Cindy Corriveau appointed to Brown Medical School faculty
We are pleased and proud to announce that our RN, Cindy, was recently appointed clinical instructor in family medicine at the Alpert Medical School of Brown University. For the past ten years, Cindy has generously added instruction of our many students and trainees to her busy schedule of responsibilities at PCP. She is a gifted teacher, tirelessly researching current topics and challenging diagnoses in the medical literature, bringing fresh information to her practice as our director of clinical staff. In her capacity as teacher she has helped students pursuing many levels of training, including medical assistant, nurse practitioner, and medical doctor. She most enjoys her direct patient care duties, and makes sure that the advice she gives is well-supported and evidence-based. She teaches by example, as well, demonstrating care and compassion in all that she does, and treating each person she encounters, be it patient in need, coworker, scheduling clerk, or insurance representative (and this can be quite taxing!) with respect. She is noted for her unparalleled ability to assume the best of those with whom she interfaces in the course of her work day, thereby bringing out the best in all. We are quite happy to celebrate this noteworthy accomplishment with Cindy, and look forward to following her academic career.
New Doctor: Cristina Pacheco, MD
We are very pleased to welcome Dr. Cristina Pacheco to Primary Care Partnership. She will be seeing patients with us 3 days per week starting January 18th, 2010. A graduate of the Brown University Program in Liberal Medical Education, she received her Bachelor of Science in Cognitive Science in 2000, and her MD in 2004. She then completed the Brown affiliated Residency in Family Medicine at the Memorial Hospital of Rhode Island in Pawtucket in 2007. She is Board Certified in Family Medicine, and has worked for the past 2 ½ years in the Pawtucket underserved community, treating a broad range of problems in patients of all ages. Dr Pacheco will share in the care of all patients at PCP. Patients age 6 and up will be welcome. We are calling patients on our waiting list to invite them to select Dr. Pacheco as their PCP as of 1/18/10. We thank all those who have waited patiently for the opportunity to join us at Primary Care Partnership. We are very pleased to be welcoming Dr Pacheco.
Flu Season is Upon Us
10/1/09
This year’s flu season is presenting some unique challenges for us all. Because not only the traditional influenza virus, but also the H1N1 “Swine” flu virus, is a concern, many patients are asking about how best to protect themselves and their families.
Here is what I am recommending:
1) Everyone get a flu shot (against traditional influenza types A and B-1 shot) as long as you are not allergic to it, or to eggs. One shot will do unless you are a young child, who will need 1 plus a booster a few weeks later. The injectable form is killed and cannot give you the flu; the nasal spray “Flumist” is an attenuated live vaccine so is slightly more risky, but also believed to be more effective, especially for children. No one with immune compromise should get the Flumist. It is only recommended from 6 months to 55 years of age. Primary Care Partnership will only have the injectable form of the flu vaccine this year. Right now we have used up our first shipment and are waiting for our next. The vaccine manufacturer is behind schedule because of trying to get the H1N1 vaccine to market. We hope to have more flushots by end October. If you can get one somewhere else, I suggest you do, as we will only have 100 more doses and they will go fast when we get them. We will give them out to patients who are being seen, as we go. If we happen to have leftovers, we will have a one-day clinic around the first of the year, and will publicize that in the waiting room, and on this webpage.
2) Consider getting the H1N1 vaccine if you were born after 1957, as you are at greatest risk of a more severe form of the disease. Those of us born before 1957 seem to be more naturally immune to it, perhaps from having lived through other flu seasons. This virus is somewhat like others that have come before it. Very contagious, it is serious primarily in younger people. Infants older than 6 months are eligible. Pregnant women not only can, but should be vaccinated. One shot should do. The sooner the better. We will not have it available to give our patients, so are encouraging everyone to get them wherever they can. Towns and cities are likely to have available vaccine, as well as big clinics, and pharmacies. Because this is a new vaccine, I share the concern that there could be unforeseen side effects to it, but I think we have to weigh the potential risk of NOT getting it, and take some chances. For example, if you are in the risk group agewise, and among children or sick people or a densely populated area on a day-to-day basis, the risk of not getting the H1N1 vaccine probably exceeds the risk of getting it.
Guillain-Barre syndrome is something you may come across in your own reading about viruses and vaccines. It is a serious neurological problem that impairs muscular control in a rapidly advancing fashion, reversible in time, but often requiring life support in the interim. Fortunately, there is treatment for it, but even in the best of cases, there is a lengthy recovery. The estimates of possible complication of fluvaccination by Guillain-Barre syndrome range from 1-100,000 people to 1-1million people. It occasionally occurs as a consequence of viral illness, as well, so concern about Guillain-Barre disease should not dissuade you from getting a viral vaccine against influenza or H1N1 Swine flu.
Of course, the longer the new vaccine is in the community being administered, the more confident we will feel that it will not create a worse problem then it is meant to prevent. You can be sure that the Vaccine Adverse Event Reporting System will be paying close attention to any initial reports of untoward events associated with the shots we are receiving.
You can also go to www.cdc.gov for daily updates.
Cathleen S. Hood, MD
What You Should Know About H1N1 Flu
Link to article in Fall 2009 edition of Your Health Matters, Southcoast Health System.
Commonwealth Choice
Under the Massachusetts Health Care reform law, insurance companies now offer specific insurance plans for affordable health insurance for uninsured individuals. These plans are offered under the name of Commonwealth Choice. Each insurance company has instituted Commonwealth Choice plans and selected the providers who may accept the plans. Low income individuals may be eligible for the subsidized Commonwealth Care plans. Additional Information.
HPV testing
You may have seen recent advertisements on television about testing for Human Papilloma Virus. There are also kiosks at the mall and orange rubber bracelets with the logo "right to know" on them referring to the same thing. HPV is the causative agent of cervical cancer, and there is now a patented DNA test that can be done at the time of your Pap smear, to detect the presence of the virus. At Primary Care Partnership we perform the Thin Prep Pap smear, processed at Southcoast Hospital. If an abnormal smear is discovered, the HPV test is performed automatically. Results are always called to the patient if positive. If negative, we inform our patients by letter, with any recommendation for follow-up care. An abnormal Pap smear, HPV positive, may signify precancerous or cancerous changes of the cervix. A referral to a gynecologist is made at that time, and a culposcopy is usually done there to determine whether treatment to eradicate the virus and restore normal cellularity is needed. The company that markets the HPV test is urging all women over the age of 30 years to demand that HPV testing be done at the time of their pelvic exam/Pap smear. The reason for the age recommendation is that, under the age of 30, many spontaneous remissions of HPV positivity to negative occur without intervention. The American College of Obstetrics and Gynecology has yet to issue a consensus statement on the advisability of universal testing over 30. Until it does, we are making the test available to all of our patients, and will continue our current practice of receiving HPV tests on all abnormal Paps as before.
Please familiarize yourself with the complex issues surrounding the discovery of HPV and its potential implications for your health. A good initial resource is the US Government Center for Disease Control in Atlanta. Go to www.cdc.gov. There you will also find current information on the newly approved vaccine against HPV, Gardasil, now recommended for girls and women aged 9-26.
New American Heart Association Guidelines
As of Spring 2007, new AHA guidelines have been released, recommending a brisk 30 minute walk every day for every woman, at every stage of life as the best prevention against coronary artery disease and heart attacks. Women with even borderline high blood pressure or an unfavorable cholesterol profile are urged to treat them aggressively if even 1 other coronary artery disease risk factor is present: smoking, diabetes, previous heart disease, or a family history of heart disease. Stress with spasm of the coronaries was identified as a particularly worrisome factor in women, so active measures to reduce stress are also important. Barbara Smith, licSW is here to help with counseling where needed, but simple practical tools to mitigate physiological effects of stress are also available.
Researcher Aggie Casey at MGH instructs her patients to take “2 minute vacations” during the day. She describes these as deep, diaphragmatic breaths, in through the nose then, with pursed lips, out through the mouth while thinking “I am...at peace.” Her studies have shown that this simple measure can significantly lower circulating levels of adrenaline, heart rate, and blood pressure, de-stressing the heart.
2 minute vacations also reduce stimuli to the adrenal glands, so that production of cortisol, the chronic stress hormone, is reduced. This, in turn, helps prevent deposition of fat around the waist, a clear correlate of cardiac risk, and the bain of most middle-aged women.
If you have been in for your yearly health maintenance exam, you have probably already learned about the AHA guidelines. Please make them a priority for this year and beyond. If stress is an issue, please consider massage with Sarah Snyder, acupuncture with Stacy Delaura, and Yoga with Karen Moore Holliday. Best advice yet: listen to your “inner voice.” It will tell you what you need!
Food for Thought: Vitamin D and Wheat Gluten
One of the fat-soluble vitamins (A,D,E,& K) vitamin D is naturally best absorbed through the skin. Sunshine is our optimal source, but those of us at risk for skin cancer are best advised to avoid direct sunlight and use sunblock, which prevents D absorption. For this reason, and also because we in New England live in the Northern hemisphere where the weather often blocks the sun, an oral supplement may be needed.
It is possible to measure vitamin D levels in the blood. You may have been notified of a low level, and advised to take more. We measure the 25 OH (hydroxylase) form of the vitamin, as it best assesses overall activity. Previously, a blood level of 10-60 ng/dl was deemed adequate. In response to recent research, target level has been increased to 30-100 ng/dl, a big change. In our experience, since beginning to test our patients last year, many patients fall in the deficient range.
In addition to known activity as an aid to absorption of calcium (recall that severe vitamin D deficiency causes rickets) recent studies have demonstrated a much greater likely role for vitamin D. It is now believed it may be involved in autoimmune disease, thyroid function, depression, fibromyalgia, arthritis, and heart disease. Specific research is looking at the connection between vitamin D and multiple sclerosis.
Assuming a normal diet and at least some natural exposure to sunlight, most women are well advised to take an additional 800 IU per day of vitamin D. The form known as “D3” or cholecalciferol is apparently best absorbed orally. In the event of an acute deficiency (level of 16 or less) we may recommend a higher, prescription level. Care must be taken, however, to avoid toxicity or secondary too-rapid calcium accumulation. Retesting after a period of replacement is prudent.
Because sunscreen effectively blocks vitamin D, we have begun to propose to patients considering only applying sunscreen between 10 AM and 4 PM, so that some D can get through. Apparently, 10-15 minutes of exposure translates into 10-15,000 units of D, so that is still the most efficient way to get the vitamin D we need. Depending on skin type and cancer risk, however, even this limited amount of exposure can be damaging. We can help you decide.
Wheat gluten is the new hot topic, as you may know if you have come in for a visit recently. Guided by our nutrition specialist, Sheryl Turgeon, I have begun to counsel select patients to consider a trial of gluten avoidance in the diet. It seems that for certain predisposed patients, ingestion of wheat gluten (the protein in wheat) may trigger inflammation in the GI tract. That, in turn, starts a cascade of events resulting in autoimmune activity. Target tissues may include joints, thyroid, skin, brain, in addition to the gi tract itself. Eliminating gluten seems to be associated with fairly rapid reversal of symptoms in these areas, as well as more normal metabolism in patients struggling either to gain or to lose weight. Sheryl reports a patient who lost 6 pounds in one week. I have a patient who experienced an 8 pound loss in the first month off gluten.
A typical gluten-sensitive suspect would be an overweight middle-aged woman suffering from irritable bowel and arthritis. Gluten avoidance means looking at the ingredients on your food labels and substituting gluten-free choices for those foods listing wheat, gluten or wheat gluten on the label. Celiac disease represents a severe form of gluten sensitivity, associated with malabsortion and diarrea. Those patients must avoid all gluten to feel well, but many of us may feel alot better with relative gluten avoidance. Ironically, those attempting to “eat right” by adding whole wheat may be adding extra gluten.
Physical signs of possible food sensitivity include rough skin on the upper outer arms, a horizontal crease across the middle of the nose, stuffy nose, or extra creases under the eyes. Of course, many foods are potential offending agents, and testing, although imperfect, is available when an elimination diet doesn’t seem to work. (Please be aware that much of this advice is based on clinical anecdotal observation, as opposed to systematic scientific research.)