Overcoming Pain

Awakening to the Reality of Chronic Fatigue Syndrome

Dr. Mark Borigini — Wed, 18 Nov 2009 16:39:38 +0000

It has been twenty years since chronic fatigue syndrome was recognized by major medical organizations as a legitimate medical condition. Still, there are many in the medical profession who doubt its existence.

Thus, the Centers for Disease Control (CDC) is embarking on an effort to increase awareness among medical practitioners, so that they might know how to identify sufferers of chronic fatigue syndrome, allowing for more timely initiation of therapy. It is hoped that earlier intervention can play a crucial role in ameliorating-if not eliminating-the chronic exhaustion and pain that plagues patients.

This is no small task, as it is estimated that only 16% of the 1 million Americans who have chronic fatigue syndrome are diagnosed with chronic fatigue syndrome. It is therefore not surprising that diagnosing chronic fatigue syndrome can be a long and laborious process, as this is one of those "diagnoses of exclusion": that is, the physician must make sure there is no other cause for fatigue and pain. The other causes for fatigue and pain are certainly entities a patient would not want his or her doctor to miss: cancer, neurologic disease, thyroid disorders, depression, and so on. By the time these illnesses are ruled out or rule in, quite a bit of time may have passed, with visits to the lab, the radiology department, and other specialists. Patients must have patience.

So, what characterizes a patient with chronic fatigue syndrome? According to the International Chronic Fatigue Syndrome Study Group, a patient with chronic fatigue syndrome typically experiences unexplained fatigue for at least six months. This is fatigue not made better with rest. This is fatigue that results in a reduction in social interaction and employee productivity. At least four of the following must accompany the fatigue: sore throat, muscle pain, joint pain, headache, and difficulty with memory.

Unfortunately, there is no typical chronic fatigue syndrome patient. Patient complaints can vary from day to day, as symptoms wax and wane. Additionally, many chronic fatigue syndrome patients also suffer from fibromyalgia. And many Gulf War syndrome patients eventually develop chronic fatigue syndrome. Not surprisingly, such overlap issues cause many professionals to feel uncomfortable with chronic fatigue syndrome as a diagnosis in and of itself.

Treatment of chronic fatigue syndrome generally involves treating the symptoms of chronic fatigue syndrome, and nurturing coping behavior in the patients.

The CDC endorses aggressive attempts at maximizing sleep hygiene, through avoiding daytime naps, caffeine and large meals before bedtime. Exercise in moderation is helpful. Anti-depressants can help those patients who also suffer from depression. Anti-inflammatory medications are helpful in taking the edge off the pain. The psychostimulant Provigil can increase energy, but still allows patients to sleep at night.

Alternative remedies such as acupuncture and herbal supplements work for some, and psychological counseling can help with coping mechanisms. Always, working with the patient allows for wellness, improves the patient mood, and it is something we as doctors should know by now makes for better patient outlooks, and outcomes.

American College of Rheumatology (ACR) National Meeting, 2009: Update on Novel Rheumatoid Arthritis Treatments

Dr. Mark Borigini — Wed, 04 Nov 2009 16:38:38 +0000

Rheumatoid arthritis, with a worldwide prevalence of about 1%, remains a major cause of chronic pain and disability and depression. Ironically, (current) patients and their rheumatologists are fortunate this prevalence number is so high, as it gives incentive to pharmaceutical and biotech enterprises to continue to explore treatments. The recent ACR meeting in Philadelphia showcased some interesting research, and below is a peek at what is happening in the world of rheumatoid arthritis treatment.

The Janus Kinases (JAKs) is a family of enzymes discovered in 1988. Some of these enzymes located in cells can play a role in the control of biochemicals which are involved with diseases, including rheumatoid arthritis.

JAK inhibitors continue to draw much attention from investigators in the never-ending search for better drugs for a terrible disease. These oral drugs interfere with the events occurring on a cellular level which make daily life so miserable for rheumatoid arthritis patients. Thus far, the studies show that JAK inhibitors have the potency of the biologic agents such as Humira and Enbrel, but they are obviously more attractive in that they are oral-a plus for those of us who hate needles; in addition, oral drugs are generally significantly less expensive.

The JAK inhibitor named by the manufacturer (Pfizer) CP-690,550 has not been associated with the infections that can be seen with the injectable biologic agents, and there have thus far been no reports of malignancies/lymphomas with this drug. There have been reports of significant anemia, and increases in LDL-the so-called "bad" cholesterol. Large clinical studies should give us more of a sense as to where JAK inhibition will fit into the treatment plan for the rheumatoid arthritis patient.

Some other interesting drugs, a little farther up the pipeline:

1. GSK315234 is a monoclonal antibody which attacks human Oncostatin M (OSM). OSM is a member of the interleukin (IL)-6 family, and is present in the inflamed joints and blood of rheumatoid arthritis patients. OSM can be thought of as an agent which contributes to the severity of joint inflammation. The study presented at this year's ACR meeting had the goal of confirming the safety and tolerability in healthy people; and, indeed, it was well-tolerated. Now, we all must wait for the study of its effectiveness in rheumatoid arthritis patients. I think we should all be interested.

2. LX2931 is an oral drug which inhibits sphingosine-1-phosphate (S1P) lyase. This allows for more S1P, and reduces inflammation in mice and rats. The study of this drug just presented at the ACR meetinng showed its safety in humans already on methotrexate. Studies on the effectiveness of LX2931 in reducing the inflammation of rheumatoid arthritis will be coming soon.

3. ARG098 is a monoclonal antibody which targets molecules on the surface of certain cells involved in producing the inflammation seen in rheumatoid arthritis. In this case, ARG098 was injected into the knees of rheumatoid arthritis patients, resulting in overall improvement of pain of the knee. It appears safe, and resulted in less pain and swelling. It is a new concept, but may prove helpful as both an add-on drug, or even as a first-line drug.

I apologize for the numeric and alphabet soups I have splashed you all with today. I hope you were wearing your bibs. But the future is there, and so it is here, whether you think it is exciting or not. There were a number of other new compounds and molecules presented at the meeting, including a few thus far only tested in rats and mice. They all have the potential for success, failure, or a combination of the two. And so it remains important to keep the eyes on the prize, as it might be here sooner than you think.

GHB: Rave or Relief?

Dr. Mark Borigini — Fri, 30 Oct 2009 06:04:02 +0000

I guess, all things considered, Philadelphia was not a bad place to be last week.

Philadelphia hosted the American College of Rheumatology annual scientific meeting, and while there were certainly no earth-shattering revelations, there were still many thought-provoking discussions. The mission remains: To help those suffering from rheumatic illness.

Rheumatologists are still grappling with figuring out fibromyalgia: One research presentation discussed the development of a Fibromyalgia Responder Index, as it is important to determine which fibromyalgia symptoms and expressions of function drive how an individual patient determines whether or not there is improvement with treatment. Not surprisingly, the analysis of the data showed that modulating pain, fatigue, and sleep were associated most strongly with improvement in fibromyalgia.

Likewise, the cost of repairing the damage due to fibromyalgia continues to be a significant burden on society. Indirect costs due to unemployment or time away from work accounts for the largest proportion of these costs.

I was interested in particular in some of the data presented for the drug, sodium oxybate. Even more interesting is the fact that sodium oxybate is in fact GHB, a known drug of abuse which is currently indicated for the treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy:

1. A controlled clinical trial found substantial reductions in pain in over 40% of the study subjects compared to the control group. In addition, patients on sodium oxybate also experienced greater overall "global" senses of improvement.

2. A multicenter, randomized, placebo-controlled clinical trial of sodium oxybate again proved of interest, as pain was found to be significantly improved as early as one week into the treatment regimen, and pain relief was maintained over the duration of this 14 week study. Fatigue was similarly improved. And patient global sense of improvement started at week 4, persisting throughout the study. Patients also showed significant improvements in sleep-related daytime functioning compared with placebo; sleep disturbance itself was greatly reduced by week 4, and the improvement continued throughout the study. Positive correlations were found between reduction in pain and sleep disturbance, and pain and fatigue. Finally, a positive correlation was also found in patients' assessment of sleep disturbance and fatigue with the global impression of improvement.

It is hoped that the findings at this year's meetings will germinate into available treatments for those patients suffering from the persistent and refractory symptoms of pain, fatigue, sleepiness which so well characterize the fibromyalgia patient. Let us hope that new treatments will continue to lessen the burden of fibromyalgia, for both patient and society.

The Impact of Immunosuppressive Drugs On The Risk For Swine Flu (H1N1 Virus)

Dr. Mark Borigini — Sat, 10 Oct 2009 02:02:51 +0000

Many medications prescribed for rheumatoid arthritis can weaken the immune system, including prednisone, methotrexate, and of course the biologic agents such as Humira,
Enbrel and Remicade, to name but a few. The use of these medications can make a patient more susceptible to so-called swine flu (H1N1 virus), and the regular seasonal influenza. And if a patient on an immunosuppressive drug does contract such a viral illness, there is a much higher risk of developing more severe-and thus more life-threatening-disease.

So, the key is to avoid contracting influenza or the H1N1 virus. This can be best achieved through frequent hand washing, having those around you covering their mouths when they cough or sneeze, and avoiding individuals known to be ill, including family members or acquaintances in social gatherings. The H1N1 virus spreads mainly from person to person through coughing or sneezing by people with the virus. However, individuals can also be infected by touching objects contaminated with the virus, and then in turn touching the mouth or nose. Therefore, try also to get out of the habit of touching the mouth or nose.

A recent article in "The Lancet Infectious Diseases" examined how influenza affects immunosuppressed individuals with HIV/AIDS, cancer, transplant patients and patients on dialysis or steroids. Rheumatoid arthritis patients per se were not studied, but it is my opinion that the conclusions can be extrapolated to those rheumatoid arthritis patients taking immunosuppressive medications.

The article found that there is little research on using vaccination to prevent influenza in immunosuppressed people. Studies of HIV/AIDS patients show a lower antibody response to vaccination, but studies also show that vaccination results in lesser and less severe cases of flu in these patients. But larger studies are required to assess the utility of vaccination.

Transplant patients have higher flu infection rates due to the immunosuppressant drugs that are taken to prevent rejection of the transplanted organ. Cancer patients on chemotherapy also experience significant immunosuppression, the data showing that up to 33% of these patients contract flu. Patients taking corticosteroids such as prednisone appear to have a positive response to flu vaccination.

The authors of this paper conclude that most immunosuppressed populations have a greater risk of influenza-associated complications. These patients may have an impaired antibody response to vaccination, thus rendering the vaccine less protective: One study found that patients on cancer chemotherapy had a poor antibody response to vaccination, whereas dialysis patients and transplant patients achieved fairly good antibody responses when vaccinated.

While most immunosuppressed patients can be safely vaccinated, it is not known whether all will develop significant immunity to ward off swine flu or traditional influenza. Rheumatoid arthritis patients in particular have not been well-studied.

Some patients have asked whether the H1N1 vaccination itself poses a danger to immunosuppressed patients. Thus far this does not appear to be the case.

Interestingly, scientists have been exploring the possibility that drugs that affect the immune system in rheumatoid arthritis might one day be used to fight both traditional seasonal flu, and the H1N1 swine flu. A group of lab mice were treated with the biologic drug Orencia after being given a lethal dose of the traditional seasonal influenza A virus. Researchers found that 80% of the treated mice lived, compared to 50% of those not treated, according to the data presented in the June 1 issue of "The Journal of Immunology". Researchers also injected mice with T-cells that had been programmed to react to an H1N1 strain of influenza A virus: Those mice given Orencia cleared the virus more quickly, were less ill, and recovered more rapidly

It appears that Orencia enabled infection-fighting T cells to fight off the infection. This is an exciting finding, as drugs such as Orencia would have the advantage of being effective against different strains of the flu virus, as the immune system is being targeted, not the virus. On the other hand, an annual vaccine is only effective against certain viral strains.

Obviously, humans are not mice, and more work would have to be done to ensure safety in humans infected with influenza. In the meantime, I think we all have to assume that many of the drugs used to treat rheumatoid arthritis can weaken the immune system in humans, resulting in more susceptibility to both seasonal influenza and H1N1, and the potential for more severe disease due to the weakened state of the immune system.

FDA Announcing More Painkiller Warnings

Dr. Mark Borigini — Fri, 04 Sep 2009 19:22:23 +0000

Hot on the heels of the media blitz surrounding acetaminophen toxicity due to perceived excessive Vicodin, Percocet and Tylenol use, the United States Food and Drug Administration (FDA) is now turning the spotlight on those pain medications containing propoxyphene (Darvon) and opioid.

The FDA is now requiring manufacturers of propoxyphene-containing products to enhance the label, emphasizing the potential for overdose with these medications. In addition, manufacturers of these pain-relieving drugs will be required to provide a medication guide to patients, containing information regarding the importance of using the drugs appropriately. Such precautions were initiated due to fatal overdoses associated with propoxyphene use.

If propoxyphene manufacturers do not submit the required literature, or if the FDA disagrees with the patient information the pharmaceutical companies propose, then the FDA has the right to issue orders dictating the labeling changes so that there is compliance with the dissemination of the new safety information.

In the midst of all these new requirements due to concerns surrounding pain-relieving medication abuse, the FDA has approved Onsolis, a medication most likely to be used by cancer patients to manage breakthrough pain.

Onsolis delivers the opioid fentanyl through the mucous membrane of the mouth via an absorbable film that attaches itself to the inside of the cheek. As fentanyl is a potential drug of abuse, Onsolis was approved with a concomitant plan for managing the potential abuse risk. Onsolis is thus approved for the management of breakthrough pain in patients suffering from cancer, who are currently using regular dosages of opioid pain medications and who require---and are tolerant of-high dosages of an additional opioid medicine. These are so-called opioid tolerant patients.

For those patients who are not opioid tolerant, the use of Onsolis can lead to overdose, respiratory failure, and death. Hence, Onsolis will only be available through a highly restrictive distribution program. This program is designed so that only prescribers, patients and pharmacies registered with the program will be able to prescribe, dispense, and obtain Onsolis. Participating pharmacies will send the product directly to the home of the patient.

It will be interesting to see whether one day, most, if not all, drugs with the potential for abuse will be so heavily regulated. Considering the well-publicized concerns recently being voiced by the FDA and other agencies and societies regarding the abuse of many pain-relieving drugs, that day may not be too far in the future.

Impact of Depression In The Spouses Of Chronic Arthritis Patients: Disability Versus Divorce?

Dr. Mark Borigini — Sat, 29 Aug 2009 02:09:16 +0000

In the latest issue of "Arthritis Care and Research", there is finally a longitudinal study demonstrating an association between spouse depressive symptoms and disability and disease course in individuals with rheumatoid arthritis.

Of course, past studies have shown a correlation between the moods of partners in the face of chronic illness; and therefore it would not be unreasonable to assume that such findings are representative of a contagion of sorts: A partner's negative distress and demoralization impacts the other's mood. However, this study is different in that the study design was able to dismiss initial similarity between partners' moods, as it is most likely that these couples became romantically involved before the onset of significant rheumatoid arthritis disease activity and disability-which of course would affect the mood of the ill partner.

Unfortunately, this latest study defers to the future the explanation of any underlying behavioral mechanisms which may exist; instead, the focus is on care giving and support processes in a relationship. We all may-or certainly should-assume that intimate couples are interdependent when it comes to social and physical roles played out in both the relationship and society. Tensions occur in relationships when the restrictions caused by rheumatoid arthritis, for example, impact the emotional and physical duties of the well partner. In addition, the existence of a chronic illness with its associated pain and disability can cause deterioration in the quality of spousal social support; perceived hostility by the partner affected by rheumatoid arthritis can in turn impact that individual's social and emotional functionality, and also impact physical manifestations of an inflammatory illness. Other researchers have found a demonstrable negative effect on disease activity in the face of marital hostility, with increased inflammation and deleterious effects on immune function. It would be very nice indeed to see complete measurements of stress hormones and markers of immunity, to correlate with the partners' behavioral displays.

Counseling for couples will in many cases be as important as the drugs prescribed to the individuals suffering from rheumatoid arthritis. When spouses are depressed, they may be less likely to provide the necessary quality support needed by the partner with rheumatoid arthritis. It has been found that spousal support given to the partner with rheumatoid arthritis enhances coping mechanisms, and therefore reduces pain; support also reduces catastrophizing---which can become an irritant to those sharing the environment with chronic pain patients. Spousal depression, and the criticism and hostility depression often engenders, can result in a rheumatoid arthritis patient having maladaptive coping behaviors, and therefore poor psychological adjustment, not to mention more pain.

Perhaps we rheumatologists should have long ago stopped treating only the patient with rheumatoid arthritis. Instead, we should be treating the couples. It is not enough to feel we are enlightened enough to care about the psychological well-being of our patients: We must consider also the psyche of the spouse.

When Chronic Pain Confronts Remission In Rheumatoid Arthritis

Dr. Mark Borigini — Sat, 22 Aug 2009 02:48:05 +0000

To arrive at the definition of remission, perhaps it is best to discuss how the field of Rheumatology has managed to get to the point of even talking about remission. Those of us who remember those days when the only treatment for rheumatoid arthritis was aspirin and hot paraffin treatment, also remember that to speak of remission was considered by many an audacious act.

However, in the past twenty years a couple of breakthroughs allowed for improvement in the treatment of rheumatoid arthritis:
1. The development of measures of response for rheumatoid arthritis, accepted by regulatory agencies such as the United States Food and Drug Administration (FDA) and pharmaceutical companies, and therefore allowing for drug studies which if positive can lead to the approval of new medications for the treatment of rheumatoid arthritis. The tool to measure rheumatoid arthritis had been discovered.
2. Advances in the biotechnology field, leading to "biologic" treatments for rheumatoid arthritis, such as Humira, Enbrel, and Remicade; these drugs are some of the most effective therapies developed for rheumatoid arthritis.

In other words, remission suddenly became not audacious, but a reality.

One of the first well-done studies to show remission was the trial of Enbrel and methotrexate in combination for the treatment of rheumatoid arthritis. After one year, remission was achieved in 37% of the patients treated with both methotrexate and Enbrel, compared to 14% of the patients on methotrexate only.

So, how to define remission? Is part of remission a reduction in the sed rate? Does remission occur over a period time before it is called remission? Is remission truly remission if a patient is still taking medication? Even if the goal of remission is a comfortable patient, that patient can still be experiencing continued inflammation as seen on MRI, which can lead eventually to structural damage and deformities. So, remission should include radiologic evidence of quiet disease.

A recent study showed that sustained remission is associated with a halt of joint damage, no matter the type of therapy. The shorter the period of remission, the more likely at least some mild progression may be found. Thus, sustained remission is the ultimate goal to prevent the occurrence of joint destruction-and therefore disability-in rheumatoid arthritis.

Currently, the American College of Rheumatology preliminary criteria for remission in rheumatoid arthritis does not consider radiologic findings, but does include:
A minimum of 5 of the following for at least 2 consecutive months:
1. Morning stiffness not to exceed 15 minutes.
2. No fatigue.
3. No joint pain.
4. No joint tenderness or pain on motion.
5. No soft tissue swelling in joints or tendon sheaths.
6. ESR (sed rate) less than 30 mm/hour in women or 20 mm/hour in men.

Currently, the American College of Rheumatology and the European League Against Rheumatism are collaborating on defining remission in rheumatoid arthritis. This new definition should be strict, and based on no or very low disease activity, and validated against long-term outcomes, including physical function and x-ray changes. Treatment should not be part of the remission definition. This collaborating group of experts feel that there should be perhaps two definitions of remission, one defining remission for patients enrolled in clinical drug studies, and the other for the patients seen in the rheumatologist's office.

The definition of remission, alas, remains a moving target. We rheumatologists see it, but we can't quite nail it. Every time we think the answer is at hand, new information makes us realize we should not be so confident that all is well with our patients' joints.

While patients and doctors wait for the experts to come down from the mountaintop with all the answers, treatment should aspire to the idea of remission, looking toward the absence of joint pain and swelling, the absence of morning stiffness, and the elimination of fatigue. In other words, the absence of the complaints that brings rheumatoid arthritis patients to their doctors in the first place.

What Wedding Vows?

Dr. Mark Borigini — Fri, 14 Aug 2009 23:52:20 +0000

Unfortunately, more than a few of us will have to face the "sickness" part of those iconic words, "in sickness and in health". This confrontation with reality can take place in a moment of self-reflection, or it can occur when we must change the soiled diapers of a spouse.

Are we all prepared to face chronic pain in a marriage? Are we all able to tolerate the chronic pain a partner suffers? Chronic pain is a stressor which can potentially have the greatest chronic impact on a relationship, notwithstanding the heretofore major "major stressors" as listed in the famous Holmes-Rahe Social Readjustment scale from 1960. This is not surprising, considering the amount of time and the emotional investment partners contribute to a relationship. And one must not ignore the loss of the economic contribution which might result when a spouse's chronic pain impacts employment.

Relationships can deteriorate rapidly when illness strikes, as roles accepted and expected at the beginning of marriage may be forced to change. This is a prime example of the importance of the approach of maintaining functionality in the face of pain; despite pain, hopefully roles and duties will not be radically changed, and thus lessen the burdens on a relationship.

Returning to the Holmes-Rahe scale, one can extrapolate that many of the stressors listed therein can result from chronic pain: Chronic pain can result in frustrations or pharmacologic addictions, which in turn can result in domestic violence, or traffic violations, or worse; these consequences can lead to more stress in the relationship, not to mention life.

The effect of chronic pain on sexual intimacy is perhaps the most devastating to a relationship. Some published data has shown that up to 75 percent of couples living with chronic pain have little or no sexual contact. The partner suffering pain may fear more pain, or the "well" partner may avoid intimacy because of the fear of causing pain. And the well partner, who might already be burdened with more duties because a partner is impacted by chronic pain, could grow to look upon sex as another chore he or she is asked to perform. Of course, the baggage (depression, anger, anxiety, guilt, to name a few) which often accompanies the sufferer of chronic pain in a relationship is capable of damaging a relationship in a variety of ways.

Perhaps the wedding chapels in Vegas should add another line to the vows which echo ad infinitum between the canyons of neon: "Being able-bodied is a temporary condition".

Big Pharma Feels Your Pain, But You Are Responsible For The Co-pay

Dr. Mark Borigini — Sat, 08 Aug 2009 02:25:58 +0000

Two large pharmaceutical companies have spent hundreds of millions of dollars over the last year or so, all in the attempt to raise awareness among physicians and patients of the existence of a chronic pain syndrome, known as fibromyalgia.

Not surprisingly, this education of the sufferers and the soothers has resulted in increased sales of medications approved for the treatment of fibromyalgia, not to mention an impressive revenue stream for shareholders.

In the first three quarters of 2008, the giant pharmaceutical concerns, Eli Lilly and Pfizer, donated more than $6 million in the first three quarters of 2008 to individuals and groups for medical conferences and educational sessions, all dealing with fibromyalgia. Interestingly, money spent by Lilly and Pfizer in this manner for fibromyalgia ranked behind only cancer, AIDS and depression. And this has upset some, as fibromyalgia is not so much a disease in the minds of many health care workers, as a syndrome marked by unexplained pain and fatigue: The cause is really not known, and there are no objective lab tests or imaging modalities which are able to assist in the establishment of a diagnosis.

I do believe that fibromyalgia patients are in pain, but somehow this "pushing" of the diagnosis of fibromyalgia may be dangerously influencing physicians and patients: Studies have shown that lack of sleep due to stress or depression can cause chronic pain very much like fibromyalgia. Do these new pills for fibromyalgia, approved by the FDA and broadcast via network advertising into our homes, lull us into not doing the hard work involved in discovering the at times hidden reasons for the development of chronic pain and fatigue. Somehow, telling a patient to shut up and just take a pill just does not provide the needed treatment and evaluation we all deserve.

That being said, the sales tell the only story that matters to many an accountant in many an industry: Between the first quarter of 2007 and the fourth quarter of 2008 sales rose from $395 million to $702 million for the Pfizer drug, Lyrica; and sales rose from $442 million to $721 million for Lilly's Cymbalta.

Of course, advertising dollars-not just educational enlightenment-have contributed mightily to the bottom line: Lilly spent over $128 million in the first three quarters of 2008 on advertising promoting Cymbalta; Pfizer spent over $125 million getting the word out on Lyrica.

Promoting a treatment is one thing. What bothers some is that simultaneously our friends in the pharmaceutical industry might be promoting a diagnosis.

A Little Protocol, Please

Dr. Mark Borigini — Tue, 04 Aug 2009 22:50:16 +0000

It would be wise to make sure your health care provider is not only keeping things real, but keeping things clean, also.

The Centers for Disease Control (CDC) has been keeping tabs on 26 health care workers infected with the H1N1 virus (heretofore known as the latest version of the "swine flu"), and it has been found that none of these 26 individuals was following CDC's recommended infection control practices.

The most important thing is identifying infectious patients as soon as possible, and thus avoiding the continued spread of infection, through isolation of the suspected infected one, or at least the strategic placement of a mask.

The CDC found that 50% of the 26 cases contracted the virus in the health care setting: Twelve cases occurred as the result of transmission from patients to health care providers, while one case was the result of transmission from one health care provider to another.

The CDC found concerning the fact that health care providers did not always use gloves, gowns, and a mask or N95 respirator. Only three said they always wore a mask or N95 respirator, five said they consistently wore gloves, and none admitted to using eye protection.

The CDC recommends that health care professionals remain home when ill; wash hands frequently, and use protective gear such as surgical masks, N95 respirators, gloves, surgical gowns, and eye protection.

At this point in time, the CDC data indicate that health care providers do not make up a large part of the reported cases of H1N1. But if this outbreak continues, health care providers must adhere to infection control recommendations, identify quickly potentially infectious patients, provide infection control equipment, and train staff in infection control practices.

We must all be vigilant, particularly as a new flu season is not far off. And we have to have trust in those in whom we entrust our health. Transmission of the H1N1 virus in this country is expected to continue throughout the summer, and likely increase in the fall.

A culture of wellness should welcome patients when they visit the offices of their health care providers. This culture grows from an awareness of self-health and disease prevention, which anticipates illness, and likewise expects the prevention of the same through sound medical practice and the adherence to scientific and professional guidelines.