News & Alerts
INFLUENZA by Diana Podlecki, PA-C
Flu season is almost here! Here are some reminders about flu shots and some updates about the 2014-2015 flu season.
Last year, slightly more than 100 children died from influenza, according to the U.S. Centers for Disease Control and Prevention. Of these, almost half had no underlying medical conditions, according to the American Academy of Pediatrics. More than 90 percent of children treated for influenza in intensive care units weren't vaccinated for flu last year, the AAP reported.
Who Should be Vaccinated?
Everyone 6 months and older should get an annual flu vaccine. It takes about two weeks after vaccination for your body to develop full protection against the flu, so the recommendation by the CDC is to be vaccinated by October.
The American Academy of Pediatrics updated their influenza vaccine recommendations to advise that the youngest kids, those aged 6 months through 8 years old, should have two initial doses of vaccine to build immunity. New to the recommendation this year is a stronger recommendation for the nasal spray form of the vaccine. That vaccine, called the live attenuated influenza vaccine (LAIV), should be considered for healthy children aged 2 to 8, the AAP said. While the flu shot and the nasal spray both protect against the flu, there is evidence that the nasal spray may work better in younger children than the flu shot. These recommendations were published online Sept. 22 in the journal Pediatrics.
Pregnant women should get vaccinated to protect themselves as well as their newborns. During the first six months of life, it's the mother's immunity that protects the baby. Anyone who has contact with newborns should also be vaccinated.
People who are at high risk of developing serious complications (like pneumonia) if they get sick with the flu for example people who have certain medical conditions including asthma, diabetes, and chronic lung disease.
People who live with or care for others who are at high risk of developing serious complications. Household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease and caregivers of infants younger than 6 months old.
Health care personnel should be vaccinated. Really, everyone should be vaccinated against flu unless there is a medical reason not to be vaccinated.
Get a Flu Vaccine Every Flu Season
You should get vaccinated every year for two reasons.
Flu viruses are constantly changing and different flu viruses circulate and cause illness each season. The flu vaccine is often updated from one season to the next to protect against the influenza viruses that research indicates will be most common during the upcoming season.
A person's immune protection from vaccination declines over time so annual vaccination is needed for optimal protection. Antibodies to flu drop 50 percent in the six to 12 months after vaccination. Annual vaccination is recommended even for those who received the vaccine during the previous flu season.
This 2014-2015 season, there are multiple options available.
Trivalent flu vaccines protect against two influenza A viruses and one influenza B virus. The following trivalent flu vaccines are available:
A high-dose trivalent shot, approved for people 65 and older.
A standard dose trivalent shot containing virus grown in cell culture, which is approved for people 18 and older.
A standard dose trivalent shot that is egg-free, approved for people 18 through 49 years of age who have an allergy to eggs.
Standard dose trivalent shots that are manufactured using virus grown in eggs. These are approved for people ages 6 months and older.
Quadrivalent flu vaccine protects against two influenza A viruses and two influenza B viruses.
There are 2 quadrivalent flu vaccines available: the standard dose quadrivalent flu shot and the standard dose quadrivalent nasal spray, approved for people 2 through 49 years of age (recommended preferentially for healthy children 2 to 8 years old when immediately available and there are no contraindications or precautions).
The flu vaccine is safe. People have been receiving flu vaccines for more than 50 years. Vaccine safety is closely monitored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Hundreds of millions of flu vaccines have been given safely to people across the country for decades.
A common misconception is that the flu vaccine can give you the flu. Remind patients that it cannot. The most common side effects from a flu shot are soreness where the shot was given, and maybe a low fever or achiness. The nasal spray flu vaccine might cause congestion, runny nose, sore throat, or cough. These side effects are NOT the flu. If you do experience them at all, these side effects are usually mild and short-lived.
Union College PA Students Serve in Peru
The sky was overcast and threatening to burst with rain as we sat down under our makeshift village clinic in Iquitos, Peru. Stray dogs sat beneath our feet and chickens pecked at the dirt floor as we attended to our first patient. "Hola, en que puedo ayudarle hoy?" That phrase translated “hello, how can I help you today,” would be said more than 500 times by the end of our week of serving in rural clinics.
In June, a small group which included seven, first-year Union College PA students traveled to Iquitos, Peru--a city located in the Amazon Basin that can only be reached by plane or boat. Each year Union College's Chaplain, Rich Carlson, gives the PA students an opportunity to partner with the People of Peru Project--a non-profit organization providing aid to those in the region. The students have the opportunity to provide free medical and dental assistance to the inhabitant’s of this remote poverty stricken area.
For the majority of our clinic days we traveled by bus packed to the brim with medical and dental supplies to villages at the edge of the city. Our “clinical office” ranged from tents in the middle of the street to the humble homes of generous locals. Each day as we set up triage, consultation and our pharmacy, villagers congregated often waiting several hours to be seen. We were able to put our classroom knowledge to practice as we attended to over a hundred patients each day. We saw people of all ages from one week old to one hundred years old. We listened to heart sounds, looked in ears, bandaged wounds, and even pulled teeth.
It was such an amazing experience to be able to sit down and talk with each person. I was humbled by the confidence each one had in us, even though we were only students. We were limited in the care we were able to offer and there were many times I was saddened wishing I could do more for the people. But more often I was amazed at how grateful they were for even the little things. For some patients, all we could offer them were vitamins and yet they would take our hands in theirs with a smile on their face and an appreciative look in their eyes as they thanked us as though we had given them a miracle cure.
By: Jenessa King, PA-S
New DEA Guidelines on Tramadol
Tramadol will be classified as a controlled substance beginning August 18th, 2014. This includes all products containing tramadol: Ultram, Ultram ER, Ultracet, Ryzolt.
- Tramadol will be classified as a Schedule 4 controlled substance (same as benzodiazepines)
- Maximum of 5 refills are allowed at any time
- It can be legally phoned in by a prescriber or their nurse
ICD-10 Delayed! *again*
- This may be a great time to reorganize and re-prioritize her documentationIt may be beneficial to ask administrator or coder to run a list of the 50 most common ICD-9 codes that you use and then research and learn the ICD-10 equivalent.
- And continue to watch and listen for coding updates for Medicare.
CMS Eliminates PA Practice Barriers in Rural Areas
By Michael Powe
May 8, 2014
The Centers for Medicare & Medicaid Services (CMS) issued a rule on May 7 that provides regulatory relief for PAs and physicians who deliver care in rural communities. This regulatory change advances a federal initiative to remove burdensome and unnecessary regulations.
The final rule, for which AAPA advocated, eliminates a requirement for a physician to be physically on site once every two weeks at certified rural health clinics, federally qualified health centers and critical access hospitals (CAHs). PAs will continue to follow state law and facility policies.
Two additional issues in the rule include:
- Confirmation of existing CMS policy that PAs may be members of a hospital’s medical staff.
- Elimination of a requirement that CAH physicians review outpatient medical records at least bi-weekly for patients treated by PAs (or NPs). CMS will now defer to state law on this issue.
Ensuring patients receive timely access to medically necessary, high-quality care is the goal behind the federal effort to remove regulations that are outdated, don’t lead to improved patient care or are no longer reflective of the enhanced manner in which PAs deliver care.
Nebraska Hospital Association Sponsors Health Careers
Within a year of starting my first job as a Physician Assistant I was asked to precept a PA student. My first thoughts were along the lines of; “I just graduated and started this job and now I am going to try and teach someone else?” I would like to go back and “redo” those first few rotations as I am sure I could have taught them more and given then a better clinic experience. Now, after 6 years of precepting, I finally feel as though I have a better understanding of what makes a good preceptor. There are three main reasons that I have continued to precept students; furthering the PA profession, furthering my education, and furthering the education of the PA student. Any time a PA student comes into our office and interacts with patients, family members, and/or staff they are exposing the PA profession and educating others about what we do. There is no way that our profession would be where it is today without all of the PAs who have volunteered their time and talents to be a preceptor for students. A benefit I receive as I continue to precept students is learning something from each one, whether it be the answer to a question that we have to look up together or an update they have learned in one of their lectures. Teaching students will always keep you on your toes. Of course one cannot forget what preceptors are doing for the education of the students themselves. Try to imagine being the PA you are today without the hands on rotations that you were able to participate in. Thank you to those who already serve as preceptors and if you do not, I encourage you to think about starting, as the benefits will be great for the student, teacher, and profession.
Chelsie Doane, PA-C
2014 NAPA President Elect
New Guidelines for Treating Hypertensive Patients
In the United States, 78 million (1 out of 3) adults have high blood pressure (BP). Early detection and appropriate treatment of hypertension is important to reduce the risks of other progressive diseases such as stoke, renal failure, myocardial infarction, and death. In 2003, the Seventh Joint National Committee (JNC 7) issued a report with guidelines including changes in the categorization and definition of hypertension with recommended lifestyle modifications and pharmacologic strategies for treatment. These hypertension definitions based off of systolic blood pressure (SBP) and diastolic blood pressure (DBP) from JNC7 were simplified to 4 categories as follows:
· Normal blood pressure: SBP <120 mmHg and DBP <80mmHg
· Prehypertension: SBP 120-139 mmHg or DBP 80-89 mmHg
· Stage I hypertension: SBP 140-159 mmHg or DBP 90-99 mmHg
· Stage II hypertension: SBP ≥160 mmHg or DBP ≥100 mmHg
Last month, the Eighth Joint National Committee (JNC 8) published a report in the Journal of American Medical Association (JAMA) on evidence-based guidelines for the management of high BP in adults. During the literature review process, these recommendations were guided by three BP management questions:
· In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
· In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
· In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific outcomes?
JNC 8 issued nine recommendations concerning thresholds and goals for BP treatment and selection of antihypertensive medications and a summary for starting and adding antihypertensive drugs. These recommendations were assigned a score for both the strength of the recommendation and an evidence quality rating of each recommendation. The nine recommendations can be summarized into the following points:
· Patients 60 years or over, start treatment at SBP ≥ 150 mmHg or DPB ≥90 mmHg and work towards a goal lower than that threshold.
· In patients <60 yearswithout major comorbidities and patients >18 years with chronic kidney disease (CKD) or diabetes, treatment initiation and goals should be 140/90 mmHg.
· In nonblack patients (including diabetics), initial treatment should includethiazide-type diuretic, calcium channel blocker (CCB), angiotensin- converting enzyme inhibitor (ACE inhibitor), or angiotensinogen receptor blocker (ARB).
· In general black patient population (including diabetes), initial treatment should include thiazide-type diuretic or CCB.
· In patients >18 years with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status to improve kidney outcomes.
· HTN treatment is to attain and maintain goal BP. If goal BP not reached within a month of treatment, increase dose or add second drug and use up to 3 drugs from above recommendations. Do not use an ACEI and an ARB together in same patient. If target BP cannot be reached, referral to specialist maybe indicated.
Along with these guidelines, lifestyle modifications such as weight control through physical activity and a healthy diet should not be underestimated. JNC 8 included a convenient HTN guideline Management Algorithm in the article to be utilized by clinicians. For full free access to the JNC8 article on HTN management guidelines please visit jamanetwork.com
Submitted by Jessica Taylor, PA-S
Are You Updated?
Have you moved recently? Have you changed practice locations? Have you gotten a new job? If so, did you update you NPI number with Medicare? Every time a PA gets a new place of employment or changes jobs you need to update your information with Medicare (updating your state license information doesn't update your information with Medicare). Go to https://nppes.cms.hhs.gov or call 800-465-3203 for help updating your information.
The Use of Fluoride to Control Dental Caries
The Use of Fluoride to Control Dental Caries in the Pediatric Population
The use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries in the U.S. When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries. Both healthcare professionals and the public need guidance on selecting the best way to provide and receive fluoride.
According to the American Academy of Pediatric Dentistry, 25% of our nation’s children have 80% of the cavities and this is largely due to the consumption of bottled water versus tap water in certain patient populations. Water fluoridation is still the number one most cost effective way to prevent tooth decay. This is because fluoride decreases tooth decay by as much as 70%. In cases of early cavities, fluoride can actually reverse the decay. Fluoride encourages mineralization and strengthening of weakened areas of tooth enamel.
Because frequent exposure to small amounts of fluoride each day will best reduce the risk for dental caries in all age groups, the CDC recommends that all persons drink water with optimal fluoride concentration and brush their teeth twice daily with fluoride toothpaste. For persons at high risk for dental caries, additional fluoride measures may be needed. Measured use of fluoride is particularly appropriate during the time of anterior tooth enamel development (under the age of 7).
According to the CDC, the goal in the use of fluoride should be to achieve maximum protection against dental caries while using resources efficiently to reduce the likelihood of enamel fluorosis (which is a staining of the teeth).
“Smiles For Life” is a national oral health curriculum that aims to build the capacity of primary care providers to carry out oral health throughout the lifespan. Because fluoride not only helps prevent tooth decay, 45 state Medicaid programs now reimburse PCPs for applying fluoride varnish to young children’s teeth as a way to cure beginning cavies and buy time until children can be seen by a dentist who accepts Medicaid patients.
It is also well known that babies can catch cavities from their caregivers and this should be addressed at all prenatal and at all well child visits. In 71% of cases of dental caries, their mother is the source. The better mom’s oral health, the less chance baby will have problems. Cavity causing bacteria, Streptococcus Mutans, can be transmitted before teeth erupt. It is important to tell parents to avoid putting their baby’s pacifiers in their own mouths, and to avoid sharing bottles or pacifiers with other children.
Thirty percent of communities in the U.S. do not have fluoride in the public water supply so it is important to address this with your patients as well. Any city utilities department can give you the testing information every few months which is measured in parts per million. From that, one can determine how much supplemental oral fluoride is needed for children under the age of 7.
According to the American Academy of Pediatric Dentistry and the American Academy of Pediatrics, these guidelines should be used with pediatric patients:
$11. Wean infant from bottle at 1 year of age.
$12. All children should have their first dental examination by 1 year of age.
$13. Never dip pacifier into anything sweet or clean pacifier with parent’s saliva or share with other children.
$14. Do not allow children to fall asleep drinking a bottle.
$15. Never put anything but water in a baby’s bottle if the baby needs to fall asleep with a bottle.
$16. Brush gums and teeth twice daily.
$17. Stop pacifier usage before the age of 3.
$18. Use supplemental fluoride if needed until the age of 6.
$19. Although children should be encouraged to learn to brush, parents should brush their children’s teeth until they are about 6 years of age or can write cursive. This is due largely to the inability for young children to have the coordination to brush effectively.
The American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry all that parents to schedule their children’s first dental appointment by their first birthday.
Adoption of the recommendations from the CDC and dental academies can further reduce dental caries in the U.S. and save public and private resources. Brush Up on further recommendations for your practice at www.smilesforlifeoralhealth.org.
Submitted by Dara Schroeder, PA-C