Monthly Matters:

• Seasonal Allergies (Allergic Rhinitis)
• Transformation at GreenField Health - Tips For Success
• Family Matters - Well Child Checks
• Immunizations and Autism - Is there a link?
• Office Notes

GreenField Health’s Health Matters

April 2008

Seasonal Allergies (Allergic Rhinitis)

We are lucky to live in Oregon. The winter rains, summer sun, and rich soil make our environment lush. It is a paradise for gardeners and farmers. Flowers, flowering shrubs, grasses and trees love it. Filbert (hazelnut) trees and conifers generally start pollinating in February. We grow a lot of grass in Oregon (the lawn variety). Oregon produces more grass seed than any other state in the US. However, the lushness of our environment and the wonderful agriculture results in a very large amount of pollen (allergens) in the air each year, which can be a plague to those who suffer from allergies. The ubiquitous plants spread their pollen from March through July, peaking around Memorial Day. Fortunately, Oregon has almost no ragweed, the primary culprit of late summer hay fever in most of the country.

In the summer of 2006, the highest grass pollen level ever taken by a certified pollen-counting station in the United States was recorded in Coburg, Oregon. Any count over 200 pollen grains per cubic meter of air is considered "very high." The Coburg counts topped 1,000 in late May and mid-June. The readings were taken in a study that showed a big increase in allergy and asthma visits on days when grass pollen counts are high. The lower and mid-Willamette Valley are actually worse than Portland.

Thus, large numbers of Oregonians suffer from allergic rhinitis (seasonal allergies sometimes called hay fever). The sneezing, stuffy nose and itching eyes starts in March for some as the flowers and trees in the area start to bloom and can last through July.

For unknown reasons, people with allergies have immune systems that respond excessively to harmless pollen. When pollen contacts the lining of the nose and eyes in those with allergies, their white blood cells release various chemicals including histamine. In the nose and eyes, histamine causes the sensation of itchiness and makes the blood vessels dilate and get leaky. This results in the classic symptoms of seasonal allergies including sneezing, a clogged and runny nose, red eyes, and an itchy throat and eyes. In some people, the allergens can trigger asthma which is a hypersensitivity of the bronchial tree in the lungs.

There are several kinds of drugs to help people cope with seasonal allergies:

• Steroid Nasal Sprays: Nasal steroids in the form of a spray delivered directly into the nose are the mainstay of treatment for those who suffer significant nasal symptoms. The steroid reduces the immune reaction in the nose and therefore reduces the release of histamine. It takes five days or more for the sprays to build to their maximum effectiveness. For those who suffer regularly each year, a nasal steroid spray such as Flonase (the generic is fluticasone) should be started at the very beginning of allergy season and be continued daily until the season is over. Good studies demonstrate the safety of daily nasal steroid use over prolonged periods.

• Antihistamines: Unlike steroids which block the release of histamine, antihistamines work to block the impact of histamine once it is released. This is why antihistamines are frequently less effective than steroids. Antihistamines do work very quickly however and don't have to build up over time, so those with intermittent allergies can use them only on bad days. Older antihistamines such as Benadryl (diphenhydramine) make many people sleepy while newer, "non-drowsy" pills may minimize that effect. The non-drowsy antihistamines are loratadine (Claritin, Alavert, and others), fexofenadine (Allegra), and cetirizine (Zyrtec). Many of these are available over-the-counter without a prescription.

• Decongestants: These medications don’t interact with histamine or the allergic reaction at all, but they counteract some of the effects of histamine. A significant part of an allergic reaction is that blood vessels dilate and get leaky. That is what causes the nose to feel congested and to be runny as fluid leaks out of the blood vessels. Decongestants are analogs of adrenalin or epinephrine which causes the opposite effect – it causes the blood vessels to constrict (tighten up) and become less leaky, thus reducing the stuffy, runny nose symptoms. Common decongestants include pseudoephedrine (Sudafed and others) and phenylephrine (Sudafed PE and others) which are generally available over-the-counter in most states although pseudoephedrine containing medications now require a prescription in Oregon due to their association with the methamphetamine problem.

• Eye Drops: Various eye drops contain antihistamine and decongestants to help reduce the itching and redness that can accompany allergies. Some of these are available over-the-counter and some require a prescription. Zaditor is the strongest anti-histamine that is presently available over the counter in eye drop form. Because the direct application of steroids to the eye itself can cause long term complications such as glaucoma and cataracts, steroid eye drops are not used for seasonal allergies.

While a few other therapies are available, these are the mainstay for allergic rhinitis treatment.

Allergy shots are an additional option for those with severe allergies. After skin testing to identify the specific type of pollen causing the problem, weekly desensitize shots are given in order to reduce the body’s response to those allergens, and thus reduce their allergic symptoms.

Seasonal allergies can be a real nuisance, particularly in Oregon. If managed aggressively with the mediations above, most individuals are able to successfully control the symptoms.

Transformation at GreenField Health- Tips for Success

The Transformation program at GreenField Health is a lifestyle and weight management program. There have been scores of participants over the three years of its existence and their experience has led to the development of “The Seventeen Habits of Successful Weight- Appropriate People.” Each month in Health Matters, we have been sharing one of these habits with you and discussing its benefits.

The topic for this month is to encourage everyone to eat breakfast every day. Even if you are “not a breakfast eater,” it is important to break your fast in the morning, even with a small snack. Since we do not eat from bedtime until morning, we usually go at least 8 hours without eating. That is appropriate since we are sleeping and need only minimal calories to get to our brains, muscles and organs at night. However, if we add onto that fasting time an additional 4 to 6 hours without food (for those who don’t eat until noon or later), our body gets the message that we are starving. When we finally do eat, we utilize the calories we need for the moment and store all the excess, usually around our waist. If our bodies are zig-zagging from feast to famine on a daily basis, our metabolism will gradually slow more and more to prepare itself for the next famine. This is why some of us can gain weight even on a low calorie food plan.

What we eat matters, but what matters even more is how often we eat and how much we eat at any one time. As we discussed last month, eating small meals throughout the day stabilizes our metabolism and leads to a healthier weight and less fat around our middle. So, start early in the day and eat something healthy!

Family Matters - Well Child Checks

Many parents wonder why it is important to take their children in for a checkup when they are not sick. When they are babies, the reasons are clearer. They need immunizations. The parents are always curious to find out how much their baby has grown. As their children grow older and complete the immunization schedule, many parents feel that there is not as much need for a checkup. In this issue of Family Matters, we wanted to review all that goes into a “Well Child Check” and to show that a great deal of important information is exchanged in such a visit for a child or adolescent of any age.

Let’s get to the obvious parts first. The well child check is a chance for the health care team to observe your children and to take a look at them when they are not ill. How do they interact and behave when they are not sick? What do their ears and tonsils look like? What does their skin look like when not covered with a rash? How do the lungs and heart sound when they are not coughing? It is also a great chance to look more closely at growth and development. Height, weight, and head circumference (for babies) are all plotted out on graphs to help the team assess your child’s growth. We may want to delve deeper into diet, habits, social and home environment if we find that the growth is not following a normal pattern.

The well child check is also a great chance for parents to address any concerns about their child. The job of parenting is inevitably accompanied by worries and concerns about the child’s health, growth, dietary patterns, and behaviors. We want to check in and make sure that we address all of these concerns with thoughtful evaluation and sometimes just reassurance, if that is all that is needed.

As health care providers, we want to also ask more detailed questions about many of these same issues because we recognize the important impact that environment, diet, sleep, self-care habits, and behavior can have on the health and development of a child. How do you put your baby down to sleep? Did you know that putting your baby to sleep on their back and pacifier use have both been shown to decrease the risk of SIDS? A simple question about sleep habits helps us assess current habits and also may lead to a discussion about “best practices” as shown from current medical evidence or from expert advisors.

In all well child checks, the health care team is also doing some type of developmental assessment. This can be in the form of a developmental survey, such as a question about your child’s current language development. At times, we may administer a more detailed developmental screen which is a questionnaire covering all aspects of child development. Monitoring the development of your child’s language abilities, social skills, and gross and fine motor milestones can lead to early identification and treatments of problems in these areas.

In primary care, we strongly believe in prevention. The best way to treat a problem is to avoid it in the first place. In most well child checks, we have a list of “anticipatory guidance” items that we would like to cover – items that could lead to changes in the way you do things that could lead to better health. Does your child wear a bike helmet? Have you child-proofed your home? Have you had a discussion about sexuality or drug use with your teen? The number one cause of death in the US in children and teenagers is unintentional injuries. Brief interventions about car seats, home safety and safety at play can lead to changes in habits that may save lives.

As your child moves into the teen years, the well child visit is also a chance to establish more of a rapport with them. It becomes more important for the health care team to have a direct relationship with the teen so that the teen feels comfortable discussing concerns which may be intimate and which he may be too embarrassed to bring up in front of a parent. We will probably ask you to leave the room at some point in each visit. This is not to exclude you, but again to help strengthen that doctor-patient relationship. If we have concerns that your child may be in danger or may potentially harm someone else we will certainly involve you. Otherwise, we do ask you to respect your child’s privacy in regards to what we discuss. As always, if you have concerns about your teen that you’d like to discuss with us privately, you’re welcome to do so.

Lastly…of course…THE SHOTS!! We have recently discussed the importance of immunization here so we won’t go into that further. Hopefully, this has given you a better sense of all that we are trying to accomplish. Even though we all focus on the shots, worry about the shots, ask about the shots…the well child check is much much more than just shots.

Immunizations and Autism- Is there a link?

In our February ’08 Health Matters we reviewed reasons for vaccinating our children. This month we will discuss the perceived link between vaccinations and autism.

Many online communities during the past 10-15 years have driven a concern that vaccines and autism may be related. Specifically, concern has arisen that the measles-mumps-rubella vaccine (MMR) and thimerosal, a vaccine preservative, may be causing autism in children.

Multiple large medical studies have demonstrated no association between autism and the MMR vaccine. Below are some of the more significant studies.

• An article published in the New England Journal of Medicine in November 2002 which studied all of the children born in Denmark from 1991–1998 (over 500,000 children) found no increased risk of autism from the MMR vaccine
• A study from the Journal of the American Medical Association in 2003 reviewed children born in California from 1980-1994 (each year 600-1900 children were included) and no link was found between autism and the MMR vaccine
• In a study published in Pediatrics in 2002 over 500,000 children in Finland were evaluated for effects from the MMR vaccine and no link to autism was found.

Similarly, many large studies also have demonstrated no association between autism and the preservative thimerosal. Thimerosal has been used as a preservative in vaccinations since the 1930s.

• An article published in the January 2008 Archives of General Psychiatry found that the rate of autism in children in California continued to rise from 1995-2007 even though thimerosal was eliminated from most childhood vaccines in the United States by 2001
• A study from Pediatrics in September 2003 revealed that the rate of autism in Denmark continued to increase for the ten years that were studied following discontinuation of thimerosal in that country in 1990
• A population based study published in the October 2003 issue of the Journal of the American Medical Association evaluated all children born in Denmark from 1990-1996; children who had received vaccines containing thimerosal were compared to children who had not received such vaccines and no difference in rates of autism was found.

Because of the clear scientific data, many groups of experts, including the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP) and the Institute of Medicine (IOM) all agree that vaccines are not responsible for the number of children now recognized to have autism. We at GreenField Health agree with these expert groups and recommend that your child follow the routine childhood immunization schedule to promote good health.

Office Notes

We extend a warm GreenField welcome to Cindy King, our newest team member. Cindy will be working with our billing group and with our consulting clients, and we’re delighted to have her as part of the family. She comes with many years of experience in office management, billing and insurance benefits coordination. Please join us in welcoming Cindy!

Receipts for you – we generally send you a receipt for any check that we get in the mail from you. Please check to see if what you have received is a bill or a receipt. Frequently, when we’ve mailed a receipt, we receive another check from you in the amount of the receipt, and we’d love to avoid the double payment. The receipts are useful for tax purposes to document deductible medical expenses, and they can be submitted for your MSA/HSA accounts for reimbursements as well. Please let us know if you have any questions about that.

As the days get longer, we hope you’ll enjoy getting out in the sunshine, or the liquid sunshine as the case may be. As always, please call or email us if there is anything we can do for you.

Sincerely,

Your GreenField Team

Amanda Clark, MA, your Health Coordinator (email)
Angie Ashburn, CMA, your Health Coordinator (email)
Beth Davis, your Benefits Coordinator and Biller (email)
Chuck Kilo, MD (email)
Cindy King, your Benefits Coordinator and Biller (email)
Connie Turner, MA, your Health Coordinator (email)
Cynthia Ferrier, MD (email)
Dana Lee, MA, your Clinical Supervisor (email)
David Hays, MD (email)
David Shute, MD (email)
Desi Lowder, CMA, your Health Coordinator (email)
Elizabeth Hays, MD (email)
Eric Murray, MD (email)
Jill Arena, your COO (email)
Joel Swartzmiller, your IT Manager (email)
Justine Stephens, MA, your Health Coordinator (email)
Kristin Walker, your Program and Executive Assistant (email)
Lea Robinson, your Administrative Assistant (email)
Maria Soutavong, MA, your Health Coordinator (email)
Meena Mital, MD (email)
Pam Mockenhaupt, CMA, your Health Coordinator and Biller (email)
Paula Koeller, MD (email)
Samantha Charles, your Clinic Administrator (email)
Todd Canon, MD, (email)
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GreenField Health System
9427 SW Barnes Road, Suite 590
Portland, OR 97225
Phone: 503.292.9560
Fax: 503.292.9510
Web: http://www.GreenFieldHealth.com

questions, concerns, comments always appreciated:
questions@GreenFieldHealth.com

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