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Remember all the Drugs With a Narrow Therapeutic Window?

November 7, 2011 Dr. Pullen

The concept of the therapeutic window, the dose of a medication where the serum level is high enough to be effective but not so high as to be toxic, is much less of an issue today than it was in my days as a younger physician. I am sure I’m not alone in being delighted and relieved by this welcome change. I thought it would be fun to muse about the drugs we used to use routinely whose narrow therapeutic window was often a dilemma.

We still commonly use a relatively few medications with a narrow therapeutic window, notably warfarin, digoxin, and lithium, but many others have fallen out of favor because safer effective treatments have become available. For fun and historical perspective let’s look at some of the drugs with troublesomely narrow therapeutic windows.

Thoephylline: Prior to the widespread use of inhaled corticosteroids, long acting inhaled beta agonists, more aggressive use of short burst courses of oral corticosteroids, and new medications like spireva, Singular, and others the mainstay of asthma and COPD management was theophylline. With a non-linear metabolism (the serum levels do not gradually and steadily increase with increased dose, but rather jump quickly at times with minor dose changes), severe toxic side effects at only slightly supra-therapeutic serum levels, and many drug interactions, theophylline toxicity was a common cause of ICU admission for many years.

Digoxin: Digoxin is still used for many patients, but not nearly as often, and usually at considerably lower doses than when it was considered a key part of management of most patients with CHF and tachyarrythmias of many types. We have learned a great deal about CHF treatment in the last 20 years, and digoxin plays at most an ancillary role in cardiology today for most heart conditions. This is nice as often life threatening arrhythmias were commonplace in years past, and digoxin toxicity was extremely common.

Tricyclic Antidepressants: These are a prefect example of a narrow therapeutic window. At a daily dose of 300 mg daily, amitripylene ingestion of as little as 4-5 days of dosing could be lethal. In contrast ingestion of a full month prescription of most SSRIs is unlikely to be life-threatening. Amitriptylene, imipramine, nortriptylene, desipramine and later some tetracyclics like trazodone were the only effective antidepressants available prior to Prozac, and the SSRIs have been popular not just because of their lack of bothersome side effects. The fact that lethal overdose of an SSRI is extremely uncommon, whereas ICU admissions and deaths from tricyclic intentional and unintentional overdose were daily occurrences 30 years ago. We rarely use the tricyclic antidepressants in doses needed for depression today.

Warfarin: We still use warfarin plenty, but new directly acting drugs like Pradaxa, Xarelto and apixaban are becoming available for prevention of stroke in atrial fibrillation, and are likely to be used in the future for DVT therapy. It remains to be seen whether bleeding complications will be significantly less problematic, but it is clear that the therapeutic window with warfarin is about as narrow as they get. A patient therapeutic on 5 mg daily, may be significantly over-anticoagulated at a dose of 6 mg daily, and with many drug interactions, dietary variation of vitamin K ingestion, and patient compliance issues with frequent INR monitoring this is a major factor in patient care.

Aminoglycoside antibiotics: These remain a very effective therapy for many gram negative bacterial infections, but have in large part been replaced with much less toxic drugs. Use of these antibiotics requires close monitoring of serum levels and renal function to assure both therapeutic serum levels and non-toxic levels.

Lithium: Lithium remains an effective therapy for the mania associated with bipolar disorder, but the narrow therapeutic window where serum levels below 0.5 usually not effective, but levels much above 1.0 leading to toxicity, drugs with a much wider therapeutic window are often preferred by patients and physicians alike. (Visit this Lithium side effects resource)

Aspirin: No not 81-325 mg daily for their anti-platelet effect, but three Ecotrin or Bufferin 325 mg tablets four times daily. Prior to the huge list of NSAIDs beginning with ibuprofen and naproxen, high dose aspirin was the standard of therapy for rheumatoid arthritis, osteoarthritis and most inflammatory disorders. Who remembers checking salicylate levels, watching for tinnitis and bleeding ulcers or hemorrhagic gastritis from aspirin toxicity. I don’t miss those days.

Other drugs like many of our chemotherapy agents still remain in widespread use despite the need to push dosing to levels where toxicity is expected, but overall the development of safer and improved drugs has made consideration of the therapeutic window much less of a day-to-day concern than it was just a couple of decades ago.

Please leave your stories about use of drugs with narrow therapeutic window issues for readers to enjoy. Leave your e-mail in the subscribe area on the right side bar to be notified of future DrPullen.com posts, and follow on Twitter @DoctorPullen to get additional thoughts and health care commentary.

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Pfizer Strategy to Get You to Buy Lipitor not Generic Atrovastatin

November 3, 2011 Dr. Pullen

The patent on Lipitor expires this month, and inexpensive generic atorvastatin should be available within months. I cannot think of any good reason that generic atorvastatin prices should be higher than the prices of the other generic statins once true competition comes to the marketplace. Pfizer has in place a strategy to try to keep patients buying and physicians prescribing brand name Lipitor and maintaining their market share to some degree. Here is how they hope to retain sales as outlined in the Wall Street Journal in an article by Peter Loftus:

Discount Drug Coupons: In every state except Massachusetts the use of manufacturer coupons to reduce the copay for brand name drugs is legal. Federal insurance plans Medicare and Medicaid disallow these coupons, as their real effect is to negate the intent of the payer (the U.S. government and its taxpayers in the case of Medicare and Medicaid) to force the individual patient to pay a premium in the form of higher copayments in order to use higher price brand name drugs. The effect is to give incentive to patients to use cheaper generics, save money themselves and save money for the health care system. Discount drug coupons take the incentive away from the individual patient and end up raising the cost of health care. Pfizer hopes that physicians and patients will make use of these coupons and help them retain market share instead of using less expensive generic atorvastatin.
Making deals with the pharmacy benefits managers that insurance companies use to give rebates or market share incentive deals that in essence give larger profits to these companies if patients use Lipitor instead of generic atorvastatin. These pharmacy benefits managers have considerable power in the choices patients have and drugs they are dispensed.

If Pfizer is successful in their attempts to retain significant market share of the $11 billion in annual sales of Lipitor, the #1 grossing U.S. drug for the last several years we can be sure other pharmaceutical companies will follow suit as their drugs lose their patent. Don’t be fooled by drug discount coupons. They may save you dollars in select situations where an expensive drug is clearly the best alternative, but in my opinion are rarely good choices, and certainly not in the case where their sole purpose is to convince us to use a more expensive brand name of a drug where a generic alternative is available. Everyone wants to reign in the cost of medical care, and discount drug coupons are trying to circumvent incentives to lower the cost of health care.

I’d be in support of either the federal government or each of the states following the MA lead and make drug discount coupons illegal.

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Sequenom™ brings MaterniT21™ and a Whole New Set of Difficult Choices

October 22, 2011 Dr. Pullen

Coming to 20 major U.S. metropolitan areas this week will be a test called MaterniT21™ from Sequenom™. Over the past 25 years we’ve gone from alpha-fetoprotein testing, to adding 2, 3 and more recently 4 tests as “penta” screen to try to improve the estimation of a woman’s risk for having a trisomy-21, or Down’s syndrome pregnancy without actually obtaining fetal cells, but all they have really done is improve statistical prediction capability. Up to this point in order to tell if a woman is carrying a Down’s Syndrome baby required amniocentesis to obtain amniotic fluid at about 16-18 weeks gestation, or the arguably higher risk chorioamniotic villous sampling at 10-12 weeks gestation. Both of these tests ran low (estimated 1/350) but real risks of fetal injury and miscarriage. Now from a company named Sequenom™ comes a test on fetal cells obtained by a venous blood sample of the pregnant women’s blood as early as 10 weeks gestation that can do genetic screening for Down’s Syndrome without more invasive ways to obtain fetal cells. The initial study of 212 women showed a >99% accuracy rate. (1 false positive, 2 false negatives in 212 women tested).

This is both exciting and frightening. It raises huge questions including who if anyone should get this testing. Here is a list of some of the issues that come to my mind as we start the process of figuring out the role of this new technology:

Increased Abortions and Earlier Abortions of Down’s Syndrome Pregnancies: One consequence of a more accurate test for Down ’s syndrome if it leads to more widespread testing or women for this condition is that more women will face the decision of abortion or not. Now women first face the question, “Would I abort my pregnancy if I knew I had Down’s syndrome, and if so am I willing to undergo a test that could cause miscarriage to get that information.” With the Sequenom™ MaterniT21™ test women will be able to get much more definitive information without a test that puts their fetus at risk from the test itself. This may lead to more women choosing to be tested. Putting aside the whole “pro-life vs. pro-choice” debate, the opportunity for earlier diagnosis will make technically easier and less physically traumatic abortions possible in women who have a Down’s Syndrome pregnancy.
Who should be Eligible for the Test?: Although the risk of Down ’s syndrome rises with increasing maternal age many Down’s Syndrome babies have young Moms. With a more accurate and less dangerous test available should all or more women be offered the test?
Who should pay for the testing?: This is a very complicated question. This test is not going to be inexpensive. On the Sequenom™ press release they suggest that the cost will approximate the cost of amniocentesis testing. They do not make it clear if this means the cost of the amniocentesis test itself, the cost of the genetic testing of the cells obtained, or both. If the test is done it will lead to higher costs for prenatal care as the test itself will significantly increase the overall cost of prenatal care. On the other hand the cost of having a Down ’s syndrome baby is not inconsequential. Down ’s syndrome children sometimes have major other congenital deformities, and the long term cost of education, support as adults, and associated family and societal costs are real and significant. A comprehensive cost-benefit analysis of this process will be interesting to see when it becomes available. These issues themselves will lead to ethical and moral choices.
Lower Incidence of Down’s Syndrome: If this tests becomes widely used, and if more women choose to abort pregnancies with Down’s Syndrome fetuses, the incidence of Down’s Syndrome could significantly decline. While many may consider this the desired outcome, some Down’s Syndrome supporters fear that this may lead to reduced support and reduced research into drugs and other techniques to help Down’s children.

I’m sure I’ve only touched the surface of the ethical, emotional, medical, moral and financial issues this new MaterniT21™ test from Sequenom™ and likely others to follow will bring. It seems a near certainty that with the ability to sample fetal cells from maternal blood other genetic tests like tests for cystic fibrosis, sickle cell disease, and many others will follow.

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Moral Responsibility to Get Your Flu Shot

October 10, 2011 Dr. Pullen

Moral Responsibility to Get Your Flu Shot

I Got Mine

This topic comes to mind again this year as we have plenty of influenza vaccine, on time this year and ready for distribution. A prior version of this post was posted in 2010. I have strong enough feelings on the subject to repost an updated version. If anything good came of the Swine Flu epidemic on 2009 it was that more Americans get immunized not than ever before.

This year as every previous year Dr. Pullen was first in line at our office for my influenza vaccination. I take seriously the mantra primum non nocere, first do no harm. It’s hard to imagine doing more harm than seeing a patient with influenza on Monday, and on Wednesday, the day before I get sick, sneezing and passing the influenza germ to one of my vulnerable older patients, or a pregnant woman, or a young baby who then dies from influenza. This scenario is just inexcusable given that I could have avoided harming the patient if I had received the recommended and easily available influenza vaccination. It would be immoral and irresponsible to put my patients at that type of risk unnecessarily. I encourage, coax, tease, and everything short of intimidate my employees and fellow physicians to get their influenza vaccination also. School teachers, emergency workers, and others in close contact with the public should similarly feel morally compelled to get influenza vaccination. It is our moral responsibility.

I also got a Tdap vaccination last year also, even though was several years until I was due a tetanus shot. See Dr. Pullen Gets His Tetanus Booster Shot Years Early! My thinking was the same, try to avoid a pertussis infection, and not put my patients at risk.

It’s a small step from discussing health care workers and influenza and pertussis vaccination, to talking about parents and childhood vaccinations. The parent who chooses not to vaccinate their children against measles and pertussis puts not only their own child, but other children in the community and the school who may be at particular risk for complications from these infections in danger. These children at high risk may catch these infections from these unimmunized children. As a parent I’d feel terrible if my child died or became brain injured from measles, but I’d also feel horrible if my child passed Pertussis or measles on to a child with leukemia, or HIV because I chose to not immunize my child. I appreciate that this is a free society, and we can make our own personal choices about health care including immunizations. It’s not illegal to decline recommended immunizations, but in many cases it is irresponsible and not living up to our community moral responsibility. Parents who choose not to immunize their children and take advantage of the herd immunity of the majority of children whose parents responsibly immunize their kids are just ignorantly selfish. They think they are protecting their children from risks of immunizations, though a great mass of evidence refutes this point of view. In fact they are putting both their own child, and other children who lack immunity through no choice of their own or their parents at risk.

I’m anticipating a rash of angry comments calling me a mouthpiece of the brainwashed physicians of organized medicine. Don’t believe them.

See these references on the safety of childhood immunizations.

Prenatal and Infant Exposure to Thimerosal From Vaccines and Immunoglobulins and Risk of Autism (there is none).

Data Fail to Support Thimerosal-Autism Link

The end of the autism/vaccine debate?

Book Is Rallying Resistance to the Antivaccine Crusade

Also see the great video at the top of the Musical Docs page Immunize: The Vaccine Anthem.

Actual Causes of Death in the U.S.: Not What You Think

October 6, 2011 Dr. Pullen

by Kenny Lin MD

Any standard public health or medical school prevention text includes (or ought to include) some version of the figure below, which illustrates that the leading causes of death in the U.S. at the turn of the century (heart disease, cancer, stroke) were actually surrogates for what have come to be known as the actual causes of death: unhealthy behaviors such as tobacco use, poor diet, and physical inactivity.

The most effective preventive services that primary care clinicians provide, then, are not screening tests but counseling interventions that aim to change one or more of these behaviors for the better. Community-level initiatives such as tobacco-free restaurants and campuses, pedestrian-friendly cities, and increasing access to nutritious food sources play a critical role in changing health-related behaviors, too.

Unfortunately, the impact of behavioral or “lifestyle” approaches to prevention is likely to be limited by two factors: 1) even intensive interventions produce very modest benefits; and 2) behaviors don’t exist in a vacuum, but are largely shaped by economic and social circumstances. Family medicine professor and former U.S. Preventive Services Task Force member Steven Woolf has published a number of studies showing that the risk of death is strongly associated with levels of college education and income; his research team at Virginia Commonwealth University worked with the Robert Wood Johnson Foundation to develop an interactive County Health Calculator that illustrates how many premature deaths could be avoided by eliminating educational and income disparities.

Researchers from Columbia University went a step further by publishing “Estimated Deaths Attributable to Social Factors in the United States” in this month’s issue of the American Journal of Public Health. Using estimates derived from the literature on social determinants of health and year 2000 mortality data, they found that the “actual” causes of death looked like this:

1) Low education: 245,000
2) Racial segregation: 176,000
3) Low social support: 162,000
4) Individual-level poverty: 133,000
5) Income inequality: 119,000
6) Area-level poverty: 39,000

Clearly, we know a great deal more about successful strategies for fighting clinical and behavioral causes of death than we do about social causes, some of which often appear intractable. But I could not agree more with the authors’ conclusion that “these findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.” The point being: poverty, discrimination, and low education aren’t just social or political issues best left to non-clinicians – they’re health issues, too.

Originally posted by Dr. Kenny Lin at Common Sense Family Doctor Friday, August 26, 2011

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PSA Controversy Continues

October 5, 2011 Dr. Pullen

The controversy over PSA testing is tough. Nobody wants to hear that although prostate cancer is the second leading cause of cancer death in men behind lung cancer that there is no good reason to believe that PSA testing leads to either longer or better lives. It is a tough dilemma. Death from prostate cancer is not good. Men sometimes die after long, painful illness with metastatic bone cancer and a wasting painful death. Everyone including me wants to believe that early diagnosis must be good. Unfortunately the evidence just does not lead you to that conclusion. You may have enjoyed my last post on Prostate Cancer Screening, “Don’t Do Something: Just Stand There” and in todays New York Times is a very thourough historical and analytical article outlining the controversy of PSA screening. It is full of emotional quotes by advocates and skeptics. Also is a link to Dr. Kenny Lin’s latest article on the subject also. These make a good read for anyone considering PSA screening.

Can Cancer Ever Be Ignored? by Shannon Brownlee and Jeannie Lenzer

I especially like the article’s visual. It raises the seldom stated but often considered axiom that every good primary physician knows: If you don’t want to know the answer, don’t ask the question.

Dr. Kenny Lin, a key player in the PSA debate as the ex-USPSTF point investigator on the PSA screening dilema who resigned in protest of political pressure to withhold new recommendations to make PSA screening a grade D (as in don’t do it) for PSA screening in healthy males that was based on the best available evidence but was politically unacceptable writes another excellent discussion of the topic:

The Meeting that Wasn’t Revisited by Kenny Lin MD.

Stay tuned for the latest on this controversy. Subscribe to DrPullen.com to not miss a post. You can choose to subscribe to all posts, or just by category. Just enter your e-mail address in the subscribe area at the right.

NOTE THAT SINCE THIS WAS POSTED THE USPSTF HAS POSTED A PROPOSED UPDATE TO THEIR RECOMMENDATIONS FOR PSA TESTING FOR MED AS A “D” RECOMMENDATION, i.e. RECOMMENDING AGAINST USE OF PSA AS A PROSTATE CANCER SCREENING TOOL.

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Medicare Wellness Exam: A Family Physician’s Nine Month Perspective

September 29, 2011 Dr. Pullen

With the implementation of the Affordable Care Act now since Jan 1, 2011 for the first time Medicare authorizes a wellness exam for our elderly patients. I have been doing a large number of these exams and have a few thoughts on the experience so far. A good description of the encounter is like a sprint to cover the mandated components of the Medicare Wellness Exam and get these documented so there is a little time left to meet the patient’s expectations of a physical exam.

At the crux of these comments is that the required elements of this wellness exam bear little resemblance to what most patients would consider a physical exam. CMS intentionally made up brand new CPT codes for these exams so that they are not considered the same service as a preventative care “physical exam” code for an adult patient. Those cynics among us suspect that the primary reason for this was financial. Medicare did not want to use the age adjusted RVU payment multiplier for this newly authorized service. In order to justify a mush lower payment amount they simply defined a new service as a Medicare Wellness Exam. The RVU for a preventative service code is considerably higher than the code for a routine office visit, so Medicare conveniently chose to reimburse the Medicare Wellness Exam at the level of a routine office visit, not as at physical exam level. That when combined with the fact that Medicare uses a compensation scale per RVU that is considerably lower than all commercial insurers make doing a Medicare wellness exam for an elderly patient pay considerably less than a typical office visit for younger insured patient with modestly complex medical problems.

Given that a family physician who wants to stay in business cannot spend twice the time of a regular office visit on a Medicare Wellness Exam that pays considerably less, the required elements of the Medicare Wellness Exam visit consume much of the time a reasonable physician can allot for the visit.

Making this all the more complicated for patients is that Medicare patients in my practice for years have become used to not being able to have a wellness visit, and so I have tried to provide these services broken into pieces at the time of disease management visits. This rather sudden change has left patients wondering what I’m doing spending my time at a wellness exam discussing things that may seem silly to them, or may not be what they perceive as having much to do with wellness. Most patients coming in for a wellness exam reasonably expect this to include a medical history, a medical exam and addressing preventative services due as well as at least documenting and formulating a plan for future evaluation of any concerns they bring up at the visit. This seems reasonable, except that the Medicare proscribed wellness exam has to include an assessment of:

Patient fall risk
Depression screening
Addressing their end of live decision status
Ability to accomplish a variety of needed daily tasks like managing money, shopping, housework, and transportation needs, and other activities of daily living.
Vision assessment
Hearing assessment
Assessment of immunization status
Assessment of other USPSTF category A & B preventative services due, including colon cancer screening, breast cancer screening, prostate cancer screening discussion, and diabetes screening.

The healthy, active and otherwise well 67 year old may think many of these queries re irrelevant, and they may in fact be irrelevant. Some may even feel insulted that I’m asking about their risk of falling and managing their household when they want to talk about their risks of heart disease, diabetes, stroke and cancer. The frail, near blind and near death 96 year old living with family may have difficulty with so many of these issues that to adequately cover even some of them would require more time than can be allotted to the entire exam. Many of these patients may feel this visit should include a much more comprehensive hands-on physical exam than is realistic in the visit given the mandated topics to cover and the time reasonably expected for the level of compensation allowed.

Still other patients will expect their chronic health conditions, or various other complaints to be addressed at this visit. Their shoulder hurts, their ankles swell, they have some constipation, and their back aches in bed at night. It is difficult to tell the patient that this visit is only for the mandated Medicare Wellness Exam issues and not to address their multiple chronic health problems. Yet other patients really don’t want a Medicare Wellness Exam at all, rather they want a problem focused visit but want to have the visit billed as a Medicare Wellness Exam because it is paid by Medicare without copayment or deductible payments by the patient.

It is simply not realistic to try to complete the mandated Medicare wellness exam points, do a history and physical exam in the traditional sense, and have time to even listen to other complaints. To try to listen to and also address these complaints is even less likely.

I think Medicare is way off base in setting rigid and rigorous expectations for a wellness exam. Allowing the patient and the physician to set an agenda that meets the patient’s needs and expectations would have been a much wiser approach. The concept of giving patients the opportunity to see their physician once annually to address their personal preventative care issues without making a laundry list of mandated issues to include in the visit could have been great. As it is now the visit becomes a race to cover the mandated topics while trying to include at least some of the reasons the patient wants to be seen. This is one more example of the Medicare rule-makers just trying too hard standardize care and mandate excellence, with the unintended consequences of forcing every American over age 65 and on Medicare to be subjected to essentially the same one-size-fits-all Medicare Wellness Exam.

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What is Hospice: A Hospice Volunteer Point of View

September 26, 2011 Dr. Pullen

by Christina Lufkin, Hospice Volunteer and Author.

What is Hospice?

Hospice is not a death sentence. It is an opportunity to live life to the fullest until you die.

I have been a Hospice volunteer since 1994. It is my passion. To be of service to others during such an important and intense time of life is an honor. The more I give, I am repaid tenfold. In order to qualify for Hospice a patient must be diagnosed with a terminal illness that if it were to progress at the normal rate, would only have six months to live. To be eligible a patient can’t be involved in treatment to try cure the illness. Their doctor must write a referral for the patient to be evaluated for Hospice care.

Once enrolled, if the patient lives to the six month timeframe they can be evaluated and reinstated in the program. Hospice provides many services that assist both the patient and the family. I have had many conversations with family members and friends of terminally ill patients who were anxious because of unresolved issues with the patient or because they just felt they needed to share something and had not done so. I always encourage them to make time to talk about the issues. It will be too late once the patient has passed. If left unresolved these situations can lead to the survivor feeling regret, sadness, guilt or frustration. Grief is natural but adding the pressure of not talking openly before someone dies can make the grieving process much harder.

Many patients have talked with me about the importance of relationships in their life. They have never expressed regret about wishing they had more money, possessions or fame. It is so important to most people to know that they don’t have any unfinished business, which allows them to pass peacefully. Once a patient has been diagnosed with a terminal illness, Hospice is the best way to have their wishes met. The Hospice team; Nurse, CNA, Chaplain, Social Worker, Medical Director, Volunteer Coordinator and Volunteers work together to accomplish the patients desires. This team effort helps address the patient’s complete needs; physical comfort, emotional and spiritual support. Treating the entire patient is very important. Then, after the patient passes the family has a great support system and grief counseling, and support groups available anytime there is a need. I have had many heart-to-heart talks with patients in addition to fun and silly times together. After every assignment I take time to reflect on the experience. I have always learned something from each patient. The patients and families have always thanked me and said how much my service and the Hospice services in general made a positive difference.

I encourage anyone interested in Hospice or in volunteering to call your local Hospice organization. If you have questions please contact me at christinalufkin1@yahoo.com. Christina is also available for interviews or guest speaking engagements. Christina Lufkin, Author “Live with Purpose:Die with Dignity” www.christinalufkin.weebly.com

Comments by Dr. Pullen: Over the years I have had nothing but positive experiences with hospice. When my Mom passed last spring Hospice was involved and they definitely made for a better experience all around. See my post, Saying Goodbye. Hospice has several major advantages from a flexibility and financial standpoint also for terminal patients. The Medicare reimbursement for Hospice is on a per-diem basis, and the Hospice team has a great deal of flexibility in choosing services to provide to patients, many of which would not be eligible for regular Medicare coverage.

You may also enjoy How We Fail and End of Life Care.

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Alzheimer’s Complicates the Vow Till Death Do Us Part

September 19, 2011 Dr. Pullen

Many of us had the vow, “Till death do us part” as the last phrase of our wedding vows. Probably nothing makes this more complicated than when one partner in a marriage develops end stage dementia such that the relationship becomes extremely one sided. Alzheimer’s disease and dementia in general is among the more dreaded of maladies we face in life. How to deal with the tragedy of living as the surviving cognitively competent spouse has to be among the more difficult situations a person can find themselves left to face. Sometimes the partner with dementia may not even recognize who the spouse is at the end.

I don’t watch televangelist Pat Robertson but interestingly his recent response to the question about the moral issues facing the spouse of an institutionalized patient with advanced Alzheimer’s disease has pushed this type of dilemma into the public eye. This and similar very difficult and sticky personal, ethical, religious situations usually are relegated to individuals, families and friends to face quietly and personally. That is likely where they belong, maybe in consultation with one’s personal pastor or confidant. Certainly live on a televangelist’s show is no place to have the issue of an individual debated. The New York Times ran an article that addresses some of these issues that makes for a thoughtful read:

Robertson Stirs Passions With Suggestion to Divorce an Alzheimer’s Patient

By ERIK ECKHOLM

Published: September 16, 2011

With his suggestion this week that a man whose wife was far “gone” with Alzheimer’s should divorce her if he wanted a new companion, the television evangelist Pat Robertson stumbled into treacherous moral terrain, setting off storms of criticism and questions about a disease that shatters lives and families.

Other conservative Christian leaders were swift to condemn his remarks as a call to violate the biblical sacrament of marriage. Many doctors and patient advocates had a more complex response, with many suggesting that Mr. Robertson, 81, had repeated misleading stereotypes about Alzheimer’s but had also broached an important subject, how spouses and other family members of dying patients can prevent their lives from being engulfed and start to move on. Read more

Here is a clip from Pat Robertson’s show where he addresses this issue.

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Which Argument Shoots Down Your Excuse for Not Getting a Flu Shot.

September 16, 2011 Dr. Pullen

Got My Flu Shot Today

I really don’t like the term “flu” or “flu shot” because the term flu should not be used interchangeably with “viral illness.” Influenza is a specific, often very severe and even deadly viral illness and influenza vaccine is a very specific vaccine. Still the term flu shot is so integral to our everyday language that I’ll us the term, and encourage all of you to GET YOUR FLU SHOT. I hear excuses every day during the fall and early winter when I offer influenza vaccine to my patients. Here are some of the most common excuses (explanations?) I hear and my explanation (argument?) of the folly in that line of reasoning.

“I never get the flu. I don’t need a flu shot.” – Most people only get influenza once every several years. It is not unusual for any given individual to go 10-15 years without contacting influenza. Influenza is a severe illness much of the time and it is worth getting a flu shot every year to prevent one case of influenza every 10-20 years.
“The last time I got a flu shot I got the flu.” – This is just not true. An influenza vaccine simply does not cause influenza. Since the influenza vaccine contains a killed virus, it is not possible for it to cause influenza.During the season when we give flu shots minor illnesses are common. It is not unusual to become ill during the time shortly after getting a flu shot. Also a small percentage of people who get a flu shot may have some minor aching, low grade fever or malaise. This is not even close to as severe a problem as a real case of influenza, and is no reason not to get a flu shot.
“I just don’t like shots,” or “I hate needles,” or “Shots hurt.” – Nobody likes getting shots, or being stuck with a needle. The benefits of influenza vaccine, both for yourself and for those you care about are important enough to suffer through an injection. Just get it over with.
“I heard the flu shot this year is just the same as last year so I don’t need another shot.” – I heard this today from a medical student at the office. They should know better, and I tried to set them straight. It is true, that in 2011 the components of the influenza vaccine are the same as they were in 2010. I suspect that this student was just trying to find an excuse not to get a shot. It is good news that the vaccine has not changed this year. First it means that no new and very different influenza virus lurking and ready to cause a severe influenza pandemic was discovered. Getting a second vaccine will be the equivalent of a booster shot, making you even more immune to these strains of influenza, whereas the remaining immunization from last year’s flu vaccine are not adequate to provide immunity sufficient to prevent contacting influenza this year.
“I’m healthy and if I get the flu I won’t get all that sick.” — I’m happy that you are a healthy person who takes good care of yourself. Now get a flu shot and stay healthy, because influenza can be very severe or even lethal for even the strongest and healthiest of us. In addition if you catch influenza you will be putting others at risk. You’ll be sick enough that someone will need to take care of you, and they will be at risk needlessly because you chose not to be immunized. This is especially true if you are around the elderly, the very young, pregnant women, or persons with chronic disease. Respect yourself and those around you and get a flu shot.
“I want to leave my immune system alone so I will develop good immunity naturally. If I get a flu shot I weaken my immune system.” – - This is just faulty reasoning. There is no evidence to suggest that getting an influenza vaccination reduces your immunity against other germs. It simply provides antibodies against certain strains of influenza A and B. This immunity likely is increased by annual flu shots, so that by getting a flu shot annually you develop better influenza immunity each year.

Last year I posted on The Social and Moral Responsibility of Immunizations for health care workers, teachers and others in positions where others at high risk may be exposed to them if they contact influenza. I wrote earlier this year on the Flu Season. This health blog also links to an AFP article on The 12 Basic Rules of Influenza and I wrote on how to Avoid Getting Sick. I hopt that all of these are informative, but if I could accomplish one thing with this blogging effort, I’d convince every one of my patients and readers (except the uncommon patients with severe egg allergy or other valid reason to need to rely on the herd immunity that could occur if the rest of us got immunized) to get an influenza vaccination every year. If I could do that I’d feel that I’d have made a real difference in the tiny part of the world that I touch.

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