Dear Community,

As you have likely heard, the FDA and McNeil Pharmaceuticals has announced a voluntary and precautionary recall of certain lots of OTC (over-the-counter) children’s meds.  I recommend checking any Tylenol, Motrin, Benadryl, or Zyrtec that you may have in your medicine cabinet to see if it is affected by the recall. Here is a link to the website listing affected NDC numbers or “lots”.  Most stores and pharmacies will replace your affected bottle with one that is not affected by the recall.

I hope this is helpful and finds you healthy and thriving.

Sincerely,

Dr. Chrissie

15 January 2010

Dear Friends of Nanopractice PDX,

Greetings! I am pleased to report that we are fast approaching the second anniversary of Nanopractice PDX and that things are going swell. Who knew that the giant risk of leaving big medicine would lead to such an excellent adventure? As you know, I set out to create a smaller, nimbler medical practice where the doc actually knows her patients and the care is truly relationship-based. My ongoing intention has been to create a place where patients feel heard, receive high quality, cost-effective care, have greater access to their medical provider, and are invested in the practice because of these attributes. Many of my colleagues could not understand why I would take on all the added responsibility and complexity of this venture while virtually ensuring myself a drastic pay cut. The answer for me was simple- this is my version of practicing medicine with meaning and integrity. Added integrity in how I do my work in the world fuels my late nights and weekend tasks and the fondness and admiration I have for my community makes the medicine I practice full of relevance and meaning. Of course I could do none of this without the willing participation and commitment of a group of people like you. Thanks for allowing me into your lives and for your confidence and cooperation!

2009 brought many exciting experiences. I was fortunate to host a dear friend and mentor, Dr. Bill Manahan for a few days last July. I have enjoyed hosting students and residents as well as helping some fellow docs jump-start their own micropractices. I attended a national conference in August with like-minded physicians who are in similar models of practice and I was even quoted in a few articles. I am looking forward in 2010 to continuing the quality improvement project called “How’s Your Health”. More on this later!

Suzanne Sanchez, my partner and unofficial manager of all things manageable, is taking on a few more administrative tasks in 2010 so you may be receiving email communications, etc from her. We hope this will free up some time for me to write articles and update the blog more frequently - feel free to make requests for blog topics and such. Some upcoming articles will be about vaccines and alternate schedules, healthy recipes, gluten sensitivity syndromes, and a virtual bookshelf of vetted resources. I hope to create a forum on the website where you all can collaborate with and learn from one another as well.

Here are some other fun Nanopractice PDX facts from the close of 2009:
- There are about 450 active patients and a waiting list of over 100 which is 9 months long now!
- There were over 1100 office visits in 2009. About 40% of these were pediatric visits.
- On average, one new patient was seen per working day in 2009.
- There were approximately 4500 outgoing emails and faxes in 2009, and about twice that many incoming for an average of 37 electronic communications per calendar day. Wow!
- Almost 150 doses of H1N1flu vaccine were administered here since November 6th (and I am still well stocked for those of you that need H1N1 or seasonal flu vaccination).

As you probably recall, a small annual fee was implemented in 2009. The annual fee is essential for the fiscal health and sustainability of Nanopractice PDX and it represents your ongoing commitment as a member of the community. The 2010 fees are now due: $60 per adult and $30 per child. You may send a check or use the form on reverse side to send credit card information by mail. As always, your prompt payment is much appreciated and will save trees! Please contact me for consideration of financial hardship discounts if needed.

Thanks for your partnership in health and may you each have a fun, fit, fantastic 2010!

With Gratitude,

“Dr. Chrissie”

Lots of concerned and well-informed families have been inquiring about flu season this year.  Most want to know whether they or their children should get the seasonal flu vaccine and most are especially curious as to whether they should get the swine flu vaccine when it becomes available (in October). The answer is not a simple one in my opinion, and is intricately connected to your own thoughts, concerns, and circumstances.  Because of the complexity of the question, the frequency with which it is being asked, and my time limitations, I must direct your questions to this blog rather than answer each one individually.  If you would like to discuss your situation in detail further, please bring it up in a future appointment or make an appointment to discuss it further, and thank you for understanding!

The illness:  We all know what is like to have the flu or care for someone with the flu.  It is much more than a nagging congestion and cough that you can work through.  It usually forces us to stay home a bit, and the associated fatigue has been described as feeling like you were hit by a truck.  Some folks get sick enough to go to the hospital, and others have such severe respiratory problems that they wind up in the ICU or worse.  Swine flu is not necessarily going to be any more severe than the seasonal flu in terms of symptom severity, but it does seem to be causing more sickness in young children and young adults as well as pregnant women.  The phenomena has been labeled a pandemic by the World Health Organization because of the rapid rate of spread.  We believe it is spread the same way the seasonal flu is spread, but most humans do not have any pre-existing protection for this particular strain of flu virus, making it easier for the virus to infect one person after another after another. Ninety percent of the deaths associated with seasonal flu each year are in patients who are elderly.  Conversely, the disease burden of H1N1 is highest in adults younger than 25 and in children.  This is why those special groups are being targeted for vaccine first.

First, let’s agree that prevention of the illness is the primary goal. Preventing incidence of the illness will also prevent spread of the illness; the fewer get sick, the fewer will spread the disease.  I am convinced that the data collected by the Center for Disease Control,  and the World Health Organization is to be respected.  Yes, the media coverage has been on the dramatic side, but since I cannot guarantee to you, my flock of patients, that this is more panic than pandemic, I feel the better part of wisdom is to recommend the H1N1 vaccine in accordance with the CDC recommendations.  Influenza can be a very serious illness (an average of 36,000 patients die of flu related complications each year), and an ounce of prevention is worth more than a pound of cure, especially if you or your loved one has ever suffered serious consequences from an illness like the flu. Of course, prevention includes MUCH more than vaccinating.  Please follow the suggestions about prevention below whether you choose to receive the vaccine(s) or not.

I know some of my patients are averse to non-essential vaccines, and we can only speculate at this point in time whether this should be considered essential or not. I really wish we could see into the future to know how bad this expected pandemic will be.  In the last century we have had such events as the flu pandemic of 1918 in which 500,000 Americans lost their lives in one year. The CDC status report of September 11, 2009 shows that H1N1 is widespread in the southeastern United States already.  The complication rates are no higher than with seasonal flu, but the number of cases is quite high for September.  The conclusion seems to be that this may be the beginning of a really tough flu season.

Prevention, Revisited

1. If you (or your children) have significant flu symptoms (fever, cough, sore throat, runny or stuffy nose, muscle aches, extreme fatigue, etc), please STAY HOME.  Do not send a sick child to school or daycare.  This will decrease exposure to others and could make a huge difference in prevention on a community level!  Stay home until you (or your child) have been afebrile (no fever) for a FULL 24 hours - without the use of fever reducers like acetaminophen (Tylenol), ibuprofen (Advil/ Motrin), naproxen (Alleve), or aspirin. And never give aspirin to a person younger than 18. Ever.  BTW- If you are sick and must leave your home, consider wearing a protective mask- it will at least prevent touching your nose and then touching other items!

2. Wash your hands with soap and water for a good 20+ seconds under warm water frequently.  If you must, use antibacterial hand cleaners, but know that soap and water are preferred.  It is a good idea to wash your hands any time you are preparing food, preparing to eat, after using or even entering a restroom, and after touching surfaces in public places (doors and railings at shopping outlets, etc.) Try to avoid touching your mouth, nose, or eyes especially after touching surfaces in public places.

3. Cover your cough or sneeze - try to do it with your upper arm rather than your hand, and if you are using a tissue, please throw it away immediately.

4. Consider supporting your immune system with probiotics.  Early studies seem to indicate that the benefit of keeping healthy bacteria in your gut with these supplements or “live foods” decrease the severity of flu-like illnesses.  Perhaps when less of the immune system is dealing with imbalances in the digestive system, more is available to fight microbial invaders like the viruses that cause flu and swine flu.

5. Since flu viruses replicate best in colder, drier air, consider a humidifier or even a diffuser with some essential oils like Eucalyptus to “cleanse” your home breathing environment.

6. Avoid close contact with others who are ill.

7. Get adequate rest.  Stay well hydrated and well nourished. Consider a mutli-vitamin supplement (not a proven strategy, but unlikely to harm) and be sure you are getting adequate vitamin D.  Regular exercise can help your immune system too, but over-exercising can deplete you.  Do NOT pull all-nighters this flu season, folks.  Just don’t do things that you know make your immune system weaker. (Smoking is in this category, too, friends.  Smoking of any kind!)

Now, about the vaccines.

There will be 2 types of vaccine - one for the regular or seasonal flu, and one for H1N1 flu (also known as “Swine Flu”).  They will be discussed separately below, and neither will offer protection against both types of flu.

Seasonal Flu Vaccine

- Recommended even more strongly this year by the CDC because we are expecting a heck of a flu season.

- Approved for ages 6 months and up.

- Not to be given to people who are ALLERGIC to EGGS - because it is incubated in an egg based culture.

- Recommended especially if you are caring for a child under 6 months (they have weaker immune systems) or live with a frail or elder adult.  They also may have reduced immune function.

- Please consider for you and your child especially if you have concerns about your (or your child’s) immune system’s integrity or if you have chronic illnesses like asthma, diabetes, heart disease, kidney disease, cancer, or are on medicines that affect your immune system.

- I will have vaccine doses for children this year but have been UNABLE to procure doses for adults, presumably because there was such a rush on vaccine from retail outlets like Safeway who are offering vaccines.  Therefore, please do get the vaccine wherever it is offered- your pharmacy, workplace, or community centers, places of worship, etc.

- If this is your child’s first flu season for vaccine, s/he will need 2 doses 1 month apart to get full immune protection.  The first one introduces the virus particles, the second one boosts the immune system’s reaction to it, so that is exposed, the child will be less likely to develop the illness.

- It is worth mentioning that this vaccine is changed slightly every year- it is aimed at the strains of the virus that epidemiologists and infectious disease experts think will be the most likely to prevail in the coming flu season.  It is not a perfect vaccine because the flu virus tends to mutate quickly (this is called antigenic shift), but it has been shown to decrease incidence of the influenza illness.

- Seasonal flu vaccine comes in several forms.  The injectable doses are killed or inactivated vaccine- they cannot cause influenza.  There is a less common vaccine that is administered by nasal inhalation.  It is a live, weakened (attenuated) vaccine, so can cause mild influenza illness.

Swine Flu/ H1N1 Vaccine (estimated availability October 2009)

- I will be giving vaccine in Friday-Saturday flu clinics when it is available- look out for updates in your email.

- Most want to know about its safety.  It is manufactured in the same way as seasonal flu, so I anticipate exactly the same kind of safety profile.  I do NOT have reason to believe there is reason to suspect this vaccine any more than seasonal flu vaccine.  It is likely also to be a killed virus vaccine, so it will NOT cause actual flu illness, though your immune reaction may cause you to feel poorly for a brief time after the injection.  I do not know yet if it is safe for those who are allergic to eggs.

- Who to vaccinate? Highest risk groups include younger patients (6 months to age 24) and pregnant women.  Next in line are healthcare workers and caregivers for infants under 6 months of age.

- How many shots?  As of 9/11/09, we believe adults will need only one injection while children under 4 will need 2 shots separated by 4 weeks as they do with seasonal flu vaccine the first year they are vaccinated.

- When to vaccinate? As soon as the vaccine is available.  Protection should be present 8-10 days after the shot.

What about treatment if you’re sick?

- Supportive treatment at home is all most people will need.  It’s a really great idea to stock up NOW on tissues, anti-fever medicines, decongestants, and things of the like so you do not feel the need to venture out in an infected state.

- It is OK to give over-the-counter cold medicines to children age 5 and older.  Do NOT give these medications to younger children due to safety concerns.

- Tamiflu and Relenza are the anti-virals that we have all heard about in the context of this flu and others.  Right now it is recommended that only patients with illness serious enough to warrant hospitalization be given these mediations as they may be in short supply when the rubber hits the road.

What about the rationale to decline vaccination?

- There is one potentially convincing reason to avoid vaccine, and that is the possibility of immunity conferred by illness.  Medical science has not yet evolved to the point that we can answer the risk/ benefit question with pinpoint precision, and honestly, that would be a lot to ask. Some thoughtful providers are recommending their patients err on the side of not vaccinating because if we get a mild H1N1 season this year, we could be better protected if and when it comes back later in life.  In fact, it is estimated the about one third of adults over age 60 have some antibody to H1N1 from their previous illness with a similar flu strain years ago.  It is not known whether the presence of this antibody confers protection to the current H1N1 strain, so this information is not compelling to me as a reason not to vaccinate, especially if you or your kids are in a higher risk group.

- As I alluded to earlier, I know that some of my folks are simply in an anti-vaccine place intellectually or from a “gut feeling”.  That’s OK.  We all decide what risks are acceptable for ourselves and our families.  I hope and expect no harm will come of that position as I hope and expect no harm will come to those who choose to vaccinate.  Compelling arguments are available for either position.  Some families allow kids to ride motor bikes and four wheelers; others would never consider that risk - it’s nice we have the freedom to choose.  However, when we take measured risks in either case, it is essential that we are prepared to shoulder the burden of potential consequences.  I would be devastated as a provider and as a parent if my patient or loved one had a bad outcome from a vaccine preventable disease OR  from a vaccine.  I choose to vaccinate because I would feel more integrity with that decision in retrospect.  As many of you know, I have not been the most adamant or aggressive flu vaccinator in past flu seasons.  I have a sense that this year may be different, so I will be getting vaccinated against both.

Where to get more information?

http://www.cdc.gov/h1n1flu/qa.htm

Since we are all baring more of our skin in this heat wave, I thought it might be a good time to mention skin infections.  I’ve had several healthy patients develop significant skin infections over the last year and thought I would address it in a brief blog.  We all have bacteria living on our skin - it’s normal.  Staphylococcus aureus is one of the most commons as is Streptococcus.  Most of the time, these skin organisms are innocuous and cause no problems.  However, there are some troublesome strains out there such as the famous “MRSA” which means a Staph bacterium that has become resistant to certain antibiotics.  One of the more common places it is spread is in athletics: wrestlers and football or basketball players have skin to skin contact which can spread the bacteria directly or the skin of one player is in close contact with a mat or other surface where the skin of another player was recently, spreading the bacteria indirectly.  In this vain, yoga mats (and other work-out surfaces) may also be an important point of contact with troublesome bacteria.  As one is moving through sun salutations or holding chataranga (sp?), the skin may allow entry of bacteria.  Anecdotally, at least one of my patients likely contracted a serious skin infection in this manner.

A good approach to containment and prevention is to use only your own yoga mat.  If that is not possible, please be sure to wipe down the community mat you are using with a bacteriocidal cleaning product.  Being sure to bathe after contact with a shared yoga mat may also be helpful.  If using gym equipment, wipe down the areas that come into contact with your bare skin before and after use.

Signs of infection are warmth and redness in the affected area that spread, fevers, chills, and pain.  Please do not delay care of a potential skin infection as delayed attention can result in more serious would that are slower to heal and may even require hospitalization with intravenous antibiotics.

To your health!

-dr chrissie

Hello, All! 

Time for a few reminders about enjoying the summer  safely.  I’ve been fielding some very thoughtful questions about sunscreen safety and mosquito repellents for children, and I thought many of you would like to hear what I’ve found.  

Sun Exposure

Most of us are aware that too much sun exposure increases our risk of skin cancer as well as premature skin aging, but you may need a reminder that most of our sun damage is done in childhood and adolescence.  For this reason, it is especially important to cover up and apply your favorite SPF 30+ sunscreen to enjoy the sun sustainably.  In our Northwestern climate, I know it can be easy to feel more than a little sun-deprived and yes, the sun feels fantastic after a long NW winter, but trust me- too much of a good thing (even in Portland) can result in a very unfortunate sunburn.  I do think that depending on one’s complexion and personal + family history, moderate sun can be very healthful.  It is helpful for some skin conditions like psoriasis, and it is our primary source of vitamin D, so go ahead and get 15 minutes or so a day if you can do so safely, but after that, go get some sunscreen on!  

*Please note, infants under 6 months should be in the shade or well covered with clothing and light blankets, as their skin is especially delicate as well as absorptive for chemicals found in personal care products.  

Sunscreens

The Environmental Working Group (EWG) is non-profit organization that independently analyzes and reports on safety of personal care products as well as other environmental hazards and works for solutions and policy change.  Their consumer product site, Skin Deep, is a tremendous source of information, and they recently reported on the efficacy and safety of chemicals routinely used in sunscreens in the U.S.  

Link to EWG Article

Link to List of Rated Sunscreens  (Preview: Favorites included California Baby, Soleo, among others)

Insect Repellents

With increasing awareness of insect-born illnesses such as West Nile virus, many folks are more interested than ever in safe insect repellents.  We have an astonishing variety of products available, ranging from low or high concentrations of DEET to oil of lemon eucalyptus and others.  It is a great idea to try to prevent insect bites for ourselves and the young ones, but please do not use any insect repellent on infants under 2 months of age.  Another potential pitfall is using a combination sunscreen + insect repellent product which carries the risk of over-exposure to the insect repellent due to the need for frequent re-applications of the sunscreen.  To minimize risks with these products, always read and follow the instructions, observe the age limits, and be sure to wash off any residue. Also, I recommend reading the AAP notes on the topic (click here!).  EWG has rated many insect repellents as well (click here!).  I have also been recommending that parents consider using a low-toxicity repellent when needed on an infant’s clothing before dressing them, and taking advantage of light clothing that will minimize exposed skin.

I hope that’s helpful and that you are having a fantastic summer already!

Dear Community,

Greetings! Thanks to your kindness and participation, Nanopractice PDX is now over one year old!

I have been touched and humbled by the trust this practice community has placed in me.  I have learned much with and from you all and am deeply honored to have witnessed triumphs, assuaged fears, and hopefully, to have empowered you to take steps toward creating healthier habits.  One highlight of this year has been the enthusiastic reception that continues to welcome Nanopractice PDX into being.  By November, a waiting list for adults was required to support a sustainable pace of growth while maintaining availabilities for existing community members.  I offer gratitude to each person who has referred a friend, family member, or colleague, and I am honored by your positive regard.

Ours is a unique and interdependent practice community, I think, as this kind of creative healthcare cannot be achieved without the context of an active and reciprocal relationship.  I appreciate the shared excitement and willingness to create a new way of experiencing allopathic medicine.  I am indeed fortunate to be able to use my Western medical training to evaluate and treat illness, while using my integrative medicine resources and referrals to simultaneously support your individualized journeys in healing in so many ways.

I have enjoyed as much as anyone the comforts of my small office, the absence of waiting room time, and the lengthier, more relaxed visits we are able to share.  I am pleased to offer direct email and phone access, and I really love knowing the people I serve.  This makes my experience as a healthcare professional much more meaningful.  That said, I am still refining this young practice and looking for ways to improve.  I am committed to staying “nano”-sized to preserve accessibility, and I am committed to making the practice increasingly sustainable while offering new and valuable services like an upgraded website and blog!  As a one-woman enterprise, it will come as no surprise to most of you, that this means lots of time spent on patient care, research, and investigation of referral sources outside our visits.

A common theme among many practices that strive to offer this level of interaction and access to one’s personal physician is an annual fee.  Some even offer an annual membership and stop billing insurance! I considered implementation of an annual fee at the outset of this practice, but decided to weigh the pros and cons after the first year.  After careful analysis and some market research, I have concluded that a small annual fee is needed to subsidize the slower pace and intentional mission of Nanopractice PDX.  This fee will be $60 per year per adult, and one-half that per child (think: $5/ month).

How it works this year: The first 2 months of 2009 will be pro-rated so that the 2009 fees are $50.00 and $25.00 for adults and children respectively. (A couple, then, would send $100 for 2009 and a family of four would send $150).  I ask that these fees be paid relatively soon though I am sensitive to the economic climate and am open to conversation about extenuating financial circumstances.  Please consider this letter your “invoice” to avoid additional billings.

For new patients joining the practice mid-year, the prorated fee should be paid at the first appointment, and starting in 2010, the annual fee should be paid at the beginning of the year.

If there are some among you who have decided to move on to other providers, it would be helpful for me to know that so as to adjust the waiting list, et cetera.

I look forward to our upcoming visits, and I so enjoy being part of your lives.

With much gratitude and affection,

“Dr. Chrissie”