Tuesday, January 27, 2015

San Francisco Medical Society Blog


Providing news to the San Francisco Medical Community.

SFDPH Health Advisory: Be Alert for Measles Cases

California is currently experiencing a measles outbreak, with at least 59 confirmed cases of this airborne, highly contagious disease. San Francisco has had no reported measles cases since 2013. Several other Bay Area counties, however, have reported cases in this outbreak. 

The outbreak originated with exposures at Disneyland in mid-December and early January, but additional secondary cases have occurred. The vast majority of case-patients for whom vaccination status is documented were unvaccinated. Although measles is no longer endemic in the United States, measles epidemics overseas have resulted in imported cases and resulting secondary cases. In addition, undetected community transmission may occur.   

Measles should be considered in patients presenting with fever and morbilliform or maculopapular rash. The purpose of this update is to provide guidance for clinicians who may be responding to inquiries from concerned patients, and to review proper infection control and testing procedures for patients presenting with potential measles symptoms. Suspected measles cases should be reported immediately to the SFDPH Communicable Disease Control 24-hour line: 415-554-2830. If calling after hours, listen to the instructions on the voicemail to page the on-call physician.

Clinical Guidance

Please see “Quick Guide for Clinicians: Measles” for detailed and updated information concerning measles reporting and diagnostic testing. The document is also available at: http://sfcdcp.org/measles.html.  

Patients presenting to a medical facility with fever and a maculopapular or morbilliform rash should immediately be masked and placed in isolation or a private exam room. Patients with rash who request advice over the telephone and who are advised to present for evaluation should travel to the medical facility in a private vehicle if possible and don a surgical mask upon arrival. 

Treatment of measles is supportive.   

Immunization is the most important preventive strategy for measles. Patients who have been vaccinated against measles or who have a history of measles disease are considered immune. Medical providers should work with all their patients to ensure up-to-date measles immunization status. In addition, measles immunity should be routinely documented for health care workers in order to prevent loss of work time if exposed. 

Individuals planning travel outside the USA should be up to date with measles immunization. Early immunization with MMR is recommended for infants aged 6-11 months before travel outside the USA. For detailed recommendations concerning measles vaccination for travelers, please click here
For the California Department of Public Health’s updates on the current measles outbreak, as well as measles alert flyers to post in clinical settings, click here.

Click here to view the SFDPH Health Advisory issued on January 22, 2015.

2/25 Seminar: Mastering the Art of Disclosing an Unexpected Outcome

When an unexpected outcome occurs, a discussion explaining what happened can help prevent a negative patient response, improve patient trust, and reduce the risk of a lawsuit, yet few physicians have been trained in this specialized set of communication skills in how to effectively manage these difficult conversations. Skillful physician communication and early disclosure of unintended outcomes can benefit all parties, including patients, doctors, health care systems and insurers without compromising meritorious defenses.

With this in mind, Medical Insurance Exchange of California (MIEC) has created an interactive workshop that examines the elements of providing timely and effective disclosure when an unexpected outcome occurs. The workshop will be facilitated by UCSF Associate Clinical Professor of Medicine Denise Davis, MD, who teaches communication skills for physicians nationally and is a Fellow of the American Academy on Communication in Healthcare.

Wednesday, February 25, 2015
6:00 pm - 9:00 pm; complimentary dinner served from 6:00 pm - 6:30 pm
Saint Francis Memorial Hospital

The program is FREE to SFMS members. Please email rochellel@miec.com for registration information.

*MIEC is the first physician-owned medical liability insurer in the Western United States, and has been a SFMS-endorsed partner since its inception. Click here for more information on MIEC.

2015 Medicare Benefit Changes

Each year, the Centers for Medicare and Medicaid Services reviews and determines what changes are needed for deductibles, premiums, and other Medicare program limitations. The table below illustrates benefit changes from 2014 to 2015:




Part A deductible



Part B deductible






Annual physical therapy/speech pathology limit



Annual occupational therapy limit



Amount in controversy for ALJ hearing



Amount in controversy for judicial review



The Medicare Physician Fee Schedule for January through March 31, 2015, has been posted to the Noridian website. Changes in Relative Value Units (RVU) for malpractice, work values, geographic practice index values and others may have an impact on the amount paid. Please check the updated fee schedule for any changes.

Changes necessitated by legislative decisions made during the first quarter of 2015 will be posted as they become available.

New Reassignment of Medicare Benefits (855R) Enrollment Form

The Centers for Medicare and Medicaid Services (CMS) finalized a new 855R form, which is used to reassign an individual physician's Medicare billing privileges to an organization.

The revised form will become available on CMS.gov on December 29, 2014, and can be found by searching "855."

Once available, Medicare administrative contractors will accept both the current and revised versions of the form through May 31, 2015. The new version must, however, be used for applications received by the Medicare Administrative Contractor on or after June 1, 2015. Prior versions will be denied. The online Medicare Provider Enrollment, Chain and Ownership System (PECOS) will be updated to include the revised Medicare reassignment information.

SFDPH Health Advisory: Increased Shigella Cases; Ciprofloxacin-Resistance Common

SFDPH has noted an increase in Shigella reports this December (37 cases as of 12/18/2014). Many isolates have been resistant to ciprofloxacin. A number of the cases have been in homeless and HIV-infected individuals and have resulted in hospitalization, although there have been no deaths or severe complications reported.

Shigella infection can be subclinical, but typically causes watery or bloody diarrhea with abdominal pain, fever, and malaise. A small inoculum (10-200 organisms) is sufficient to cause infection, and spread occurs easily via the fecal-oral route. Sexual transmission is known to occur. Young children, the elderly, and HIV-infected individuals with CD4 count <200 are more likely to have severe symptoms including dehydration, bacteremia, and seizures.

Although Shigella gastroenteritis is generally self-limited, lasting 5-7 days in an immunocompetent host, untreated individuals may shed the organism in stool for up to 6 weeks. Shortening the duration of shedding with antibiotics can reduce the risk of person-to-person spread. Due to growing antimicrobial resistance in both developing and developed countries, antibiotic susceptibility testing is essential.

Actions Requested of All Clinicians:

  1. Suspect Shigella gastroenteritis in cases with compatible symptoms.
  2. Test with stool culture and order antimicrobial susceptibility testing.
  3. Tailor therapy based on results of susceptibility testing, recognizing that routine antimicrobial susceptibility tests for Shigella may not include some commonly available oral antibiotics. For isolates that are resistant to ciprofloxacin, azithromycin may be a reasonable oral treatment option, and ceftriaxone may be a reasonable parenteral treatment option.
  4. Report cases to SFDPH Communicable Disease Control Unit (CDCU) at (415) 554-2830.
  5. Inform patients that meticulous hand washing and avoiding fecal-oral exposure during sexual contact can decrease risk for infection.

Click here for SFDPH's Health Advisory on Shigella, dated December 22, 2014.

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