What’s a Patient Portal?
A portal just as is suggested by the Latin derivative, is basically a gateway or access into some space or situation.
Enter, the 21st Century! with yet another new technology: A Patient Portal. Alas! Patients can now enter and see aspects of their own health records and communicate with their doctors online! Technology and the sometimes friction laden-ride with the practice of medicine may have found a perfect fit. Medicine today as an art form has many antecedents from the past, from Hippocrates through the Renaissance and the post WWII era that still shape many aspects of patient care, health care delivery and research. These past influences while valid did not anticipate the sprawling codes of zeros and ones and mega mass of bits and bytes in supercomputers that drive our world daily today. Troubling ethical and potential legal issues loom over different forms of electronic communication with patients, and their protected health information safety beyond the scope of this post.
Dr. Edmund Pellegrino, captured the paradox when he correctly stated, “being ill is a special state of human existence. It moves the patient into a position of dependence, vulnerability and exploitability. We hold medical knowledge in trust, it is not proprietary, for all of us (as providers of health care) have entered a covenant, and the sick have a claim on that knowledge”.
The availability and rising popularity of patient portals is very much in keeping with the position taken by the renowned physician and bioethicist quoted above. We all at some point in time have to access healthcare services for different concerns and we have a claim on the knowledge vested in those who provide medical services to us. As Dr. Wymyslo explains in the attached video link: http://bcove.me/dgcma7cq Patient portals have their own potential pitfalls too despite the strengths and advantages. Electronic health records have a certain permanency about them and a huge amount of discretion and due caveats rest with the patients when asking certain questions through the portal. Once these responses are posted on the portal they become permanent portions of the health record with diverse implications for all concerned.
Our efforts to launch a patient portal at our practice have found traction this year and will go live in July 2013. We have huge expectations as the community we’ve been privileged to serve over the past year has shown to be very receptive to patient engagement, family centered care and empowerment and we anticipate this service will complement their overall health care needs.
Allergies are on the rise! No one has quite figured out all the answers at this point. There’s the “hygiene hypothesis”, which we spoke about previously and other areas of intense on-going research beyond the scope of this post today.
A parent wondered recently and asked if her 13-month old son could be having nasal allergies? My answer was, Yes. This surprised her and this is why. This parent realized and correctly so that you can only respond with allergy-type symptoms to something you’ve been exposed to and subsequently sensitized to. The baby at 13-months old has barely gone through his first allergy season and presumably his very first exposure to the annual tide of environmental allergens (trees, weeds, grasses) and really unlikely to be reacting now, let alone mount an allergic response barely after the first year of exposure.
This parent is factually correct. The development of allergy symptoms often has many factors and is seldom a singular reason. Features of seasonal allergic rhinitis usually do not occur until after the second year of life on the average. A number of exposure cycles are sometimes required before the cascade of body changes which eventually manifest as allergy peak. This 13-month old however was having nasal allergy type symptoms with sneezing, clear runny nose and frequent eye-rubbing not from seasonal “outdoor” allergens - but from perennial “indoor” allergens!
Perennial allergic rhinitis sufferers go through an accelerated cycle of exposure and subsequent sensitization easily due to the ubiquitous nature of the offending allergen in their immediate environment at home usually. The body’s allergy cascade could be sufficiently primed and put in effect within the first year of life. House dust mite, pet/ animal dander, mould, cockroach infested environments are common causes. Airway irritants like cigarette smoke are also harmful to the airway structures and can directly cause injury that may manifest with allergy type symptoms in the early stages.
My patient referenced above lives in an environment where cigarette smoke is present and a number of pet animals are also present in the home. These factors together present poor air quality around this child and have inevitably led to the evolution of allergic rhinitis at a young age. Cat dander is an especially powerful allergen and can be carried by unsuspecting pet cat owners into environments where cat allergy sufferers also hang out. Another patient on our service experienced a situation where sitting close enough to a cat owner at the movies was all it took to get her cat allergy symptoms up.
There is a direct relationship between allergic rhinitis and asthma symptoms. Both conditions tend to reinforce each other and early control with an “all-of-the-above” approach to controlling symptoms with medications and improving the quality of air in the home are often very helpful.Smoking cessation is an important component of the treatment plan. Smoking away outdoors as we often see is welcome. We realize in addition that the cigarette smoke irritants stay on the clothing, hair etc and can still be inhaled by the infant. Smoking cessation helplines are available nationwide and we encourage to avail themselves of the opportunity. I’ve heard of a case though where the family decided to get rid of the Pediatrician rather than the offending pet! - we hope that won’t be the case this time.
Potty Training: A synopsis for parents
In pediatric practices across the country, the delicate issue of potty training becomes a theme at preventive health visits typically around the 18th month visit. This period is fraught a good number of developmental changes and milestone acquisition in the toddler.
We frequently encounter children and parents for whom the transition to independent bowel and urinary sphincter control is more challenging than most, here’s a quick outline of steps to successful toilet training culled from the Zuckerman and Parker textbook of Developmental and Behavioral Pediatrics, 3rd ed. that will help.
· Buy a potty. Place it in a conspicuous location and colorfully emphasize its importance and purpose using the child’s (and yours) terms for urination and defecation. The whole activity should be fun themed to sustain the toddler’s motivation.
· Allow the child to familiarize and sit on the potty for about 5min a couple of times daily, typically after meals. This ideally should be about 30 min after a meal, to catch the reflex that propels contents of the colon down the intestines for evacuation. Loose fitting underpants (not diapers) are especially useful during these times. Do not force the child – remember!
· Move to have the child do the above without underpants on after the child is well acquainted with the potty. Proceed to move the potty from its conspicuous location closer to the bathroom gradually.
· Encourage the toddler to watch older kids and parents access the bathroom to reinforce the expected behavior. Involving the child in the process of flushing and participating in throwing the stool from the soiled diaper or potty into the toilet and waving ‘bye-bye” to the excreta is a great idea, as it reinforces the perception as to where the stool really belongs. Make it a fun activity to the extent possible.
· Ask child during daytime, “Do you want to go potty?” to help child familiarize with bodily and sphincter sensations. Observe closely for signs of impending urination or defecation and help in disrobing and sprint to the potty. Continually praise success and avoid criticizing failure
· Reinforce positive features of potty training to child (e.g., “just like a big boy.”)
· With the onset of a semi-consistent pattern of daytime control, involve the child in the process of giving up the diaper “like a big boy/girl” and make a show of disposing them in the garbage and wave the bye-bye to them.
· Once training with the potty is well advanced, try an over-the-toilet-seat chair
· Nighttime control happens a few months after daytime typically and remember to involve the child in the decision to try underpants at night.
There is no cookbook approach to this big developmental leap, and the above outline is a guide. Childhood temperament, social and cultural circumstances and pressure from day care centers affect the process of toilet training in many ways outside the scope of this post. The overwhelming caveats are to remember, this is not a contest. It has a number of false starts with ample successes and relapses. The toddler needs to be empowered to take responsibility for attaining the skill and the tendency to transmit a sense of disgust to the toddler should be resisted. The preferred approach to toilet training widely used in the USA is the “child-centered” approach described by Brazelton in 1962. There are cultures where potty training is attained at much earlier ages than expected in our society and we must be cautious in comparing standards since there are other factors not mentioned above that influence social and cultural norms and expectations.
The parents of, 4 year old Sally are concerned about the stuttering they observed a few months ago in their daughter. The stuttering hasn’t improved despite efforts to correct and help the child overcome the stutter whenever it arises.
Language and Speech problems in the pre-school age group have become one of the most common problems we face in primary care pediatrics. There is a garden variety of potential neuro-developmental problems that may manifest as different forms of speech or language disorders. This post is intended to address one of the common concerns we’ve encountered in our experience and we caution our readership about the gross simplification introduced here since these concerns are seldom simple. We will address, Sally’s stuttering in this post.
Stuttering, typically occurs as the young child begins to make the transition from two word utterances to more complex sentences. This usually happens between ages 2 and 5 years. It is estimated that ~ 5% of all children experience stuttering at some point in childhood lasting for more than 6 months. The condition is characterized by dysfluencies within words. The medical criteria for diagnosing stuttering as a speech disorder is met when a patient like Sally has dysfluencies like “W-w-w-what is this? Or “Wwwww what is this? Affecting more than three words in a 100 word sequence. These may be accompanied with signs of increased physical tension like increased blinking and facial tension or hand movements. A family history of stuttering in a first degree relative such as a parent or sibling is often found in many cases. At least ¾ of affected patients improve spontaneously without any medical intervention within the first 12 - 24 months of symptom onset. The temptation to interrupt and “help” these children complete the words they are struggling with mid-speech has been shown to increase time pressure on them that adversely contribute to the dysfluency and reinforce the negative responses to stuttering. Parents are advised to avoid this practice. Speech therapy and audiologic evaluation may be warranted in some cases. Boys tend to be affected by stuttering more often than girls and tend to have a more severe disease course.
Children with other forms of concern accompanying their stuttering like sharp audible intakes of breath before the dysfluency occurs or facial tension or body, head or extremity movements have a moderate risk of developing anxiety as a co-morbid condition and would benefit from specialist evaluation in addition.
Female patients who develop these symptoms, especially at ages less than 4years at onset have good prognosis and we are happy to report that, Sally required no form of medical intervention and improved within a year of symptom onset with complete resolution and normal speech fluency today.
For more information, visit: http://www.asha.org/default.htm
Diverse symptoms ranging from an infant “spitting up” to overt vomiting or diarrhea or colic are very common in newborn infants. Abdominal pain, flatulence and constipation tend to be more common in older children. All these symptoms often bear a timed relation to the ingestion of the suspected food item when parents notice them and the perception of a probable allergy or food intolerance is made as a result. The diagnosis of food allergy is beyond the scope of this article, however once the diagnosis is established, strict avoidance and elimination of the culprit food item becomes medically necessary. The Food Allergen Labeling and Consumer Protection Act of 2004 mandates food packaging companies to identify products containing milk, egg, soy, wheat, peanut, tree nut, fish and shellfish on the packaging label. This allows parents to make an informed choice to avoid known allergens and exclude these from the diet of their children.
Do allergies last a lifetime once established?
Food allergies as with other disease processes affecting the immune system can vary widely in their clinical courses over time. Most studies however posit that 70%-80% of patients outgrow milk and egg allergy, 60% to 70% outgrow soy and wheat allergy, and 10% to 20% outgrow peanut and tree nut allergy. Repeat assessment by your physician or allergy and Immunology specialist may be necessary with an updated patient history before conclusions about ‘outgrowing” a specific allergy can be made with certainty. These can be done yearly, but it is noteworthy even from above numbers that peanut, tree nut and fish along with shellfish are less amenable to “outgrowing” and repeat testing may need to be less frequent in these cases.
What do I do, if I’m accidentally exposed to a known food allergen?
The approach to care would depend on the appearance and severity of symptoms. Immediate reactions or those that occur within a few minutes or delayed reactions occurring many hours later are both common. They may be mild and benefit from comfort measures that often include anti-histamines. Anaphylaxis is a medical term used when severe allergic reactions involve multiple body systems after exposure to a known or unknown allergen. These reactions may affect, the skin, the gastrointestinal or respiratory systems commonly. Indeed any body system of tissues and organs can be involved in a severe allergic reaction like anaphylaxis. They are life-threatening emergencies. The epinephrine auto-injector comes in two strengths for different patients depending on their weight. These are administered via injection into the muscle through clothing in an emergency. Every child or adult with a known food allergy should carry one or have immediate access to one at all times. Observation in a medical facility after use of epinephrine is necessary and activation of the emergency medical service afterwards is recommended in our practice.
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