyright 2005. MED3000 Group, Inc. All Rights Reserved

The Clinical Advisory Newsletter for Physicians and Clinical Staff March 2005 Edition

Don’t delay, schedule your appointment today.

April is Infant Immunization Awareness Month

Tools and Recall Information for Immunizations

Tools

The following are some web sites that provide information and tools you can use to educate patients as to the need for ensuring that their children’s, and their, immunizations are up to date:

http://www.cdc.gov/nip/events/niiw/ 2005/05default.htm: The official site for National Infant Immunization Week. Includes lists of community events, as well as information that you can download to create your own event.

http://www.idph.state.ia.us/ common/pdf/immunization/adults_protect_yourselves.pdf: A brochure from the Iowa Department of Health that can be printed and handed out to your adult patients.

http://www.cdc.gov/nip/diseases/ adult-vpd.htm: CDC’s National Immunization Program (NIP) site on vaccine-preventable diseases for adults.

http://www2a.cdc.gov/nip/ scheduler_le/default.asp: CDC’s NIP site that allows parents to make up an immunization schedule for their child.

http://www.cdc.gov/nip/ publications/default.htm#bfp: NIP’s brochures and flyers page. Many different brochures and flyers covering vaccinations that you can download and print for your office.

Patient Recall

Through the MED3OOO IQ data warehouse, reports are available to identify the number and percentage of your pediatric patients who have received their pediatric immunizations and who are eligible for their pediatric immunizations at both 8 months and 20 months. The upcoming attention that will be paid to National Infant Immunization Week may make this the perfect time to recall these patients. If you would like to discuss either these reports or an automated patient recall process using M3Connect technology, please contact Geoff Coleman at Geoff_Coleman@MED3000.com.

The Clinical Advisory is a clinical publication from MED3OOO dedicated to informing physicians and clinical staff about tools and information to improve the quality of patient care. MED3OOO . . .Clearly the Best.

Corporate Headquarters: MED3OOO, Inc., 680 Andersen Drive, Foster Plaza 10, Pittsburgh, PA 15220 For more information on our clinical initiatives, visit www.MED3000.com or call Geoff Coleman at 1-888-811-2411.

CHILDHOOD AND ADOLESCENT IMMUNIZATION AND SCREENING SCHEDULE

Pediatric immunizations can protect your child from deadly diseases that were once major concerns of parents around the country. In fact, a concerted effort to immunize all children has virtually eliminated some of these diseases. It is important for children to receive these preventive services as early as possible, based on the schedule below. Please notify your clinician if your child has not received all appropriate services, so a plan can be made to get “caught up.” (Likewise, you should notify your own doctor if you have not received all of the recommended pediatric immunizations yourself.) The following are minimum guidelines for preventive services needed by most people. Your clinician may recommend additional preventive services, based on your own medical history. Likewise, your clinician may determine that some of these services are not necessary for your particular health situation.

Key

Recommended for all people Recommended only for persons at increased risk

Immunizations Birth 1month

2months

4months

6months

12months

15months

18months

24months

4-6years

11-12years

13-18years

Diphtheria and Tetanus (Lockjaw) Toxoids, Acellular Pertussis (Whooping Cough) Vaccine

DTaP DTaP DTaP DTaP DTaP

Tetanus and Diphtheria Toxoids Td

Haemophilus Influenzae Type B Conjugate (Meningitis, etc.) Vaccine

Hib Hib Hib Hib

Hepatitis A Vaccine Hepatitis A Series

Hepatitis B Vaccine HepB HepB HepB

Inactivated Poliovirus (Polio) Vaccine IPV IPV IPV IPV

Influenza (Flu) Vaccine Influenza (yearly, each flu season) Influenza (yearly, each flu season)

Measles, Mumps, Rubella (German Measles) Vaccine MMR MMR

Pneumococcal Conjugate (Pneumonia) Vaccine PCV PCV PCV PCV

Pneumococcal Polysaccharide (Pneumonia) Vaccine PPV

Varicella (Chickenpox) Vaccine Varicella

Source: United States Department of Health and Human Services, Centers for Disease Control and Prevention, The Advisory Committee on Immunization Practices. “Recommended Childhood and Adolescent Immunization Schedule, United States, 2005,” approved by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). More information, including a customized pediatric immunization schedule based on your child’s date of birth, is available at www.cdc.gov/nip. The specific recommendations of your physician may vary.

Screening Procedures Birth 1month

2months

4months

6months

12months

15months

18months

24months

4-6years

11-12years

13-18years

Chlamydia Screening(women only)

Tuberculosis Screening For certain individuals at high risk

Visual Impairment Screening Routine screening in children younger than 5 years

Source: United States Department of Health and Human Services, Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force. Based on recommendations rated “A” or “B” by this task force. More detailed information is available at www.ahrq.gov/clinic/uspstfix.htm. The specific recommendations of your physician may vary.

The American Academy of Pediatrics recommends a History and Physical Examination at birth and at ages 2-4 days, 1 month, 2 months, 4 months, 6_months, 9 months, 12 months, 15 months, 18 months, and 24 months, and annually thereafter. (Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, “Recommendations for Preventive Pediatric Health Care.” Pediatrics. Vol. 105, No. 3, March 2000, pp. 645-646. More detailed recommendations from this organization are available at www.pediatrics.org/cgi/content/full/105/3/645.)

ADULT IMMUNIZATION AND SCREENING SCHEDULE

It is important even for people who have no health problems to receive appropriate screening tests and immunizations. The following are minimum guidelines for preventive services needed by most people. If you have not received the preventive services indicated on this sheet, please notify your clinician. (You should also notify your clinician if you have not received all of the recommended pediatric vaccinations.) Your clinician may recommend additional preventive services, based on your own medical history. Likewise, your clinician may determine that some of these services are not necessary for your particular health situation.

Key

Recommended for all people Recommended only for persons at increased risk

Immunizations 19-24years

25-29years

30-34years

35-39years

40-44years

45-49years

50-54years

55-59years

60-64years

65-69years

70-74years

75+years

Tetanus (Lockjaw) and Diphtheria Toxoids 1 Td booster every 10 years

Hepatitis A Vaccine 2 HepA vaccinations (6-12 months apart) for certain individuals at high risk

Hepatitis B Vaccine 3 HepB vaccinations (second vaccine 1-2 months after first, third vaccine 4-6 months after first)

Influenza (Flu) Vaccine 1 influenza vaccination annually 1 vaccination annually

Meningococcal (Meningitis) Vaccine 1 MEN vaccination, with possible revaccination after 3-5 years

Pneumococcal Polysaccharide (Pneumonia) Vaccine 1 PPV vaccination, with possible revaccination after 5 years 1 PPV vaccination

Source: United States Department of Health and Human Services, Centers for Disease Control and Prevention, The Advisory Committee on Immunization Practices. “Recommended Adult Immunization Schedule, United States, October 2004 – September 2005,” approved by the American Advisory Committee on Immunization Practices (ACIP), the American College

of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP). More information is available at www.cdc.gov/nip. The specific recommendations of your physician may vary.

Screening Procedures 19-24years

25-29years

30-34years

35-39years

40-44years

45-49years

50-54years

55-59years

60-64years

65-69years

70-74years

75+years

Breast Cancer Screening(women only) Every 1-2 years

Cervical Cancer Screening(women only) At least every 3 years, beginning within 3 years of the onset of sexual activity or age 21, whichever comes first

Chlamydia Screening (women only) thru age 25

Colorectal Cancer Screening

Fecal occult blood testing every 1-2 years and/orSigmoidoscopy every 5-10 years,

Colonoscopy every 10 years, or

Double-Contrast Barium Enema every 5 years

Diabetes Screening Routine screening in adults with hypertension or hyperlipidemia (e.g., at least every 3 years)

Hypertension Screening Routine screening by clinician for high blood pressure (e.g., at least every 2 years)

Lipid ScreeningMen with CHD risk Routine screening for all men (e.g., every 5 years)

Women with CHD risk factors Routine screening for all women (e.g., every 5 years)

Osteoporosis Screening (women only) Routine Routine (e.g., every 2

years)Prostate Cancer Screening Discussion (men only) Screening (e.g., every 2 years)

Syphilis Screening For certain individuals at increased risk for syphilis infection

Tuberculosis Screening For certain individuals at high risk

Source: United States Department of Health and Human Services, Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force. Based on recommendations rated “A” or “B” by this task force, except for Prostate Cancer Screening recommendation. More detailed information is available at www.ahrq.gov/clinic/uspstfix.htm. The specific recommendations of your physician may vary.