Back in December, it was announced that Dr. Bretsky was named for a second straight year as one of the Super Doctors of California. This award is given to physicians who have attained a high degree of peer recognition and professional achievement. Selections are made by other physicians who are asked the following question: “If you needed medical care, which doctor would you choose?”

The results have now been published online on WWW.SUPERDOCTORS.COM and in Super Doctors Magazine, a separate publication distributed with the Los Angeles Times featuring approximately 5% of the top physicians in Southern California. Join us in congratulating Dr. Bretsky on this special achievement.


Flu Recommendations: 2017-2018 Season

With the flu season approaching, we wanted to let our patients know that we now have flu shots available in our office. The Centers for Disease Control (CDC) has published its recommendations on influenza vaccination for the 2017–18 season, and they continue to recommend vaccination for all people aged 6 months and older with only rare exceptions. People who should either NOT have or should WAIT to have the flu vaccine include:

1. Individuals who have had a severe allergic reaction (e.g., anaphylaxis) after previous dose of RIV or to a vaccine component.

2. Individuals with moderate to severe acute illnesses (with or without fever). However, after resolution of the illness, the flu vaccine can be given.

3. Patients with significant egg allergy (i.e. experience more than just hives) should have the vaccine administered by a clinician with significant experience managing allergic reactions (typically Allergist / Immunologist).

Of interest to our patients older than 65, the CDC states that EITHER standard-dose OR high-dose vaccine is acceptable.

The CDC is again recommending against use of the live attenuated influenza vaccine (FluMist), given its low effectiveness against H1N1 during the 2013–14 and 2015–16 seasons. This is particularly bad news for children who would much prefer a nasal mist over a injection.

Flu Prevention and Treatment at Santa Monica Primary Care
At Santa Monica Primary Care we not only seek to prevent flu through administration of the flu vaccine but also treat flu. During flu season (generally October to April), if you experience any of these symptoms, we recommend that you make an appointment by calling us at 310.828.4411 for further evaluation (we keep same day appointments available during this time):

● Fever* or feeling feverish/chills
● Cough
● Sore throat
● Runny or stuffy nose
● Muscle or body aches
● Headaches
● Fatigue (tiredness)
● Some people may have vomiting and diarrhea, though this is more common in children than adults.
* It’s important to note that not everyone with flu will have a fever.

At Santa Monica Primary Care, we have specific testing that can identify the presence of flu virus called Rapid influenza diagnostic tests (RIDTs) yielding results in less than 15 minutes. Flu is most effectively treated when medication is started within 1-2 days of getting sick and antiviral medications are used and can lessen symptoms and shorten the time you are sick. Medication can also prevent serious flu complications such as pneumonia. For some people, treatment with antiviral drugs can mean the difference between milder or more serious illness possibly resulting in a hospital stay. Treatment is generally 5 days in duration and is generally well tolerated. There are particular antivirals recommended for children and pregnant women as specific studies have shown these to be safe in these individuals. At Santa Monica Primary Care, we may also recommend treatment for household members who have yet to exhibit symptoms but may be at risk of developing flu.

Predicting Flu Activity in Los Angeles
Columbia University maintains a website that more accurately predicts the peak timing of flu activity by city. This has been spot on for Los Angeles for the 2014–15 and 2015–16 seasons and reflected flu activity we saw in the office. The current prediction for peak activity for Los Angeles is the week of January 15th, 2018. They predict cases beginning the week of November 27th, 2017 and steadily climbing to that peak level in mid-January 2018 and remaining high through mid-February 2018 before declining. If you are traveling, the website has prediction models for US Cities from Albany to Wichita (not quite A to Z).

Our Recommendations at Santa Monica Primary Care
At Santa Monica Primary Care, we recommend having a flu shot certainly before the end of November if not sooner but will continue to provide vaccines through the entire season. To schedule an appointment with our office to have your flu shot, please call us at 310.828.4411. The visit will be quick with our experienced staff.

For more information on the CDC’s recommendations, click: MMWR article (Free)

For more information on Columbia University’s flu prediction model for Los Angeles, go to: Types&location=Los Angeles, CA

Cases of Colorectal Cancer Increasing Among Young People

After decades of declining colon and rectal cancer rates, data published last week shows that these diseases have been increasing among young adults. Colon cancer rates have increased 2.4% annually among adults in their 20s and 1.0% among those in their 30s. For rectal cancer, the increase is even more dramatic: 3.2% among those in their 20s. For those born around 1990 the rates of colon cancer are more than two fold greater (2.4 times) than those born around 1950. Rectal cancer is over 4 fold greater (4.3 times) for those born around 1990 as compared to those born around 1950.

So the question, of course, is why the dramatic rise after decades of declining rates?

When I discuss colon and rectal cancer risks with patients, I often refer to two classic epidemiologic studies. The first study was done by Armstrong and Doll in 1975. It compared incidence and mortality rates for 27 cancers in 23 countries and correlated these with a variety of dietary habits and other variables. Dietary variables, particularly meat and animal protein consumption, was strongly associated with cancers of the colon and rectum. Further, these investigators confirmed prior data suggesting a protective effect of fiber consumption.

The second study to which I refer is actually an earlier study by Dennis Burkitt published in 1971. It was here that the idea that colon cancer could be linked to diet was first advanced. He reported that colorectal cancer was rare among rural Africans and this, he suggested, was because this population had little meat in their diet and instead ate a lot of fiber from fruits, grains, and vegetables.

Obesity and sedentary lifestyles are also associated with colorectal cancer, as are heavy alcohol use and chronic conditions like inflammatory bowel disease and Type 2 diabetes, all of which are on the rise. But experts are not entirely convinced these are the only reasons colorectal cancer is increasing among young people. “It is not surprising that the timing of the obesity epidemic parallels the rise in colorectal cancer because many behaviors thought to drive weight gain, such as unhealthy dietary patterns and sedentary lifestyles independently increase colorectal cancer risk,” the authors wrote.

Of particular concern with rising rates among those in their 30s and 40s is the fact that screening by colonoscopy is only recommended beginning at age 50 for people who are at average risk. The risk is higher among African-Americans, and the American College of Gastroenterology recommends they begin screening at 45.

In terms of advice, I generally stress that maintenance of a healthy weight, reduction of animal protein consumption, limiting alcohol intake and an increase in dietary fiber would also reduce one’s risk. More recently, a 2016 USC study showed that moderate coffee consumption, between one to two servings a day, was associated with a 26 percent reduction in the odds of developing colorectal cancer. Moreover, the risk of developing colorectal cancer continued to decrease to up to 50 percent when participants drank more than 2.5 servings of coffee each day. The indication of decreased risk was seen across all types of coffee, both caffeinated and decaffeinated.

At Santa Monica Primary Care, I have long recommended for my patients 40 and older, an adjunct screening test with a fecal occult blood test kit in which a stool sample is collected at home and mailed back into the office. Whereas this does not replace a colonoscopy in terms of detection, it does represent a relatively non-invasive way in which to begin screening sooner and also between years of colonoscopies. Positive results can be followed up with a colonoscopy. Today there is even a ‘virtual’ colonoscopy which is as accurate as a traditional optical colonoscopy and can be performed at an outpatient imaging center and does not require any anesthesia. With one third of new colorectal cancer cases being diagnosed in those under the age of 55, early initiation of already effective screening techniques simply make sense. Caught earlier, treatment options for colorectal cancers are more effective.

New Medications to Bring Cholesterol Levels WAY Down.

By Dr. Philip Bretsky

Were you aware that there are two new medications approved to treat high cholesterol levels? Traditionally, patients and physicians have relied on the statin class of medication to lower LDL or “bad” cholesterol levels. The most well known of these is Lipitor (you may have seen the commercials). The newer medications are delivered by injection and are in a class called PCSK9 inhibitors.

The new PCSK9 inhibitors can achieve LDL levels far lower than can be achieved by even the highest intensity statins. Whereas one might expect to lower an LDL to under 100mg/ml or under 70mg/ml with Lipitor, studies show that the PCSK9 inhibitors can achieve LDL levels below 25mg/ml. In one study 9% achieved levels under 15mg/ml!

But we must need some cholesterol in the body, right? It must serve some function and, correctly, some researchers are concerned that very low levels of LDL could adversely affect the production of sex steroid hormones and adrenal hormones which rely on cholesterol.

However, a recent study ( analyzed 5,234 patients treated for up to 2 years and examined the occurrence of adverse events. There was no increase in a wide variety of conditions including neurologic, memory, kidney, liver or diabetes. However, the authors did see (pun intended) an increase in cataracts among those patients with LDL levels below 25mg/ml.

So is there such a thing as ‘too low’ cholesterol? Other than the risk of cataracts, so far there does not seem to be a downside.

Improving the Connection Between Patients and their Physicians

By Dr. Philip Bretsky

I recently read an article that described the importance of having a strong and trustworthy relationship with your physician. For obvious reasons, this connection leads to better medical outcomes because patients feel more comfortable communicating with their doctors about personal and sensitive topics. I believe that there are a number of intangibles that make a connection more likely. Helpful to me has been a wide array of life experiences that has afforded me the ability to meet and interact with a lot of different people with a variety of lifestyles.  Everything from my Dad’s graduate students when I was a kid, to living in India for two years, to working with the homeless in London and doing clinical HIV research in the early 1990s. Each of these experiences helped me form a non-judgmental approach to medicine and a general understanding of life’s difficulties and challenges.

Also, being independent and not working for an institution reduces the external pressure that I have. I am not working to attain any health system’s stated goals or measures of quality. I’m focused on what the patient wants and what is best for them. Our office is also structured so that when I’m in with a patient, there is no interruption. The time between myself and the patient in the exam room is protected time and allows for open and honest communication.

We also take care of a tremendous number of families – often multi generational – and this adds a layer of understanding and sensitivity to family dynamics and health risks. And because I live and work in Santa Monica, I often see my patients and their families outside of the office during daily activities. This provides me and my patients a tremendous opportunity to foster good feelings and mutual respect and caring. By building these connections, I can feel confident that my patients trust me to care for them and provide them with the best possible medical outcomes.

Link to the original article below:


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