By MARILYNN MARCHIONE, AP Medical Writer Marilynn Marchione, Ap Medical Writer

We fret about airport scanners, power lines, cell phones and even microwaves. It’s true that we get too much radiation. But it’s not from those sources — it’s from too many medical tests.

Americans get the most medical radiation in the world, even more than folks in other rich countries. The U.S. accounts for half of the most advanced procedures that use radiation, and the average American’s dose has grown sixfold over the last couple of decades.

Too much radiation raises the risk of cancer. That risk is growing because people in everyday situations are getting imaging tests far too often. Like the New Hampshire teen who was about to get a CT scan to check for kidney stones until a radiologist, Dr. Steven Birnbaum, discovered he’d already had 14 of these powerful X-rays for previous episodes. Adding up the total dose, “I was horrified” at the cancer risk it posed, Birnbaum said.

After his own daughter, Molly, was given too many scans following a car accident, Birnbaum took action: He asked the two hospitals where he works to watch for any patients who had had 10 or more CT scans, or patients under 40 who had had five — clearly dangerous amounts. They found 50 people over a three-year period, including a young woman with 31 abdominal scans.

When other radiologists tell him they’ve never found such a case, Birnbaum replies: “That tells me you haven’t looked.”

Of the many ways Americans are overtested and overtreated, imaging is one of the most common and insidious. CT scans — “super X-rays” that give fast, extremely detailed images — have soared in use over the last decade, often replacing tests that don’t require radiation, such as ultrasound and MRI, or magnetic resonance imaging.

Radiation is a hidden danger — you don’t feel it when you get it, and any damage usually doesn’t show up for years. Taken individually, tests that use radiation pose little risk. Over time, though, the dose accumulates.

Doctors don’t keep track of radiation given their patients — they order a test, not a dose. Except for mammograms, there are no federal rules on radiation dose. Children and young women, who are most vulnerable to radiation harm, sometimes get too much at busy imaging centers that don’t adjust doses for each patient’s size.

That may soon change. In interviews with The Associated Press, U.S. Food and Drug Administration officials described steps in the works, including possibly requiring device makers to print the radiation dose on each X-ray or other image so patients and doctors can see how much was given.

The FDA also is pushing industry and doctors to set standard doses for common tests such as CT scans.

“We are considering requirements and guidelines for record-keeping of dose and other technical parameters of the imaging exam,” said Sean Boyd, chief of the FDA’s diagnostic devices branch.

A near-term goal: developing a “radiation medical record” to track dose from cradle to grave.

“One of the ways we could improve care is if we had a running sort of Geiger counter” that a doctor checked before ordering a test, said Dr. Prashant Kaul of Duke University.

He led an eye-opening study that found that U.S. heart attack patients get the radiation equivalent of 850 chest X-rays over the first few days they are in the hospital — much of it for repeat tests that may not have been needed.

How much radiation is risky?

It’s hard to say. The best guess is based on the 1986 Chernobyl nuclear power plant accident and studies of Japanese atomic bomb survivors who had excess cancer risk after exposures of 50 to 150 millisieverts (a measure of dose) of radiation.

A chest or abdominal CT scan involves 10 to 20 millisieverts, versus 0.01 to 0.1 for an ordinary chest X-ray, less than 1 for a mammogram, and as little as 0.005 for a dental X-ray. Natural radiation from the sun and soil accounts for about 2 millisieverts a year.

A big study last year estimated that 4 million Americans get more than 20 millisieverts a year from medical imaging. Two percent of people in the study had high exposure — 20 to 50 millisieverts.

Another study by Columbia University researchers, published in 2007, estimated that in a few decades, as many as 2 percent of all cancers in the U.S. might be due to radiation from CT scans given now. Since previous studies suggest that a third of all tests are unnecessary, 20 million adults and more than 1 million children are needlessly being put at risk, they concluded.

Just because a scan didn’t find anything wrong doesn’t mean a test wasn’t needed. Scans are useful for many diagnoses. But many studies suggest people are getting too much imaging now. For example, Mayo Clinic researchers reviewed the medical records of 251 people given heart scans in 2007 and found that only a quarter of them were clearly appropriate.

Reasons for overuse:

_Accuracy and ease of use. Scans have become a crutch for doctors afraid of using exams and judgment to make a diagnosis. Some think a picture tells more than it does. Imaging that shows arthritis in a knee or back problems doesn’t reveal how to make it better, said Dr. Richard Baron, a primary care doctor in Philadelphia.

“Physical therapy for an orthopedic injury is always the first choice,” yet doctors rush to order tests, he said. “The question you should be asking when you do sophisticated imaging is, ‘Is there something I can fix with an operation?’”

_Malpractice fear. A missed heart attack or a burst appendix could be devastating for a patient — and mean a lawsuit.

“I have great sympathy for the ER physicians because of the responsibility placed in their hands with strangers that come in off the street,” said Louis Wagner, chief physicist at the University of Texas in Houston. “They have to make a decision that could mean life or death for a patient, and the fastest way to find out is CT.”

_Patient pressure. People urge doctors to “do something” to figure out what’s wrong, and “often, doctors feel that the way to demonstrate that they’re doing something is to order tests,” said Dr. Christopher Cassady, a radiologist at Texas Childrens Hospital and the American Academy of Pediatrics‘ expert on this topic.

At his hospital, doctors first do an ultrasound on suspected appendicitis cases instead of rushing into a CT scan. Ultrasounds require no radiation.

_Health care chaos. One doctor may not know that another has ordered the same test. If a patient is referred to a specialist, “it’s often easier for him to order another study than to figure out how to get the one that was done somewhere else,” Baron said.

_Insurance issues. X-rays often are required by insurers to prove health, or for students to study abroad.

_Availability. Rural hospitals may not have an ultrasound technologist on duty in the wee hours, but imaging machines are always there.

_Treatment choice. A quick fix for chest pain — artery-opening angioplasty — requires far more imaging and radiation than bypass surgery does. The same is true of “virtual colonoscopy” instead of the standard version.

Which tests are overused? A scientific group, the International Commission on Radiological Protection, cites routine chest X-rays when people are admitted to a hospital or before surgery; imaging tests on car crash victims who don’t show signs of head or abdominal injuries; and low-back X-rays in older people with degenerative, but stable, spine conditions.

Even when tests are justified, they often include more views than needed and too much radiation. Top offender: chest CT scans looking for clogged arteries and heart problems. Cardiologists are increasingly aware of this risk and are seeking solutions.

At Columbia University, a study on dummies by Dr. Andrew Jeffrey Einstein found two dose-modifying techniques could lower the needed radiation dose by 90 percent without harming image quality.

Another cardiologist and radiation safety expert, Dr. Gilbert Raff, showed the same in real life. A study he led of nearly 5,000 patients at 15 imaging centers in Michigan found that radiation dose could be cut by two-thirds with no loss of quality.

What should patients do?

“You should question everything — what’s the dose, why am I getting it? You should be an informed consumer,” said Dr. Fred Mettler, radiology chief in the New Mexico Veterans Administration health care system. He led a study of health effects after the Chernobyl accident and is a U.S. representative to the United Nations on radiation safety.

He advised challenging “big ticket” tests like CT scans that deliver a lot of radiation to the chest and abdomen — places where cancer is likely to develop. “You shouldn’t get too excited about feet and knee X-rays,” Mettler said.

Questions to ask about radiation scans:

_Is it truly needed? How will it change my care?

_Have you or another doctor done this test on me before?

_Are there alternatives like ultrasound or MRI?

_How many scans will be done? Could one or two be enough?

_Will the dose be adjusted for my gender, age and size? Will lead shields be used to keep radiation away from places it can do harm?

_Do you have a financial stake in the machines that will be used?

_Can I have a copy of the image and information on the dose?

Mettler suggests bringing a blank CD or thumb drive with you.

“You should have all of your stuff digitally on something,” he said. “I keep mine on my laptop.”

Initially, the focus of this partnership program is to help doctors of the provincial government deliver surgical services to patients in different parts of Misamis Oriental more efficiently.

Under an agreement with the provincial government, SMART will provide Internet connectivity to five hospitals in Gingoog, Talisayan, Balingasag, Manticao and Initao.

That agreement was signed Wednesday (Jan. 13) by Misamis Oriental Governor Oscar Moreno and SMART Public Affairs Group Head Ramon Isberto.

Dubbed the mobile surgery services project, this also includes technical support and assistance, including ICT training for hospital staff and personnel who will be involved in the computerization of operations. Internet access will be provided free of charge for one year.

SMART will also supply eight 3G phones to doctors in the mobile surgery team. They will use the handsets to send data on and/or pictures of surgery patients in five provincial hospitals to an operations center in Cagayan de Oro City.

This information will help the mobile surgery team to screen patients and make the necessary preparations to ensure the efficient delivery of surgical services when they visit the different provincial hospitals.

Under its Province-wide Investment Plan for Health, Misamis Oriental has been rehabilitating the buildings and upgrading the facilities and medical personnel services of its seven provincial hospitals.

SMART’s tele-health program is part of its broad community partnership program called Kabalikat.

Under its tele-health program, SMART is also assisting the Physicians for Peace (PFP)-Philippines‘ “Walking Free Program” by providing a mobile phone-and-web application that enables volunteer doctors to assess the readiness of indigent amputees for artificial limbs even before they visit an area.

Called Amputee Screening via CEllphone NeTworking (ASCENT), the application enables PFP to provide real-time evaluation and advice on prosthesis (artificial limb) use for amputees in far-flung communities.

1. The most effective preventive measure is the avoidance of high-risk exposure (i.e. wading in floods and contaminated water, contact with animal body fluids).
2. If high risk exposure is unavoidable, appropriate protective measures include wearing boots, goggles, overalls, and rubber gloves.
3. Pre-exposure antibiotic prophylaxis is NOT ROUTINELY RECOMMENDED. However, in those individuals who intend to visit highly endemic areas AND get exposed, pre-exposure prophylaxis may be considered.

Pre-exposure prophylaxis regimen for non-pregnant, non-lactating adult: Doxycycline 2 capsules of 100 mg/ capsule once weekly, to begin 1 to 2 days before exposure and continuing through the period of exposure Currently, there is NO recommended pre-exposure prophylaxis that is safe for pregnant and lactating women.

B. Post-Exposure Measures

1. Antibiotic prophylaxis in the prevention of leptospirosis is NOT 100% effective.
2. Factors that may affect prophylactic effectiveness include the quality of the drug, timing of intake of the antibiotic, drug interaction, the presence or absence of skin wounds, and degree and extent of exposure.
3. Antibiotic prophylaxis of leptospirosis may be achieved by administration of doxycycline depending on the risk category of exposure.
1. LOW RISK is defined as those individuals with a single history of wading in flood or contaminated water but with absence of wounds, cuts or open lesions of the skin.

2. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule single dose within 24 to 72 hours of exposure. MODERATE RISK is defined as those individuals with a single history of wading in flood or contaminated water and the presence of wounds, cuts, or open lesions of the skin, OR accidental ingestion of contaminated water.

3. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once a day for 3-5 days to be started immediately within 24 to 72 hours of exposure. HIGH RISK is defined as those individuals with continuous exposure (i.e., those with more than a single exposure; those exposed for several days, e.g., residents in flooded areas, rescuers and relief workers). People who wade in flooded or contaminated water everyday – with or without wounds, cuts or open lesions of the skin; those who swim in flooded water and ingest contaminated water are also considered high risk.

Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once weekly until the end of exposure
4. The use of such prophylaxis REQUIRES PRIOR CONSULT WITH A PHYSICIAN. It should not be taken unless prescribed and fully explained by a physician, including common side-effects and contraindications.
5. SINCE ANTIBIOTIC PROPHYLAXIS IS NOT 100% EFFECTIVE, INDIVIDUALS SHOULD CONTINUE TO MONITOR THEMSELVES FOR FEVER AND OTHER FLU-LIKE SYMPTOMS.

C. Algorithm on the Risk Category and Prophylactic Regimen

ANNEX
Doxycycline8-10

Contraindications

* Do not use this medication if you are pregnant. It could cause harm to the unborn baby, including permanent discoloration of the teeth later in life.
* Do not take this medication without telling your doctor if you are breast-feeding a baby. Doxycycline passes into breast milk and may affect bone and tooth development in a nursing baby.
* Do not give doxycycline to a child younger than 8 years old. Doxycycline can cause permanent yellowing or graying of the teeth, and it can affect a child’s growth
* Do not use this medication if you are allergic to doxycycline, or to similar medicines such as demeclocycline, minocycline, or tetracycline.

Precautions

* Before taking doxycycline, tell your doctor if you have liver or kidney disease. You may not be able to take doxycycline, or you may need a dose adjustment or special tests during treatment
* Doxycycline can make birth control pills less effective. Use a second method of birth control while you are taking doxycycline to keep from getting pregnant.
* Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Doxycycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.
* Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline
* Store this medication at room temperature away from moisture and heat
* Throw away any unused doxycycline when it expires or when it is no longer needed. Do not take any doxycycline after the expiration date printed on the bottle. Expired doxycycline can cause a dangerous syndrome resulting in damage to the kidneys.

Drug Interactions

* Drug interactions: antacids; minerals such as iron, zinc, calcium, magnesium, and over-the-counter vitamin and mineral supplements cholesterol-lowering medications such as cholestyramine or colestipol; isotretinoin; tretinoin; product that contains bismuth subsalicylate; warfarin; penicillin antibiotic such as amoxicillin, penicillin, dicloxacillin, oxacillin (Bactocill), and others.

Adverse Reactions

* Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
* Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

Other alarming side effects:

* severe headache, dizziness, blurred vision; fever, chills, body aches, flu symptoms; severe blistering, peeling, and red skin rash; urinating less than usual or not at all; pale or yellowed skin, dark colored urine, fever, confusion or weakness; severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate; loss of appetite, jaundice (yellowing of the skin or eyes); or easy bruising or bleeding, unusual weakness.

Less serious side effects may include:

* swollen tongue, trouble swallowing; mild nausea, vomiting, diarrhea, or stomach upset; white patches or sores inside your mouth or on your lips; sores or swelling in your rectal or genital area; or vaginal itching or discharge.

How to Reduce Doxycycline Side Effects

* Ensure that your physician is aware of all medications and over-the-counter vitamin supplements or herbal remedies that you are taking. Antacids and certain vitamins and minerals are known to interfere with doxycycline absorption.
* Take doxycycline with food or following a meal. If you have taken doxycycline on an empty stomach before and gotten away with it, the next time may be different. Doxycycline induced nausea is quite unpleasant and more serious stomach irritation can occur.
* Don’t lie down for an hour following doxycycline intake to prevent one of the most formidable doxycycline side effects, esophageal damage. If reclined, the medication may dissolve in the esophagus instead of the stomach. If this doxycycline side effect occurs, a patient may gag on something as innocuous as sips of water. Treatment may take days for this condition to abate, depending on the extent of the irritation or damage.
* Avoid, if possible, taking doxycycline along with other medications that are known to bother the stomach. Space out the medications accordingly and add more food intake if needed. Pain medications and NSAIDs (e.g., ibuprofen) combined with doxycycline may cause significant stomach distress.
* Talk to your physician about the benefits of acid reducers, rather than antacids, as these may be helpful in reducing or eliminating some doxycycline side effects.
* Discuss any recommended treatments for yeast infection should these occur. Some patients find lactobacillus helpful in preventing yeast infections. This healthy bacteria is found in some foods, including yogurt and cheese. It is also available as a supplement in capsule form.
* Take doxycycline 100 mg capsule BID if 200 mg OD is not tolerated.

References

1. San Lazaro Hospital Guideline on Prophylaxis for Leptospirosis 2009
2. DOH- Health Emergency Management Staff Manual on Treatment Protocols of Common Communicable Diseases and other Ailments During Emergencies and Disasters
3. Mandell’s Principles and Practice of Infectious Diseases 2005 6th ed chapter 237:2789-2795
4. Mandell’s Principles and Practice of Infectious Diseases 2009 7th ed
5. New England Journal of Medicine Feb 23, 1984 Volume 310 (8):497-500
6. Int J Antimicrob Agents 2000 Feb; 13 (4): 249-55. Randomized controlled trial of doxycycline prophylaxis against leptospirosis in an endemic area
7. Revista do Instituto de Medicina Tropical de Sao Paulo 1998; 40: 59-61. Use of doxycycline for leptospirosis after high-risk exposure in Sao Paulo, Brazil
8. http://health.yahoo.com/infectiousdisease
medications/doxycycline/healthwised00037a1.html#d00037a1-drugs
9. http://www.drugs.com/pro/doxycycline.html.
10. http://www.ehow.com/how_2165217_avoid-doxycycline-side-effects.html?ref=fuel&utm_source=yahoo&utm_medium=ssp&utm_campaign=yssp_art

Task Force Committee
Marissa M. Alejandria, MD
Rhona G. Bergantin, MD
Manolito L. Chua, MD
Raul P. Destura, MD
Raquel Victoria M. Ecarma, MD
Ma. Cecilia S. Montalban, MD
Mario M. Panaligan, MD
Minette O. Rosario, MD
Paul Salandanan, MD
Rontgene M. Solante, MD
Maria Fe R. Tayzon, MD
Dionisio M. Tiu, MD
Catherine Yu, MD

Leptospirosis worm

The death toll from leptospirosis climbed to 93 after four more deaths were reported from Metro Manila hospitals during the weekend, the Department of Health (DoH) said on Saturday.

The number of cases also increased to 1, 336 from 1, 027 recorded last October 15, or an addition of 309 new cases in barely two days.

Dr. Yolly Oliveros, director of the National Center for Disease Prevention and Control (NCDPC), said the additional cases and deaths were received by the DoH-National Epidemiology Center (NEC) last October 16 from different state-run and private hospitals in the metropolis.

“The rapid increase in the number of casualties is inevitable considering the volume of water that typhoon Ondoy dumped on most parts of Metro Manila last September 26,” Oliveros said in an interview.

“If the NEC projection of (leptospirosis) attack rate of 10 to 25 percent is right, we can expect some 4, 000 people to be admitted for confinement, and more deaths in the coming days or weeks,’’ she stressed.

Earlier, the health department declared an outbreak of the flood-borne disease in barangays Tumana, Malanday, and Concepcion I in Marikina, as the city was one of those severely submerged in floodwater.

Aside from Marikina, the cities of Pasig and Taguig, and Rizal province also suffered severely from the onslaught of Ondoy.

Health Secretary Francisco Duque III earlier said that the outbreak was declared because Marikina has zero cases in 2008.

Since Friday, the DoH had given away free “doxycycline” antibiotic drugs in Marikina as a prophylactic or means of prevention to exposed individuals.

“Ang ibig sabihin ng prophylaxis, kahit walang sakit bibigyan pa rin natin sila ng antibiotics dahil nasa ‘’high risk’’ category sila. Lahat ng residente na nandon sa high risk areas ay bibigyan ng 200 miligrams of antibiotic once a week,’’ explained Oliveros.

Given the flood magnitude, she said, the DoH will likely spend about R50-million on prophylaxis alone.

“First time tayo (DoH) magbibigay ng prophylaxis on a wide range. We have asked the World Health Organization (WHO) if they did the same, pero wala daw,” she said.

She clarified, however, that giving of prophylaxis is part of the management of leptospirosis.

The health official urged the public to protect themselves against flood-borne diseases by wearing protective clothing such as “boots’’ and washing the exposed parts immediately when wading could not be avoided.

Frequent washing of hands with soap and water, she added are crucial in preventing others diseases.

Leptospirosis is spread through animal urine mixed with floodwater. Humans can easily acquire the disease if they have open wounds.

The DoH said an infected person may manifest symptoms two-weeks after wading in filthy water. Among the more common symptoms are cough, cold, and body malaise. If not diagnosed early enough, it could lead to meningitis, liver damage, or death. By SHIANEE MAMANGLU

This is a blatant lie that I and my colleagues in the profession cannot allow to perpetuate. It may be good for the mayor and the general public to know that most of those who resigned had immediately taken positions in community-oriented health care services. Some of us are in small-staffed clinics that cater services to the poor with their low-priced medicines and consultation fees. Some had gone back to their private practice, as they find more peace of mind in the confines of their small, comfy clinics than suffer hell in the politically charged work environment that is our city hospital.

Also, we are sad that ABS-CBN did nothing to verify the mayor’s statement. We physicians may have limited knowledge on what constitutes a balanced news report, but this we know: A dubious claim or declaration should not be left unchallenged so as not to leave doubts in the public’s mind. The ABS-CBN report merely parroted the mayor’s statement. In fact, the report sounded too slanted to favor the mayor’s assertion.

We also decry the suggestion that our erstwhile employment at JR Borja General Hospital was aimed at gathering experience for improved employment prospects in the future. We were there because we love our profession. Some of us stuck there for years despite delayed salaries and poor working conditions. Some of us even had to shell out supplies from our private clinics because the hospital miserably lacked almost everything that patients badly need.

To suggest that we were carving our stepping stones from the hospital is twice an insult for us. By saying that, isn’t the mayor admitting that the local government can’t pay decent salaries for its doctors to be so desperate as to employ the inexperienced ones? Is this not a tacit admission that the local government is making JR Borja General Hospital a training center for newcomers in the profession simply because it can’t afford to pay doctors who are well established in the medical community?

We are not leeches. We are humans who are dedicated to the job of saving people’s lives, whether in our private practice or in government service. Contrary to what is purveyed in the media by Mayor Jaraula, we are not the butterfly type who hops from one employment to another. Please stop stereotyping us in the medical profession as a bunch of greedy people itching to go out of the country and earn big. It may be prudent to check our backgrounds from the hospital management itself to establish our credentials.

Unfortunately, it is local officials like Mayor Jaraula who are driving us out of government service. There is too much politicking and corruption going on at the hospital. The hospital suffered greatly in the last administration; it is suffering more under the present one.

We commend The Gold Star Daily and other media entities for exposing the ills at the city-run hospital. We hope for your unrelenting reportage on the issue would usher in the change we’ve been hoping for.

On behalf of the resigned physicians we remain,

Dr. R.D. (Resigned Doctor)
(PS. Please understand that I and my colleagues have decided to remain in the shadows, as we are aware how vindictive our current officials are.)

www.youtube.com/watch?v=TIXQH9J6WbI

We strongly oppose R.A. 6675 s.33 of the “Cheaper Bill” which prohibits us Doctors from prescribing Brand names… OUR PATIENTS… OUR CONCERN!!!!