Second opinion: Read the Rx label!

I recently was stopped by a couple riding their bicycles in my neighborhood. My reputation as a veterinarian who gives advice hit a fever pitch in my community during the pandemic.

Mr. and Mrs. Snowbird just came back from their home in upstate New York. They, like so many people, adopted a pet during the pandemic and drove their new dog Rascal, a one-year-old Corgi, down last weekend.

Prior to traveling to Florida, they brought Rascal to their veterinarian because they thought he had allergies. Rascal was shaking his head a lot and vocalized when you touched his ear.

The question that they had for me referenced back to their other dog, Ruby, a 14-year-old Schnauzer who had terrible allergies. She constantly licked her paws, scratched all the time, and rubbed her face. I recommended that they talk to their local veterinarian about Apoquel or Cytopoint allergy treatments.

The schnauzer was a happy dog after starting the medication. They were hopeful that Rascal didn’t have allergies because the medication was expensive, but Rascal seemed very uncomfortable.

I asked them about the working diagnosis. They told me that their New York veterinarian thought that Rascal had an ear infection. Two weeks ago, Rascal’s ears were red, inflamed, and painful. The veterinarian took a sample from the ear to look under the microscope and sent it out for culture.

The doctor started Rascal on an ear cleaner and pain medication and told the couple they would start treatment once the culture results came back.

The couple told me the technician at the hospital called and told them that Rascal had a bacterial ear infection and the vet wanted to start him on antibiotics. They also told them to clean his ears once a day and to continue him on the pain medications if he was still uncomfortable.

After two weeks of medication, ear cleaning, and pain medications I told them that Rascal should be feeling and looking better. They said he wasn’t and wanted to know if I could look.

As we walked to their house, Mr. Snowbird said that Rascal is not clinically better. He doesn’t seem to be in as much pain, but the veterinarian said that he would only need the medication for a few days, and he is still on them.

Rascal also hates it when Mr. Snowbird puts the medication in his ear. He mentioned that it seemed kind of cruel to put cold ear medication in an ear but what does he know. I was puzzled because I don’t know any ear medication that needs to be refrigerated, but maybe the medication was compounded specifically for Rascal.

Rascal is a sweet Corgi. He jumped up on me when I entered the house and, true to form, he smelled sour. When I investigated his ear, it was inflamed and sensitive and full of white material.

I was hoping it wasn’t pus. Mrs. Snowbird brought me the medication and it was Clavamox, an amoxicillin product that was meant to be refrigerated and given orally. I asked them if they are giving the medication orally or putting it into the ear.

I have never seen such finger pointing towards each other. Obviously, someone didn’t read the label. Mrs. Snowbird laughed and told me at least I had a funny story to tell people. Little did they know that I write articles.

Broward Health Coral Springs offers elite cardiac services

For many years Broward Health Coral Springs (BHCS) provided cardiac care services to the community, but one key component was missing—a cardiac catheterization lab for emergency catheterizations. Subsequently, patients were transported to other facilities, but that’s no longer the case.

Last June, a new state-of-the-art cath lab became operational at BHCS. “We now have the ability to care for specifi c patients with ST Elevation Myocardial Infarctions (STEMI),” said Mohamed Osman, M.D., director of the Cardiac Catheterization Laboratory and specialist in Interventional Cardiology at BHCS. “This is a unique opportunity to provide an even higher level of care through angioplasty procedures.”

Designated as a Level 1 Heart Program by the Agency for Healthcare Administration, the new cath lab was termed a “milestone” by hospital CEO Jared Smith, one that “increases our ability to provide a high level of care and uphold our recognition (per Our City Magazine) as the area’s best hospital and Emergency Department.”

Gary Lai, D.O., and chief of Emergency Medicine says the addition of the STEMI heart program makes it possible for EMS to pre-alert the ER and send electrocardiograms prior to a patient’s arrival. “We can prepare immediately to stabilize, medicate, and expedite patients to the in-house cath lab,” he said. “This saves lives and maximizes outcomes.”

The new catheterization lab allows BHCS specialists to perform invasive cardiac procedures and utilize advanced imaging for diagnoses by using contrast dye to determine the severity of the arterial blockage. Once identified, a balloon angioplasty is performed, or a stent is inserted to clear the artery and save as much of the heart muscle as possible. Pacemakers and defibrillator implant procedures are also performed.

Generally speaking, the last 20 years has seen a rapid transformation of new techniques focusing on minimally invasive procedures, rapid care, and shorter hospital stays, according to Dr. Osman. “Although open heart surgery is certainly an option, the major shift has been toward less invasive, less traumatic procedures that obtain excellent results.” People with severe heart valve problems always required open heart surgery. A significant number are now treated with stents to reduce the risk of a major heart event.

Surgical progress in cardiology can be defi ned by an alphabet soup of acronyms: SAVR (Surgical Aortic Valve Replacement); CABG (Coronary Artery Bypass Graft); BAG (Bilateral Arterial Grafting); PCI (Percutaneous Coronary Intervention); TAVR (Transcatheter Aortic Valve Replacement); EVAR (Endovascular Abdominal Aneurysm Repair): and ICD (Implantable Cardioverter Defi brillator). The term Electrophysiology refers to leadless pacemakers and remote monitoring devices. “Because of these techniques, patients spend less time in the hospital, recover faster, and there’s less trauma to the body,” said Dr. Osman. “An aortic valve replacement once required open heart surgery, but now the TAVR procedure accomplishes the same goal by inserting a transcatheter through a small incision in the groin.”

Surgical complications 

Any medical procedure has the potential for complications such as excessive bleeding, stroke, and even death, but the key is how often complications occur as a result of surgery. “Both minor and major complications are possible, but keep in mind that no patient is the same,” said Dr. Osman. “If a younger patient requires open heart surgery the only problem is the heart and nothing else, so the focus is isolated, but older patients—especially those with underlying conditions such as diabetes, kidney problems, or a previous stroke, are in a high- risk category for complications,” the specialist said.

To show that one size doesn’t fit all, Dr. Osman uses the example of two patients with the same high percentage of blockage that would be treated differently. “The one who is asymptomatic can be treated with medications and dietary changes, while the other who has difficulty breathing and may have underlying medical conditions is a prime candidate for a stent.” He reminds us that everyone is different, and each patient requires a different mode of treatment depending on general health and underlying conditions. “The key is a full evaluation to create a treatment plan with the best benefit.”

Dr. Osman refers to the doctor-patient relationship as “the art of medicine.” The unique relationship includes listening, evaluating, diagnosing, and treating. “At the end of the day when pieces of the ‘puzzle’ come together it’s the collaboration between the surgeon and interventional cardiologist that makes it happen,” he said. He recently saw a patient with a 90-percent blockage of the artery. CABG open heart surgery was performed, and the person is expected to make a full recovery. Choosing the right therapy is the goal.

The COVID consequence

When COVID’s first wave peaked in March 2020, it impacted cardiology services.

With a focus on caring for acute COVID patients, the shift was away from elective cardiac procedures. “Many patients feared coming to the hospital out of fear of COVID and that posed a huge problem,” said Dr. Osman. “In cardiology, time is a big factor and the longer treatment is delayed the worse a condition can become.” He cited a patient who suffered a heart attack yet remained at home for two days. They were able to save his life, but the heart muscle was significantly damaged and he’s now living with a very weak heart muscle. “Things like this are still happening but not to such a high degree. Remember that the margin of error is much less with age,” he said.

The medical facility keeps a log on how long it takes after arrival in the ER to when a clogged artery is opened in the cath lab. According to Dr. Osman the best time to date has been 23 minutes.

Ask Dr. Renae: Making virtual friends

Dear Dr. Renae,

I had been looking forward to beginning high school since the beginning of middle school so I could join clubs and try out for sports teams to make friends. I had to separate from my middle school friends since they were not into academics, but getting into trouble and getting high all the time. I have been waiting so long to make new friends and now it seems so difficult remotely. I am shy and do not feel confident with the way I look, especially
online. How can I make friends virtually when it feels awkward to make the first step to reach out to someone?

Shy 9th Grader

Dear Shy 9th Grader,

A huge positive in meeting people remotely is that it gives you a chance to be more authentic and versatile. You can be yourself and broadcast that person. Realistically, there are many in the same space you’re in, looking for friends but not knowing where to start. It can be difficult having a rewarding experience if you aren’t gregarious. The wonderful thing about entering high school, especially in this time period, is that everything is so brand new. Perhaps start small. Make a post about the clubs you want to join or start. If you’re active on social media, see if there’s a “class” page. It usually conveys events that each class can partake in, remotely or in person. I imagine it would look rather different this year but exciting, nonetheless. The key to success is confidence. Sports is also a great bonding topic. I’m sure you’ll make friends in no time. Hope this helps.

Your Friend

Dear Shy 9th Grader,

I understand the difficulties and initial fear of making friends, for I have been in your position as well. The easiest way I was able to make friends is by finding a common interest. For example, if you like to play video games or are interested in a particular show or book, it is easy to find people on the internet who are interested in the same things as you. It may be daunting to make the first move, but easy conversation starters can include “Hi I saw you like (insert show/book/video game/etc.), who is your favorite character?” or “Hi I recently got into (insert show/book/video game/etc.) can you help me find more content from them?” An added bonus of the internet is anonymity, so if you feel uncomfortable you do not need to disclose personal information about yourself until you feel comfortable with the person. Of course, please be cautious on the internet by not exposing where you live or other personal information. Trusting your instincts, you can make great virtual friends. Try finding a club at school and talking with the club members about common interests and how to get involved with the club. I wish you good luck on your endeavors.

Your Fellow Teen

Dear Shy 9th Grader,

Making friends is difficult, however, the new obstacle of online learning should not discourage you. I would suggest looking into the clubs at your school and attending one of their virtual meetings. From there, you will find people who have attended the meetings and you can then begin to follow them on Instagram. If they’re new like you, you should have a nice starting off point on what you can talk about. Send them a direct message and say how you’re new to the school and how they seem like a nice person and you wanted to get to know them. If they’re a considerate person they will message you back and you’ll be on your way to a new friend! If they don’t message you back, just move on to someone else. It’s all about having enough confidence to get past the first steps. Good luck and I hope you find some great people!

High School Senior

Dear Shy 9th Grader,

I totally feel for you. I remember how excited I was to make new friends in high school and start fresh. The pandemic has caused such a big obstacle when it comes to human contact, but it’s not impossible to make new friends. In my high school, clubs are still meeting virtually which is a nice way you can connect with new people, especially if it’s a club you have a deep interest in. It really comes down to looking at the clubs that your school provides and picking one you really enjoy. It’s also important to keep in mind that all 9th graders are in the same boat as you are and the chances that they’re feeling the same way as you are pretty high. So, don’t psych yourself out too much about approaching people because they most likely also want to make new friends and don’t know how. Wishing you the best of luck.

A High School Senior

Dear Shy 9th Grader,

I want to commend you for having the strength and foresight to separate from your old Middle School friends before making new friends. That takes a lot of courage and confidence! In addition, looking forward to making new friends puts you in a positive place of hopefulness. Courage, confidence and hopefulness is a great formula to begin your journey of finding new friends. You already have the ability and insight to be selective of friends who share your values. Identifying friends who share your passions and interests will follow naturally as you explore clubs at school. Perspective new friends will appreciate you making the first contact as they too might feel shy. You will be part of the first wave of teens to make treasured new friends while social distancing, so you can consider yourself a pioneer.

Dr. Renae

TEENS: Curious as to what other teens would say? If you have a
question or problem you would like to present to other teens, please email: askdrrenae@att.net and include your age, grade, and gender you identify with. All questions are published anonymously and your identity and contact information will be kept confidential.

PARENTS OF TEENS: Would you like to anonymously and confidentially ask the panel of teen Peer Counseling Writers to comment on a parenting issue you are struggling with? If you are ready for a variety of honest opinions from real teens, please address your questions to askdrrenae@att.net.

Dr. Renae Lapin, a licensed marriage and family therapist with 40 years experience, currently maintains a private practice in Boca Raton, Florida. For more information about Dr. Renae and her practice, visit her website:
https://askdrrenae.com

Medicare plan change window opens October 15

Each year in late September, every Medicare recipient should receive an Annual Notice of Change (ANOC) in the mail, which summarizes their current Medicare Advantage or Part D drug plan changes that will go into effect on Jan. 1st of the following year. Medicare Open Enrollment (Oct. 15th through Dec. 7th) is the period in which you may make changes to your current Medicare plan or your Medicare Drug plan.

Recipients should take the following steps to see if their current plan is still appropriate:

  • Check your prescription drugs to make sure they are still covered. If not, you may need to change to a plan that will reduce the cost of your drugs.
  • Since contracts can change during the year, you will need to ensure your doctors and hospitals are still in the plan; if they are no longer in the plan, you will need to go out of your network to see your usual doctor and this will probably cost more money than you want to spend. If you are currently on an HMO Advantage plan, you might need to change plans so your primary care doctor remains covered.
  •  Medicare Open Enrollment is the time to join a Medicare drug plan because if you select a plan outside of this period, you may encounter a late enrollment penalty; if you wait for future years, coverage will probably be more expensive.

Have you checked the following plan changes to see if they benefit you?

  • Plans sometimes add value items, such as gym memberships, over the counter allowances, meal delivery, and acupuncture.
  • Drug plans also make changes to which pharmacies are included as well as changes to tier coverage, deductibles, co-pays, and sometimes they will no longer cover the cost of a specific drug. Not knowing this information can save or cost you a lot of money. Also, if you went into the coverage gap last year, you need to see if changing plans can help you save money.
  • Some plans are more useful for issues that might be important to you. Aetna, for example, has a generous hearing aid allowance compared to other plans, but co-pays may be higher. And if you have money coming out of your Social Security for Medicare payments, those could be waived depending on the amount you receive from Social Security.

The best way to make sure you’re getting the most out of Medicare is to visit a broker who is familiar with all the plans. There is no charge.

Reneé Gorden is an insurance broker and the founder of Health Choice America in Boca Raton.

By Reneé Gordon

With COVID-19 there are no ‘immaculate’ assumptions

If you feel confused by the ever-changing data and recommendations surrounding COVID-19, you are not alone. As a new virus emerges, doctors and scientists are learning new information almost daily. Hence, the need to modify recommendations as this information arises.

If I say one thing to help guide you through this process, it is that as long as the virus is around, you must take measures to mitigate the risk of getting and spreading it. Over the last few months, many of us have witnessed two extremes: Those who drive alone in their car while wearing gloves, a mask, and a face shield, and those who partake in large group gatherings with no social distancing nor PPE of any kind.

Regardless of whether you fall into one of these categories or somewhere in the middle, I think we can agree that we all want to do whatever we can to keep our loved ones out of harm’s way.

The question I get asked the most from family and friends is regarding what measures to take when visiting with others. Whether it is a party for Grandma’s 90th birthday or a relatively small family gathering at a lake house, everyone wants to know a definitive answer on doing the right thing in the age of COVID-19.

Although there are evidence-based answers, anyone watching one of the numerous news networks or various social media feeds knows the research is ever-changing. Even those of us who have been critically reviewing journal articles as part of our career are relatively confused as to what the perfect answer is. As I said, you are not alone!

All of that being said, I would like to offer what I think is a risk-mitigating, comfort level approach to keeping you and your loved ones as safe as possible during group gatherings and family visits. For this, we need to make a few assumptions:

Assumption 1: When someone says they tested negative, assume this means they still could be infected with the virus.

Yes, I know this one is confusing, but it is very important. PCR and Rapid tests of all kinds (including flu) have always been known to be unreliable – this is not unique to COVID-19. This means that you should always inquire about symptoms, such as fever, cough, loss of smell/taste, etc. (refer to the CDC website for a current symptom list; cdc.gov/ coronavirus/2019-ncov/ symptoms-testing/ symptoms.html). If a person tests negative and has any of the listed COVID-19 symptoms, you must assume they are infected, and the test didn’t pick it up.

Assumption 2: Asymptomatic patients can still transmit the virus.

If someone says, “I tested positive but didn’t have any symptoms, therefore, I am fine,” be cautious. Although it seems that asymptomatic patients have a lower likelihood
of transmitting the virus, the evidence is debatable and from a personal standpoint, I wouldn’t bank on a lower potential transmission rate equating near zero chance, especially when dealing with any of the vulnerable populations. Play it safe!

Assumption 3: Assume that anyone with a fever of 100.4°F or greater has COVID-19.

For those who are taking temperatures at their door, more power to you. Although it is surely an uncomfortable welcome at the front door, it is one of the few truly objective measures we can take, even if it won’t screen in every infected person. Understand though, a temperature of 99° Fahrenheit is not a true fever. I grew up thinking anything above a 98.6° meant you were hospital-bound. We all have very normal fluctuations in our core temperatures throughout the day, but a fever doesn’t truly start until 100.4° Fahrenheit.

Assumption 4: Assume everyone has COVID-19.

Clearly, this will be the most controversial assumption, but I believe a smart approach, especially when dealing with the elderly population and those with chronic illnesses, such as diabetes or lung disease. Assume everyone has COVID and take precautions based on that. Everyone may seem okay or say they are fine, but don’t stop practicing strict hand hygiene or whatever form of social distancing you usually partake in.

If you don’t personally believe this is as bad as the news is portraying, the simple effort of regular hand sanitizing/washing and wearing a face mask during group gatherings could have maximum outcomes if it means you could prevent the spread to a vulnerable person.

Should you worry so much about your healthy 3-year-old or 16-year-old getting very ill? Not nearly as much as the vulnerable populations, but you should worry about who they will potentially pass it on to. Thankfully, although children can indeed get ill, they seem to be the safest population when it comes to COVID-19 with mortality and morbidity rates seemingly lower than influenza, but this doesn’t mean that they are not vectors.

At the end of the day, we all want to keep our loved ones as safe as possible, but unless you live in a HEPA filter bubble, I don’t think there is a 100% perfect approach in this COVID world we live in; however, you can mitigate risk. Personal interactions are core to our sanity and mental health. If you understand the risks and take precautions to mitigate them when you can, you can certainly achieve these interactions while maintaining relative safety.

By Dr. Jahn Avarello

Dr. Avarello was the Division Chief of Pediatric Emergency Medicine for the Cohen Children’s Medical Center of NY for the past 9 years and is now the Florida Regional Medical Director for PM Pediatrics Urgent Care (1st site due to open in the Sawgrass Center this fall). He is currently seeing patients for acute care needs virtually at PMPanywhere.com.