Dr. Raymond Kordonowy MD
In This Issue
Summer Information
Rabies Situations
Actionable Free Market Health Information
Something From My Kitchen
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Issue: 21July/2014

Summer is in full swing and many of the doctors in Florida are on vacation. As I have indicated in the past newsletters, due to multiple obligations I am writing in the newsletter less often.  Please be sure to visit and sign up for my blog site and more recently my professional facebook page as I am posting to these locations more often. 

Addressing obligations, I recently attended the annual national AMA (American Medical Association) meeting in Chicago, Illinois and later this month I am serving as a delegate for the FMA (Florida Medical Association) in Orlando. Hopefully a proposed referendum I offered regarding an important patient safety issue and electronic prescribing will be discussed and voted on. This is not a referendum for a law but rather a request for the involved parties in the industry to work together to resolve a mutually important issue- you and safe prescribing of medications.

Finally many of my readers have found the Independent Physicians Association of Lee County and many downloaded my free recipe book found on that site.. In May I began my second year as the acting president of that association.  I am excited to continue working to develop a useful and preferred physician network via IPALC. 
Rabies Review 
A Fatal Disease in Humans

In the past two months I have had two requests for answers regarding possible rabies exposure. One was an incident of a college student traveling in Central America who was attacked by two wild dogs.  The other was a lifetime friend's of mine significant other. His wife was clearing a bat nest in their Colorado home and she had the unfortunate situation of finding a dead bat the weekend following her attempts to kill it. She took the critter to the authorities and apparently within a day they confirmed it was infected with rabies! She reported that during the incident she was working in her bare feet and she had an open cut on her foot and leg.  She was working a water hose to try to drown the bat out of the house awnings. This meant that she had aerosolized exposure via her airway, eyes and possible direct water and batness contact on her open cut.  

In each reported situation the questions were how likely am I to have exposure, what happens in rabies and what should I do now? The college student was told some rather interesting tales from the local health care people. They indicated she had "weeks" to decide on vaccine due to the location of her bites (it involved her upper thigh and buttock area).  Both implicated dogs were euthanized (shot on sight as I understand it) and no testing for rabies were carried out. She was told she could continue her trip (which as a couple of weeks at least) and she could worry about it when she returned to the US.  Upon my review I informed her that was terrible advise and she had better get at least a vaccine and perhaps immune globulin as well.

The Colorado case consulted her doctor and she reported his opinion was "there is very low likelihood for meaningful exposure and so I would suggest you will be fine and the side effects of vaccination are significant so- do nothing".  I will admit that I initially agreed with the doctor but I informed my friend I would do another quick review on this issue and report back.   My opinion changed based upon that information.  Given that this is a rare but nearly always fatal infection in people and my own confusion on the topic, I thought it was newsworthy for my readers. So following is an abbreviated review from my research. An excellent, free summary of this topic with links to the CDC and other useful references are included in this article link.

In the US nearly all the cases in the past 10 years have occurred from bat exposure.  Dogs are very unlikely to be a source of exposure due to our aggressive vaccination laws.  If a dog gets in a fight with a rabid animal and an owner consoles the animal that person could theoretically get exposed via saliva on the pet. No cases have been reported in this scenario so far.  Rabies is caused by a virus which is harbored in the saliva of infected animals.  Raccoons, skunks, bats, foxes and coyotes are the most likely sources in the US. Small rodents are very unlikely to pose risk. Badgers and beavers if near rabid raccoons could be infectious. 

The incubation period for rabies virus (the time from exposure to multiplying and causing clinical disease) in people is 3-8 weeks but as short as 10 days.  Apparently numerous bites and bites closer to the head and brain will result in quicker disease.  I am only aware of 2 reported cases of survival in humans and an old microbiology text stated it is more than 99% fatal in humans and mammals when symptoms begin. It causes a diffuse encephalitis/central nervous system infection. Obviously you don't want to screw around wondering whether you should or shouldn't take post-exposure prophylaxis if you aren't absolutely clear the exposure involved a non-rabid animal. 

After exposure there are two things that can be offered, immune globulin and vaccine. Rabies immune globulin is injected into the muscle and it offers immediate protection against exposure.  It is indicated if exposure is within 8 days and it is to be given with a rabies vaccine series.

The rabies vaccine is given in the shoulder muscle at 0, 3, 7 and 14 days after exposure. Antibody formation is documented to occur within 14 days of the initial vaccine. Apparently there is only one antigenic strain of this virus (no mutations or need for numerous subtype concerns, etc). Thankfully the vaccine is highly effective. Veterinarians and other animal handlers are vaccinated for occupational precautions. If they are exposed they are recommended an abbreviated vaccine series.

Pain, low grade fever and flu like symptoms are common with both the immune globulin (antibodies against the virus from human harvested serum) and the vaccine.  Rarely severe reactions can occur, the alternative if infected is fatal as noted before. 
Our office does not keep rabies vaccine our immune globulin. One ER physician confirmed that Lee Memorial Hospital Downtown Campus keeps the vaccine. The local health department's should be able to accommodate folks in need as well.  Walgreen's Nationally indicates they have the vaccine but in the state of Florida, it is not available (I called to check). Hopefully none of our readers will ever need this assistance. Interestingly according to my reading bats can bite humans and the person might not be aware (night time bites).  Spooky huh? 
A Must Read Book Find

Just this weekend I discovered an information packed E-book which I downloaded on my kindle.  The title is The Self-Pay Patient by Sean Parnell.  This book explains in very clear language the many implications and developments related to Obamacare (Patient Protection and Affordable Care Act).  The author points out as I have in the past that more expensive health insurance doesn't address the question of more affordable health care. Health insurance is not health care. Our government made the intellectual mistake of equating these as their premise to trying to help address this problem, not that they should try to address this problem in the first place.

There have been numerous exemptions in the law and this book harnesses that information to show the consumer and doctors that there are many, far better and less expensive ways to access health care while maintaining legal and proper protection from financial Armageddon from either the development of chronic medical disease or inordinately expensive unexpected health expenses such as those encountered in an unforeseen accident.   Did you know the Amish as a religious group are exempted from this law?  We thought we were invoking religious issues and preference with mandated contraception practices (recent supreme court case)?  The feds gave the Amish a full pass, regardless of their role as citizens in America-what?  These are the kind of facts this book explains to us. 

I am in personal agreement with the author that the health care market is facing two choices- one is more, expensive and bureaucratic health care which is clearly the plan under the new health care law and the changes in Medicare.  The other path is a much more market based, nimble, less convoluted and more efficient use of health care dollars that will be found in many potential models, the most visible being our current hybrid, concierge and membership programs. 

Many of my readers know that I and my partners have been openly posting our office service prices on our website. Additionally I have developed an annual package for the uninsured or high deductible client. The Inpatient Advocate Service TM is my response to a serious market need and development that has risen solely out of price-controlled central command policies that have resulted in the hospitalist model for hospital care.  My service brings the proper alignment back between the patient buyer (and their choice to have their main doctor involved in their care at the hospital) and the physicians who care for their patients nearly all of the time as their primary care doctor. 

His book has recommend tactics, facts and useful links for actionable, consumer driven methods to bring about market expansion and far better options than those being imposed and mandated upon us. He starts with facts about the subsidies, facts about who is exempted and how many ways you can avoid the penalties while still avoiding the full-on Federal insurance product and it's outrageous costs. I encourage you to read this book and tell all your friends and relatives about it.  We need to remember we are the government. Markets (supply of services and goods for personal consumption) are always most efficiently served by open competition and incentives for entrepreneurial answers to supply and demand separation. I am encouraging you the consumer to take the lead because I am afraid most physician groups and hospitals are so conditioned to accept whatever the regulation police place before them that they will be very slow to learn about their ability to do things differently. 
Dr. Kordonowy's Dessert
Coconut Milk, Chia Seeds and Simple Ingredients

We need good fats in our diets especially omega- 3'sI measure something called the omega-3 index when I perform advanced lipid testing using HDL lab. Fish oil is one common source but you can find it in nuts,flax and chia seeds as well. First pressed coconut oil is 51% unsaturated fat.  While there is some saturated fat in coconut oil, I feel it is reasonable to have some of this, sometimes.  I developed this recipe in the kitchen and if divided into 8 servings as recommended it is appx 215 calories per serving. For an even more oxidative "burst" of nutrition add some blueberries or other fresh fruit to the top, calories added will be negligible. Chia seeds contain one of the riches sources of omega-3's, even more than salmon, ounce for ounce. It is also rich in fiber, magnesium and calcium. 

Heat in a saucepan- 2 , 13.5 oz cans of first pressed coconut milk. Goal is to bring to a slow boil for 1-2 minutes, use a medium heat. 

While heating add: 2-4 tablespoons of Agave nectar or natural honey ( I used 2 parts Agave to one part honey), sweeten to your tastes.
Add 2 tablespoons vanilla extract. 
Whisk in 2-3 tsp of ground cinnamon. 
Using whole nutmeg make 10-15 rotations in your nut grinder
As the mixture approaches a boil, whisk in 1/2 cup of chia seeds. 
Boil gently one to two minutes. 

Transfer using a soup ladle evenly into 8 ramekins.  Dust tops with more cinnamon and refrigerate. Serve cold as a pudding. Enjoy! 
As always I appreciate your readership, interest and patronage.  I hope you find the topics and recipes informative and useful.  I believe there is infinite empowerment with knowledge and information.  I hope you find value and personal growth reading the topics offered. I want all Americans in the best possible health and it starts with ourselves and our behaviors. 

Raymond Kordonowy MD
Internal Medicine Of Southwest Florida