News & Alerts

The Scoop on the Zika Virus

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The Scoop on the Zika Virus
News about the Zika virus has flooded the television and newspaper headlines in the last few months leading to many questions and concerns from people in the United States and all over the world.  The big concern regarding the virus seems to be the possible link between it and microcephaly in newborns.  You may already be getting questions from patients including what areas are currently affected by the Zika virus and whether or not they need to be concerned.
 
The purpose of this article is to give you a summary of the high points regarding the Zika virus to help you as a healthcare provider and to also provide concerned patients answers to questions they may have.
 
The Zika virus is primarily spread through the bite of an infected mosquito. It was first discovered in humans in 1947 in Uganda, with subsequent outbreaks being reported in Africa, Southeast Asia, and the Pacific Islands.  In May 2015, an alert was issued regarding the first confirmed case in Brazil.  On February 1st 2016, the World Health Organization (WHO) declared the Zika virus a public health emergency of international concern which is when we began seeing news of the virus start hitting the headlines. People infected with the virus typically develop very mild symptoms consisting of a fever, rash, joint pain and conjunctivitis, with the symptoms lasting for several days to a week.  Many individuals don’t even know they have the disease because they won’t have any symptoms, therefore most individuals do not seek medical treatment.  The public health emergency was issued not because of the severity of the illness associated with the virus, but because of the possible link between the virus and cases of microcephaly in newborns.  Because the symptoms can be so mild, those infected may not even know they have it and possibly spread it to other individuals.  Of particular concern is the spread of the virus to pregnant females.
 
There are three other modes of transmission of the virus in addition to transmission by mosquitos.  First, a pregnant woman can pass the Zika virus on to her fetus during pregnancy. At this time there have not been any cases reported of infants getting the Zika virus through breastfeeding. The virus can be spread via blood transfusion as well.  There have not been any confirmed cases in the United States caused by transfusion, but there have been a few cases reported in Brazil. The virus usually remains in the blood of an infected person for about a week but it can be found longer in some people.  Finally, the virus can also be spread by a man to his sexual partners.  This is still being investigated, but what the Center for Disease Control (CDC) does know is that that the virus can be spread by an infected male before, during, and even after his symptoms resolve.  This is because the virus can remain present in the semen longer than in blood.  The CDC has yet to determine a few things about sexual transmission. For example, how long the virus can stay in the semen of men who have had Zika, whether women can spread Zika to their sexual partners, and whether Zika can be spread through oral sex.
 
The Zika virus is spreading, and the CDC states it will be hard to determine how and where the virus will spread over time.  Currently, areas with outbreaks of active mosquito-borne transmission of the Zika virus have been documented in areas of Africa, Southeast Asia, the Pacific Islands, Brazil, Central America, much of Mexico, and many islands of the Caribbean. The US territories that have been affected include Puerto Rico and the US Virgin Islands.  No mosquito-borne Zika virus disease cases have been reported within the US states at this time.
 
So what can you tell patients who are concerned about travel to these areas?  First of all, prevention is the best tool to avoid contracting the disease.  Travelers should protect themselves from mosquito bites by wearing insect repellents, long sleeved shirts and pants, and trying to stay in places with air conditioning or that use window and door screens to keep mosquitos outside.  There is currently no vaccine to prevent the Zika virus, nor is there any treatment.  Remind patients, that the disease itself is very mild if they happen to contract it. The biggest concern at this point is spreading the virus to women who are pregnant or have the potential of becoming pregnant.  The CDC recommends males use a condom during sexual intercourse for as long as 8 weeks after return from an area affected by the Zika virus even if they did not develop symptoms during or after their stay.  This is because many individuals may not know they contracted the virus and there are still a lot of questions that need to be answered about the virus, its transmission, and its effect on fetal development. 
 
Information from this article was referenced from the CDC website http://www.cdc.gov/zika/ 
This is a great resource for both healthcare providers and travelers to seek the most up to date information on the Zika virus.  Recommend your patients review this website before travel to any areas affected by the Zika virus.   -submitted by Jill Jensen

Blood Pressure Targets Relevant for Children, Teens

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Blood Pressure Targets Relevant for Children, Teens:
Trajectory data indicate that childhood BP levels correlate with BP status at age 38 years
 
http://www.physiciansbriefing.com/Article.asp?AID=709397
 

TUESDAY, March 29, 2016 (HealthDay News) -- Prehypertension and hypertension in children and adolescents are associated with cardiovascular target organ damage and set the trajectory for early adulthood high blood pressure (BP), according to an editorial published online March 28 in Hypertension.

Bonita Falkner, M.D., from Thomas Jefferson University in Philadelphia, and Samuel S. Gidding, M.D., from Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., discuss whether the Systolic Blood Pressure Intervention Trial (SPRINT) blood pressure treatment target of less than 120/80 mm Hg is relevant for children.

The researchers note that a BP level of 120/80 mm Hg in adolescence may be associated with early cardiovascular target organ damage. Furthermore, trajectory data indicate that childhood BP levels correlate with BP status in young adulthood, with the hypertensive trajectory in adults having the highest BP levels in childhood and adults with normal and high-normal BP at age 38 years having systolic BP below 120 mm Hg throughout childhood. Primordial prevention, or interventions to prevent development of prehypertension/hypertension in childhood, should focus on conserving normal BP, which for adolescents is less than 120/80 mm Hg. For children younger than 12 years, below 110/70 mm Hg is likely optimal.

"If the SPRINT target of 120/80 mm Hg could be achieved in all those at 18 years of age and maintained for decades, the only SPRINT inclusion criteria that would still be relevant might be age >75 years," the authors write

Antibiotic Prescriptions for Children: 10 Common Questions Answered

shutterstock 48217207Antibiotic Prescriptions for Children: 10 Common Questions Answered

Parents need to know that using antibiotics when they are not the right medicine will not help and may even cause harm to children.  Here are answers to 10 common questions by parents that you might be asked this cold and flu season as well as responses to these questions. 

Colds are caused by viruses. Antibiotics are used specifically for infections caused by bacteria. In general, most common cold symptoms—such as runny nose, cough, and congestion—are mild and your child will get better without using any medicines. 

In most cases, bacterial infections do not follow viral infections. Using antibiotics to treat viral infections may instead lead to an infection caused by resistant bacteria. Also, your child may develop diarrhea or other side effects.

During a common cold, it is normal for mucus from the nose to get thick and to change from clear to yellow or green. Symptoms often last for 10 days. 

Not all ear infections are treated with antibiotics. At least half of all ear infections go away without antibiotics. If your child does not have a high fever or severe ear pain, your child's doctor may recommend observation initially.  Because pain is often the first and most uncomfortable symptom of ear infection, your child's doctor will suggest pain medicine to ease your child's pain

​​No. More than 80% of sore throats are caused by a virus. If your child has sore throat, runny nose, and a barky cough, a virus is the likely cause and a test for "strep" is not needed and should not be performed. Antibiotics should only be used to treat sore throats caused by group A streptococci. Infection caused by this type of bacteria is called "strep throat."

Side effects can occur in 1 out of every 10 children who take an antibiotic. Side effects may include rashes, allergic reactions, nausea, diarrhea, and stomach pain. Make sure you let your child's doctor know if your child has had a reaction to antibiotics. Sometimes a rash will occur during the time a child is taking an antibiotic. However, not all rashes are considered allergic reactions.

Most bacterial infections improve within 48 to 72 hours of starting an antibiotic. If your child's symptoms get worse or do not improve within 72 hours, call your child's doctor. If your child stops taking the antibiotic too soon, the infection may not be treated completely and the symptoms may start again. 

The repeated use and misuse of antibiotics can lead to resistant bacteria. Resistant bacteria are bacteria that are no longer killed by the antibiotics commonly used to treat bacterial infection. These resistant bacteria can also be spread to other children and adults. 

Influenza (flu) is a viral infection that can cause cold symptoms for which an antiviral medicine will work. An antiviral medicine may be prescribed for children that are at higher risk of becoming severely ill if they get the flu.

  • Antibiotics aren't always the answer when your child is sick. Ask your child's doctor what the best treatment is for your child.
  • Ask your child's doctor if the antibiotic being prescribed is the best for your child's type of bacterial infection.
  • Antibiotics work against bacterial infections. They don't work on colds and flu.
  • Make sure that you give the medicine exactly as directed.
  • Don't use one child's antibiotic for a sibling or friend; you may give the wrong medicine and cause harm.
  • Throw away unused antibiotics. Do not save antibiotics for later use; some out-of-date medicines can actually be harmful. Call Poison Help at 1-800-222-1222 or check the US Food and Drug Administration Web site for information on the safe disposal of medicines.

Portions of this posting were taken from an American Academy of Pediatrics article.  For the complete article and other helpful information for parents, please go to https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Antibiotic-Prescriptions-for-Children.aspx

Notification from Nebraska DHHS; Physician Assistant Committee [PAC]

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Notification from Nebraska DHHS; Physician Assistant Committee (PAC):

RE: Dispensing Practitioner Permit

Beginning in September of 2015, Physician Assistants will no longer be able to hold a “dispensing practitioner permit”. Anyone who holds a permit must turn it into DHHS. Records indicate that this affects fewer than a dozen Physician Assistants in the State of Nebraska.

Legislative Bill 37 (LB37) now excludes physician assistants from: Neb. Rev. Stat. 38-2850. Pharmacy; practice; persons excepted.

As authorized by the Uniform Credentialing Act, the practice of pharmacy may be engaged in by a pharmacist, a pharmacist intern, or a practitioner with a pharmacy license. The practice of pharmacy shall not be construed to include: Practitioners, (other than veterinarians), certified nurse midwives, certified registered nurse anesthetists, nurse practitioners, and physician assistants, who dispense drugs or devices as an incident to the practice of their profession, except that if such practitioner engages in dispensing such drugs or devices to his or her patients for which such patients are charged, such practitioner shall obtain a pharmacy license…

 

In the prior Rev. Stat. physician assistants were not at all listed, the addition of PAs is the only modification to this statute. It is important to note that PAs are not allowed to “engage in dispensing such drugs or devices…for which such patients are charged…” This does not pertain to providing medication samples to a patient.

In the last session, the physician assistant committee inferred that very few practicing PAs would be affected by this change in statute; however, it is possible and likely to adversely affect a PA who practices in a geographic location or underserved facility with limited resources to one with a pharmacy license.

Please contact me, Tami Dolphens, if you have any questions, concerns, or if this statute change will adversely affect your practice; so that it can be discussed directly with the department and the Physician Assistant Committee at This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it. OR 402-350-7653 (cell).

New Development in SIDS research

As a new mom, I am constantly worried about things that could potentially go wrong with my baby and as I put her to bed every night I always do a quick scan of her crib and bedding to make sure there is nothing that could be a potential suffocation hazard.  I am still quick to jump out of bed and check on her in the morning following nights that we are blessed with a full night of sleep.  SIDS is always the first thing that crosses my mind when I haven’t heard a peep from her all night long.

A recent article published in the Seattle Times, featured the work of Dr. Daniel Rubens.  Dr. Rubens is an anesthesiologist at Seattle Children’s and he believes he may have found the problem to blame for SIDS or Sudden Infant Death Syndrome.  His hypothesis is that SIDS could be caused from an undetected, inner-ear dysfunction that makes it difficult for the infant to arouse and reposition if having trouble breathing, thus resulting in suffocation. 

In his test group of 35 infants, all of whom died from SIDS, all scored lower on three different sound frequencies in the right ear.  Post mortem results from four babies showed all had bleeding and extensive damage to the inner ear.

I found this Seattle Times article very interesting.   I have provided the link, with permission from its author, Nicole Brodeur, for you to read in its entirety.  This could be a wonderful medical breakthrough if more research can be performed.  

http://www.seattletimes.com/seattle-news/health/one-seattle-childrens-doctor-thinks-he-close-to-stopping-sids/

Diabetes Medication Update

Diabetes Medication Update

by Diana Podlecki

 

In the past 2 years there have been many new medications that have come out to help us treat type 2 diabetes more effectively.  For those of you in primary care, but also for those of you who do not specially treat diabetes, but have patients who are diabetic, here is a quick overview of some of the new medications to come on the market.

 

SGLT2 Inhibitors

Canagliflozin (Invokana) was the first sodium glucose co-transporter 2 (SGLT2) inhibitor to be approved in March 2013.  Dapagliflozin (Farxiga) and empagliflozin (Jardiance) were approved in early 2014.

These SGLT 2 inhibitors work by blocking the kidney’s reabsorption of glucose, so that more glucose is excreted in the urine, thus lowering the patient’s blood sugar.  This is the first medication on the market that utilizes the kidney to lower blood sugar and works completely independently of insulin.  These medications pose a low risk of hypoglycemia. 

Unlike a lot of other medications for diabetes that cause weight gain, these medications are associated with modest weight loss caused by the increase in sugar excreted in the urine.  They also have a mild diuretic effect and can also help to lower blood pressure which is often a co-morbidity in many patients with type 2 diabetes.  Side effects to watch for include lightheadedness or dizziness (from drops in blood pressure) and genital yeast and urinary tract infections.  These medications were also found to modestly increase levels of LDL (“bad”) cholesterol, but the potential for increased rates of heart attack, stroke and other cardiac events are still being studied.  There is also a concern for dapagliflozin specifically for increase in bladder cancer and liver toxicity. These medications can be used alone, or in combination with any of the other diabetes medications on the market.  The patient who would benefit from these medications the most is an obese type 2 diabetic who also has hypertension but normal kidney function (eGFR >45).

In addition, there are combinations of these new SGLT 2 inhibitors with other oral meds: Invokamet (canagliflozin and metformin) and Glyxambi (empagliflozin and linagliptin [Tradjenta, a DPP-4 inhibitor])

 

Incretin mimetics (GLP-1 receptor agonists)

GLP-1 receptor agonists work to reduce meal-related hyperglycemia by increasing insulin secretion (only) when required by increasing glucose levels, delaying gastric emptying, and suppressing prandial glucagon secretion.  These medications have a fairly low risk of hypoglycemia, have the potential  for stimulating regeneration of beta cells, reduce triglyceride levels, decrease appetite and inhibit body weight gain.  

Eventide (Byetta) and Liraglutide (Victoza) are GLP-1 receptor analogs that have been around for a few years now.  They are injections given once or twice a day to help lower blood sugars in type 2 diabetics.  Bydureon is the once weekly form of Byetta, that was approved in 2012.  

Albiglutide (Tanzeum) and dulaglutide (Trulicity) were recently approved as once weekly injections that are given any time of the day, without regard to meals, on the same day each week.  

Similar to Byetta and Victoza, these two new medications have been associated with increased rise of thyroid cancer and pancreatitis. Common side effects include nausea, diarrhea and indiegestion.  These medications are not indicated for first line treatment. These medication are often added on to oral meds to help get better control of blood sugars, before starting long acting or mealtime insulin.

Also, important to know, liraglutide has recently been approved and marketed under the brand name Saxenda as treatment for weight loss in adults with at least one weight-related comorbidity.

 

Insulin

Toujeo is the new U-300 long acting, or basal insulin pen that was just approved a few weeks ago.  Toujeo contains the same active ingredient, insulin glargine, as Lantus. The concentration, however, is 300 units per mL instead of 100 units per mL. 

The conversion from Lantus to Toujeo is 1:1.  So if a patient takes 10 units of Lantus daily, they will use 10 units of Toujeo, but since it is more concentrated they will only get 1/3 of the volume, and the convenient thing is, the pen does the math for you!  It is approved for once a day dosing.  Also note that you get 1.5mL in each pen, which gives you 450 units per pen as opposed to 300 units in the Lantus solostar pens, so the pns last longer. This is ideal for patients using more than 30 units of a long acting insulin a day, or patients taking long acting insulin twice a day.

Afrezza is probably the most exciting new product to come out this year.  Afrezza is a rapid acting INHALED insulin that comes in 4 unit and 8 unit doses.  The conversion is 1:1, so if a patient uses 8 units of injectable short acting insulin with breakfast, they would use 8 units of Afrezza (one 8 unit cartridge).

There is a requirement for patient to have spirometry (FEV1) done before starting this medication, after 6 months of therapy, and annually there after.  It is contraindicated in patients with asthma and COPD as it may cause acute bronchospasm in these patients.Side effects, besides hypoglycemia as with injected short acting insulin, include cough, and throat pain or irritation.

 

Stomach Flu or Something More Sinister?

Stomach Flu or Something More Sinister?

Kathy Tonkin, PA-C, NAPA Treasurer 

It’s your fifth day in a row at work.  Cold and flu season is here full force.  You’ve seen so many patients with coughs, fevers, runny nose, vomiting, headache and sore throat that you think you’ve seen it all.  You walk into the exam room to see another sick patient and there is a Mom with not one, but three sick little ones.  You quickly start gathering histories on all three, even though you’ve only been given enough time on the schedule to see one.  Tommy has a sore throat, headache and fever.  You order a Strep screen for him and it’s positive.  Second child’s story is the same as the first.  But little Sally’s symptoms are a little different.  She has a headache and isn’t acting herself.  She did have a fever last week, but nothing in the last few days.  She tells you her stomach hurts and Mom states she has vomited twice at home.  Despite that she is still eating and drinking well and is going to the bathroom quite a bit.  Does she have just another case of viral gastroenteritis that is going around town?  Does she have Strep throat like the others?

No, little Sally has Type 1 Diabetes (T1) and is in Diabetic Ketoacidosis (DKA).

Was that diagnosis on your radar?  Tragically, “there is an under-awareness of T1D among the public and in the healthcare system”, says Dr. Richard Insel, Chief Scientific Officer for the Juvenile Diabetes Research Foundation (JDRF).  “Missed diagnosis even occurs in emergency rooms, people don’t always think of it”.  Every day about 80 Americans are diagnosed with T1D and this diagnosis is on the rise with a 23% increase in incidence between 2000 and 2009.  Those under the age of 5 are seeing the fastest rate of new diagnosis in their age group compared to other age groups.

T1D hits close to home for me as my daughter was diagnosed with this illness when she was 2 ½ years old.  Being a PA myself and my husband growing up with a brother with T1D, we knew the signs and we diagnosed her ourselves.  Unfortunately though, I read stories all too often of children whose T1D isn’t diagnosed when they presented to health care providers and the results are often catastrophic, even deadly.  As providers we’ve all had those moments where we realized we missed a diagnosis.  After the fact it seems so obvious – why didn’t I think of that?!  None of us want to miss something that harms our patients, just thinking about it causes us to lose sleep at night (at least it does for me).

So when I read stories of little ones who’s T1D was missed, I’m reminded as a provider to make sure I have an open mind with each patient and keep those blinders off.  I need to really listen to my patients.  Are their symptoms the same as the last 8 patients I’ve just seen, or is there something else going on?

So as you’re taking care of your younger patients this cold and flu season, keep in mind the symptoms of T1D can often overlap those of common illnesses.  Often a new T1D patient will have a ‘trigger’ illness prior to their T1D diagnosis, so parents might report a recent fever or other illness and the child just doesn’t seem to be bouncing back the way they should.  Symptoms of new onset T1D include:

$1·         Extreme Fatigue

$1·         Irritability

$1·         Stomach Ache

$1·         Headache

$1·         Increased thirst

$1·         Vomiting

$1·         Weight loss, often extreme

$1·         Increased appetite

$1·         Frequent Urination (bedwetting or accidents in those potty trained or wetting completely through diapers)

$1·         Fruity breath, heavy or labored breathing (If they have this, they are sick!)

I’m not a T1D Mom that advocates screening every child for this disease or even every child with a stomach ache, but as a provider, keep it in the back of your mind. If something about the history doesn’t sound right, ask more questions and order a few tests.  A urine dip stick for glucose and ketones cost less than 50 cents.  Checking a blood sugar via finger stick is around $1.  Pretty cheap considering the cost of some of the tests we order on our patients every day, especially to catch a disease that can lead to quick deterioration of a patient’s condition or even death.

For more information about T1D visit the JDRF website at www.jdrf.org

Thank you for taking the time to read this and for pondering the ramblings of a fellow PA and T1D Mommy.

Kathleen Tonkin, PA-C

From Classroom to Clinic

Four months ago, I was sitting in class from 8-5pm Monday through Friday, then going home to study for two to four more hours depending on the number of examinations we had that week. I’m surprised I didn’t develop any pressure ulcers from all that sitting! Today, I’m in Broken Bow, Nebraska, one of the smallest towns I have ever been in, completing my three-month family practice clinical rotation. The transition from classroom to clinic has been more enjoyable than I ever could have imagined. One of our professors told our class before we went out on rotations that the worst day of rotation would be better than the best day in the classroom. She was right. Being on call all weekend and then working a full week of clinic is a thousand times better than sitting in class all day long.  
The clinical setting has helped so much with solidifying all the crazy mnemonics, common triads, buzz words, and dreaded pharmacology crammed in during many late night study sessions. It’s quickly becoming apparent that medicine is truly an art form and not always textbook medicine. I am learning about different aspects of medicine each day, from new brand name drugs to insurance plan coverages to billing and coding. Almost every day, I go home from clinic exhausted and drained because my mind has been racing, trying to capture everything from the day. 
Gone are the days of paper assignments on theoretical patients.  Now I am interviewing, performing physical exams, making diagnoses, and implementing treatment plans on real patients. The connection that a PA establishes with a patient leaves a much stronger imprint than simply memorizing a disease name and treatment option for an exam. Over the last four months, I have had so many “firsts”, from my first patient, first blood draw, first suture, first I&D of a thrombosed hemorrhoid (how satisfying), my first on-call shift, my first hospital rounds, to my first to delivery. Wow!
One thing that has been challenging for me, as a student, has been discussing treatment options with patients and providing patient education in an effective manner. My preceptors have helped me so much with this and have been wonderful teachers and role models. I am very appreciative of the time and energy they invest in their patients and in me. With every patient encounter, I learn something new, such as how to ask the same question in multiple ways or the correct verbiage to use when performing a pelvic exam. Even as I soak up so much new learning every day, as I’ve been out on clinicals, I have felt well prepared with the academic knowledge and clinical skills my PA education at UNMC provided me. And while I am thankful to be in the clinic and out of the classroom, I sure do miss seeing my wonderful classmates and trips to the coffee shop. Only one more year until I am a PA-C! 
By Jessica Taylor PA-S

Interviewing and Contracts

It's that time of year as many new graduates are preparing for their first job. Visit this site by AAPA for tips on interviewing and contracts http://www.aapa.org/twocolumn.aspx?id=341&fb_ref=Default&fb_source=message . This is also a great resource for PAs currently out in practice.

Don't forget the great resources the American Academy of Physician Assistants has! Visit aapa.org to learn more and become a member.

Be in the know... hydrocodone

Just a reminder, for those who do and don't prescribe hydrocodone, this medication has a new schedule.Just as tramadol got reclassified this Fall 2014, so did hydrocodone. What does this mean? Hydrocodone products are now treated just the same as oxycodone products. It is a schedule II medication...

  • Must be printed. Can not be called in to the pharmacy or sent by e-prescribing
  • Can not include refills. A patient needs a paper copy for each and every renewal

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