Cirrhosis Of The Liver Diet

okay, well we'll get we'll go ahead and get started this evening. thank you for joining us. it's a beautiful evening out, but i think lee's presentation is very pertinent to most of america today. as a... my name is tiffany ricky and i'm adietitian and i've been granted the honor to be able topresent the healthy living lecture series thissummer. so i'm joining with you in learning everysingle week, so this is exciting

me. and as a dietician, i totally get the whole drug-nutrient interaction it and howpotent drugs can be in the body system. leah, of course, gets out a little bit more. she is a - leah scadden is our lecturer this evening and she'll betalking about medication therapy management and how it can actually save your life. she graduated from the university of colorado health sciences center with thedoctor of pharmacy degree in 1999. she attained the american pharmacistsassociation

national certificate for medical - for medication therapy management services - this is a lot of letters - pharmacist and patient center diabetes care, and pharmacy-based immunization delivery in 2013. currently, leah is the clinical staff pharmacist at fred meyers east and for those of you that shop there,she did survive the remodel move and back. she's been a clinical staff pharmacist since 2013 and has staffed there since 2008. she previously worked as a

pediatric clinical pharmacist atprovidence alaska medical center in anchorage from 2003 to2008. she's a member of the american pharmacistsassociation and the alaska pharmacists association asidefrom being a smarty pants pharmacist - she didn't write that in - leah is a wife and mother and she stays active running her two kids to school, soccer, swimming, and ballet practice. she also enjoys scrap booking, reading, cooking, and and working on mosaics. so, i am pleased to introduce leah scadden. (applause)

so, thank you. can you all hear me? is it, is it on? ... now? alright, help. i apparently wore the wrong shirt. (laughter) okay. well, welcome and thank you for spending your evening withme. so medication therapy management and how can it save your life. so that sounds pretty extreme, doesn't it?but in fact, it's not. medications are there to help you.

they can cure infectious diseases, theycan prevent problems from chronic diseases like diabetes, hypertension, and high cholesterol, it can ease pain. but in order to behelpful, medications must be taken correctly and appropriately. if not, harmfulreactions can possibly occur. errors can even happen, whether it's inthe hospital, the doctors office, at home or even in the pharmacy. theremust be an appreciation of the power of medicine,

the value of medications when usedproperly, as well as the consequences when used improperly. so today i'm gonna be talking about two main topics. the first one is the idea of polypharmacy and how to manage it, as well as - i really wanted to express howimportant it is to create your own medication list. and the second part in my lecture

is to understand more about vaccinesand know which ones are right for you so, polypharmacy always pretty much defined a number of different ways in theliterature, but mainly it's defined as anybody taking more than four medications.it's also the prescription, administration, or use of more medications than areclinically indicated. and polypharmacy is a growing problem seen in medicine today, especially with the increase in thenumber of people with chronic disease states.

also with the increase in the number ofmedications available to treat these disease states and also the growing elderly population. and this not only plagues patients, butalso clinicians and pharmacists as well and it's also been well documented thatas the number of medications a person takes... sorry. as the number medication... medications a person takes goes up, thepotential for drug-related problems goes up as well, such as adverse affectsand also hospitalizations.

and adverse medication outcomes havebeen estimated to be the fourth or fifth cause of mortality in hospitals. i just wanted to give you a coupleexamples of polypharmacy just so that you can get a better understanding. the first one hasto do with hospital medication formularies. probablyall of us have been admitted into the hospital one time or another in our lives, and hospitals have medication formularies and these are put in place to do a number of things, but mainly tohelp reduce costs.

and what not. but... so an example i have is that when a patient gets admitted, all of their medications are looked at on their intake and so say for instance, a patient is taking amedication called prevacid. at home. but when they go into thehospital prevacid isn't on the hospital formulary prilosec is. so those medications, they're inthe same drug class and they pretty much do the same exact

thing. but, when you're in the hospital, that patient's gonna be switched totaking prilosec. and then upon discharge, when the patient goeshome, that doctor may just write their discharge medications for prilosec, not maybe understanding that the patientwas switched when they came into the hospital. sonow when the patient goes home, they're saying, "oh i have to take this new medication called prilosec, but i still have this prevacid athome," and so then they end up taking

two of the same medications when they're at home, not fullyunderstanding that they're on essentially two medications but they onlyneed to be on one. another example: sometimes patients, the more sicker patients, whenthey're admitted into the hospital - they'll be started on a medication calledfamotidine and that is to help reduce the risk of stress ulcers developing in their stomach and sometimesthis medication may not be stopped when they leave the hospital. soagain, a person may be on a medication

that they don't necessarily need to beon when they leave the hospital. and then my other main example of polypharmacy is when additional medications are startedto treat side effects. and, so sometimes you're going to be on amedication and unfortunately medication sometimesthey just come with side effects. but sometimes patients will end up being given a whole new medication to treat that side effect and sometimespatients - it might be better for a patient to be

on a different medication that doesn'thave such a, a high side effect profile medication. as we get older we metabolize thingsdifferently so sometimes the older population, there's different criteria that doctors and pharmacists, nurses, thehealth care community, should look at what groups ofmedications will be better for the older population. but - so say for instance,sometimes sleeping medications

would be used to treat insomnia thatare some time caused by anti-depressants. sometimeslaxatives are used to treat constipation from opiate pain medications. there's other kind of a group of medications called tricyclic anti-depressants. the main one that isprescribed a lot amitriptyline and they use that a lot for nerve pain, they use it for sleep, they use it for a whole wide range of things, but unfortunately, in the olderpopulation it really comes with a high-risk

of side effects includingconstipation, urinary retention, blurry vision - so then you end up being prescribed eye drops for blurry visionand you know it just kinda spirals out of control. so sometimes wetry to curtail that trying to hopefully get the doctor toprescribe a different medication. polypharmacy has the potential tocause various outcomes - and some good - some are good and some are bad. so the good, or appropriate, uses of polypharmacy may include individuals who are very sensitive tothe side effects associated with the

when the dose is increased and theseparticular people may benefit from having more than one medication, but atlower doses. so even though you may be on multiplemedications, you'll be at lower doses so that you don't experience some of the side effects thatare seen with the higher doses. and that's a totally appropriate use ofpolypharmacy. and that way when they're at thelower dose, they don't experience theintolerable side-effects and this is often seen it with patients beingtreated with hypertension,

as well as diabetes, and they'll use multiple medicationsthat provide different mechanisms of action just to provide a betterdisease state management and improve the patient outcomes. andit's not unreasonable or even uncommon to see patients who, say for instance, have diabetes, to beon six to nine medications just to help manage their diabetes aswell as the complications that may arise fromdiabetes, such as secondary coronary events.

they're gonna be on medication for -to help protect the kidneys, to help protect their pancreas, you know, that's just - it mayseem like a lot, but again it's something that is backed up by national treatment guidelines. someof the bad or negative outcomes of polypharmacy may include an increase inadverse events - falls, hospitalizations, casts - and all of these can decrease a patient'sphysical function and overall working against the patient's health. so who is atrisk

with this mainly happening and it's like i said - mainly people with multiplethe disease states of those seen with people who seemultiple clinicians. and... us here in alaska, we see - we're kind ofa smaller community here - and so we see our doctors here but if you're needing aspecialist for some reason, we may need to travel to anchorage. somepeople even need to travel to seattle and sometimes these patients who are seeingmultiple clinicians sometimes those doctors aren't all on the same board.

you know, they don't know everything a patient is prescribed. and sometimes there's drug interactions, there's allergy interactions, there's alldifferent kinds of things that can happen. who else is at risk are the olderadults due to the fact that they're - they're more likely to require multiplemedications to treat multiple health related conditions. they can also experience cognitivedifficulties and this can lead to confusion withmedications. and also, if you've had a recent

hospital - hospitalization like i was talking about, just because when you're in the hospitala number of medications may be started or changed or stopped while in the hospital and so your wholeroutine may have changed when you get out of the hospital. and why is this a problem? so this can lead to a breakdown incommunication between healthcare professionals.

it can also lead to a disjointed careand fragmented medication lists and also fillingmedications that multiple pharmacies - this can bypass electronic safeguardsthat are put in place. so if you're going to multiple differentpharmacies sometimes you bypass those safeguards and sometimes things can be missed, whether it'sallergies, multiple retails for a medication - thatkind of thing. and also more medication... moremedication increases the likelihood of more side effects which may result

in new medications prescribed to treat theside effects, like i was currently - like i was previously talking about. sohow do you manage polypharmacy? the first step todecreasing any problem including poly- pharmacy is to consider what can be doneto prevent it. so what can you do to decrease the riskfactors associated with your particular disease state? so for example, if you'repatient with diabetes, hypertension, high cholesterol, living a healthier lifestyle with a properdiet and activity levels can help reduce the burden

on these chronic conditions and chronic conditions often lead toincreases and medications. and this is one of the most importantpoints that i wanted to stress to people because i just really don'tsee often enough, is patients should keep an up-to-date and accurate medication list and i really encourage you to use onepharmacy - you shouldn't cheat on your pharmacist. but i like i was talking aboutbefore if you're using all these differentpharmacies,

it can bypass the electronicsafeguards and yes i totally realize sometimes you just need to go to anotherpharmacy whether someone is out of stock in a particular medication, i totallyunderstand that. but ideally, you should try to use one pharmacy. and polypharmacy is a concern that may require an intervention called de-prescribing and this is theprocess of tapering off - stopping, discontinuing, or trying medications with the whole goal love improving your outcomeand i'm by no means saying just to stop these medications. thisis something that should really be

discussed with your doctor. if you're having intolerableside-effects or something like that, definitelybring this up to your doctor. i find a lot of patients just kind of go withthe flow and if something is really not making you feel correct or you know something is justhappening in your life is just not allowing you to lead the life that you want, please discuss thatwith your doctor. sometimes medications can be changedto a different whole

profile of medications and they can reallymake a drastic effect in patients. and the end and each prescribed medicationshould be linked to current disease state. and i've had a number of instances where patients have brought in duffel bags - like a duffel bag - filled with their pillreminders, stuffed with medications, bottles that were prescribed to them years andyears ago and they come in and say, "oh, well i knocked it off of my counter

and now i don't know where my medicationshould be and i don't know," and when they put them in these pill reminders, theydon't know which pill is which, and it is so scary andsometimes it's really hard to just say, "how are you still living!?" but it's really important that... you know, making sure you're on aprescribed medication that is linked to a current disease statethat you're having. and if you are not on these medications, get rid of them. just get them out of the house

that children aren't into them or anything like that. if you're not on it, you don't need itaround. so you can also help prevent errors mainly by knowing your medicine. you should keep a list of your medicinesand this should include the name, dose, how many times you take it, and what themedication is used for. and like i was saying before, i just don't see this enough. and i get patients calling meand saying, "oh i just need my, my little white pill filled." well, i don't know if you've ever really looked behind

the pharmacist to see the whole array ofthousands and thousands the medications that we have on the shelf, but probably fifty percent of them are a little whitepill and we don't know where that is, so, but your list should definitely include over-the-counter medications, anyvitamins, herbals, supplements, all of these should be on your list because justbecause it's over the counter doesn't mean that it's perfectly safe totake. there are gonna be drug interactions. nasal decongestants can increase your bloodpressure. if your blood pressure is not

controlled, it may not be the safest thing for youto take. there's many medications that can increase the risk for bleeding. if you're on blood thinners, this can bea problem. so please always check with us - anurse, doctor - we cannot help with you. we can just do screens of yourmedications just to make sure you're being as healthy as you possibly can. (...list, take it with you or carry it at all times?) carry it at all times. keep it in your purse, keep it in your wallet. and i didn't

add this to this even i should, youshould also have a list if your allergies on there. and take this list to each and every doctor's appointment thatyou go to. it... it's absolutely mind-boggling how allthese providers don't know what a patient ison and unfortunately our computers are not linked together.you know, patients say, "oh i need all my current medications filled." but you know, i can

see at the pharmacy, i can see whatyou've most currently - what you've most recently gotten filled, i can see if you have refills on something, buti don't know if something's been changed, i don't know if something has beendiscontinued, and a lot of things sometimes - pharmacies these days have automatic refills where you can you to plug into thecomputer system where it will fill routinely every month and sometimes thatcan be really great if you're mainstream and there's noproblems, but boy if you're having issues,

you're ending up getting medications filled each month thatyou may not need or duplicated therapy and we maynot know that and so it it helps if everybody justopens up the lines of communication. so... also make sure that you'rereading your medication labels and following the directions. i can'teven express to you how many horror stories i've heard up differentpatients taking their medications not how they're supposed to and i'vehad - just recently i had a guy call me and he said,

"i was just prescribed this heart - thismedication for high blood pressure but my blood pressure still really highand i've taken three doses already and this was in a span of like 10 minutes." and, i'm like, "oh my goodness." and you know, his blood pressure - it couldbottom out. he can seriously get in a lot of trouble but... so anyways and they also want to lookat the medication before you leave the pharmacy. if you're on multiple - you know, if you'reon refills and everything,

picking up your refills, make sure that the pills still look the same that you had before is it the same color, size, or shape? sometimes it's different because it's adifferent manufacturer. it's the same medication, it's the same activeingredient, but sometimes at pharmacies were at the mercy ofwhat the wholesaler has in stock and what they sent us. so even though it's the same medication it may look different, but boy, patients who only know that they takethat little white pill

they can be in a lot of trouble becausethey're just like, "this is the wrong medication!" and and you know sometimes it can really stress a lot of people out. so and you also don't want totake medications that are prescribed for somebody else. it's also illegal, but it happens. you also want to takeextra caution when giving medications to children. they're not just a littleadults - their medications are prescribedmuch differently than in the adult

and this is just an example, which it's probably a little bit hard to read. i just pull this off the internet, butyou'll see that it has like a start or stop date, it has the name of the medication, thetablet strength, how to use it or when to use it, and what the medication is for. and you by no means have to find somenice pretty piece of paper on the internet to fill this in. if you do, great! but you can definitely make your own. we can print them off at the pharmacyfor you

and i've also had - seen some patientscome in where their doctors office had printed out things for them just to help everything run smoothly. but again, i just don't see itoften enough in my line of work so... yes ma'am. yes, because there's - there's plenty ofinteractions. just for example: vitamin c - it'ssupposed to be a water-soluble vitamin so you think, "oh i can't gettoo much of that." you can definitely get it.

i... vitamin c causes kidney stones. i know that; i have tons of kidney stones in both my kidneys that i'm pretty positive came from vitamin c -taking vitamin c on a daily basis. now some people, you need to be onvitamin c, especially if you're on an iron supplement. if you take them together, it helps with theabsorption. but again, you know, everybody is different,everybody is patient-specific. so... and you definitely want to ask questions.why am i taking this medication? if

you're picking up something new, definitely know why you're taking it. when do you take it? how do i take it? do you take it with food, do i just take it with water? do i take it on an empty stomach? is it gonna... cause any common side effects? and theseare all things that you should know. all medications come with a patientleaflet that you should definitely familiar with.but what do you do if they do occur and when should you stop thismedication?

also... a lot of questions that we getare "can i take this medicine with my other medications?" there's food and drug interactions that are that are quitecommon so please ask us. and again, we can always help you withthat and if you don't know these answers, like i said, please ask us. behind the scenes at the pharmacy. so i don't know if you're ever curiousabout really what happens at a pharmacy. i guarantee you that i didn't go toschool for many, many years and pay

thousands and thousands of dollars intuition just to... pour some pills in a bottle and slap alabel on it and hand it to you. we do definitely do more than that. on the surface it may look like apatient just brings in a prescription and then we put it into the computer and pour it in a bottle and slap a label on it and sell it to you at the register, but we're actually doing much much more. we're also checking for like i saiddrug interactions, drug allergies, sometimes food allergies,

the correct dosing, checking to see if the drug or dose is appropriate forpatient's age, we're checking kidney and liver function. we're also checking refill dates to assess yourcompliance. have you gotten something filled, you know, you should have gotten itfilled last month, but it but it's been three months. are you still taking that medicine or did you just, maybe, forget about it? and you know, we run into all different kindsof scenarios. we're also complying with different state anddea laws,

cost issues, packaging issues, we're callinginsurance companies all day long, calling doctors back, whether we can't read their handwriting or in many instances, we're also processing prior authorizations, a lot insurance companies, they just - theydon't wanna pay for the more expensive so we call it, we're calling yourdoctor, as well as your insurance company, to get these processthrough so that you can be on the medication that you need to be on.

and something that the health care field is relying onpharmacies to do is to do vaccinations. so that kinda brings me to my next part of the talk, and that is vaccinations. so why am i talking to you aboutvaccinations? i think that vaccinations are justanother way of keeping us healthy. i'm a firm believer in them and everyyear, thousands of americans suffer from serious health problems and even die from diseases that we canbe vaccinated against.

and this can include diseases likewhooping cough, hepatitis a and b, flu, pneumonia, and even shingles. if you can get - if youend up getting the... the more severe symptoms. so, many adults and children are behindon their vaccinations and vaccinations just don't protectyourself. it also helps to prevent the spread of disease to others in thecommunity. it also helps to protect those who arestill too young to get the vaccine. there's also patients have allergiesto some components of the vaccines

and there's also those who cannot getthe vaccines because their bodies are too immunocompromised from diseases likecancer and also those who can't or won't get vaccinated. they can still get a benefit fromherd immunity. these diseases have not disappeared. fortunately, the us has low rates ofvaccine-preventable diseases but that's not true elsewhere -elsewhere in the world. and as we saw with just a few cases at the ebolavirus, it's just a plane ride away.

only smallpox has been totally erasedfrom the planet, except for in some laboratories, but polio is no longer occurring in the united states, but it'sstill paralyzing many children in countries like africa. and what wouldhappen if we stop vaccinating? we could find herself battling epidemicsdiseases that we thought had - that we thought we had conqueredyears ago. an example if this is in 1974, eighty percent of all japanese childrenwere getting the pertussis vaccine and at that time in 1974 there was only

393 cases the whooping cough and not asingle pertussis-related death, but within five years, immunization rateshad dropped only about 10 percent and there was over 13,000 people who got whooping cough and forty-one people died from it. and then they started vaccinating againand the disease numbers dropped again. and we also saw back in december 2014, there was a multi-state measles outbreakin california at disneyland andfairbanks also just got its first measles

case and we haven't had one in over 10years. so the first one that i'm gonna talkabout i'm gonna mainly talk aboutvaccines that are geared more towards the older population. so the first wanna talk about shingles. and, shingles is caused by the samevirus that causes chickenpox, so if you've had chicken pox before,that virus stays in your system and years later, it can potentially cause shingles later in life. it's a painful skin rash oftenaccompanied with

blisters. it typically appears on one sideof the face or body or in a dermatome, and typically this rash can last for twoto four weeks. but one in five patients canexperience severe pain long after the rash clears up andthis can happen for months to years. i have a number patientswho have what's called postherpetic neuralgia and they're on pain medications from just ahorrible nerve pain that they experience from shingles. so, symptoms of shingles can also be fever, headache,

chills, upset stomach, pneumonia, hearingdifficulties, blindness, encephalitis, or death. the shingles vaccine is a single dose that's approved for adults fifty years and older. it'sjust a one-time dose that's a subcutaneous shot that's given in the backof the arm and this can reduce the risk of shinglesby fifty percent. you can also - 50 percent doesn'treally sound like a lot but it can also help reduce the pain inpeople who still get the shingles virus even after they get vaccinated.

so i found some pictures of these different disease states that i'm going to talk about and my husband wanted me to say that they're pretty gruesome. so be warned. this is a shingles rash on somepody and you can see how it's only on one side of his body - so in one dermatome. and this is the patient who has shingles onhis face and he is at a huge risk to becoming blinded from this. yes ma'am? (if you've had shingles on the skin, can you get it again?) (and if so, will a vaccine protect against it?)

yes, you can potentially get shingles again and i would get a vaccine. there are kind of regulations on if you have had shingles you shouldwait a certain amount of time before you get a vaccine, and the shingles vaccine is a livevirus so you - there's different stipulations so you can't have another vaccine like in the previous month that you getthe shingles vaccine.

since it is a live virus, if you're immunocompromised in any way, if you're a cancer patient, that kind of thing -that's something that the pharmacists and the doctor really have to discuss tosee it and if you're well enough to get thevaccine because, by golly, i wouldn't want to give you a shot andgive you shingles essentially. so my sister-in-law is actually kind of an oddball case and she's younger than i am but shehas chronic shingles. and that's only a little bit, but shestill has chronic shingles and anything that just kinda stresses her body, she'll get an outbreak of it

and she is the only one i have ever heardof this and i was like, "are you sure that's shingles?" and she was like, "yes. they've culturedit over and over just to make sure." so she's kinda an oddball case but yes. alright so the next vaccine i'm going to talk about is the tdap and that's the tetanus, diphtheria andpertussis. and so the tetanus - this is lockjaw - and it's a painful tightening of themuscles in the head and neck so that you can't open your mouth or swallow. sometimes you can't even breathe.

and tetanus will still kill one out of tenpeople, even with the most - even with patients receiving the best medicalcare - you can still die from it. tetanus enters the body through cuts,scratches or wounds, so, diphtheria - probably you just hardly ever seesome of this stuff anymore - but diphtheria causes a thick coating to form in the back of thethroat and it can lead to breathing problems, heart failure, paralysisand death. and pertussis is probably one

that were maybe a little bit more familiar with. but that's your whooping cough and that causes severe coughing spells, difficulty breathing, vomiting, rash, sleep disturbances, weight loss,incontinence and rib fractures. this can oftenlead to pneumonia as well as death. it's especially the most dangerous in children and diphtheria and pertussis are spread fromperson to person through coughing and sneezing and

adults are typically the carriers ofpertussis. we may not really experience it but we could sure passit on to little kids. so if you have grand babies around, thatkinda thing, you should always make sure that you are at least vaccinated againstpertussis. so, and since vaccination began, casereports a tetanus and diphtheria have dropped by almost 99 percent and then by about eighty percent of... for pertussis. so, you should get a tetanus

booster about every ten years and if you can't recall if you've hadthe t gap with the pertussis, it's totally fine to get it. yes? you said the tetanus... for ten years. should i just get the tetanus or tdap? so, with you, what recommendations are is if you're due for a tetanus booster,go ahead and get the tdap if you - because the tdap came out in 2005, so we're still in the process ofvaccinating a lot of people

with the tdap so they can get thatbooster pertussis, but if you - you know where we'rekinda we've have reached at 10 your point people got it back in 2005 - so ifyou've had the tdap before then you can just get the... the tetanus component, the td booster. does that make sense? okay. and like i said, tdap or - i'm sorry - pertussis

especially dangerous for the littlekiddos, especially if they're twelve months and younger. anybody who is working in thehealthcare community should have - should be vaccinated sohealth care workers, anyone having close contact with babies, and it'salso recommended - they just changed this not too long ago - any pregnant woman, with eachpregnancy she should get a tdap. so even if she is pregnant every year, she is supposed to get a tdap every year, because that pertussis

components protect her... her child. so... let's see... back in april of this year there'sstill - we still get pertussis outbreaks and like down in nenana this past april, their elementary school was closed becausethere was, i think, twelve pertussis cases that happened and so youend up seeing a flux of people getting vaccinated for it. so if i could just plead with you: if you knowthat you have this,

please don't go walking through fredmeyer exposing everybody. we had... we've had a couple instances where doctors send over prescriptions and they're right on it, you know, positive for pertussis, un-vaccinated children or you know, something to that extent, and furtherletting us know and, boy, 10 minutes later here they come, waltzing through the whole store, exposing everybody, and it's like oh, go through the drivethrough, please. but its... it happens.

so... so anyways, a picture of a gentleman with pertussis and youcan really see how his neck and jaw is just really rigid. and this is what pertussis looks likeyou can really see it - that chick white coating in the back ofthe throat it's really swollen and i'm hoping that this works. (coughing) so that is what pertussis sounds like - healthy right? but that is - that's the definite pertussis whoopingcough sound

that is highly distinguishable. so now i'm going to talk to you about influenza. most of us are fairly... we... fairly know quite probably a bit more about influenza. it's a contagious disease that spreads typically through the winter time, usually between october and may and it'scaused by coughing, sneezing, close contact. and symptoms include fever, chills, sore throat, muscle aches, fatigue, cough, headache, runny orstuffy nose.

those that are at risk at becoming much sicker are theyounger children, as well as the older population over 65, those that are pregnant, and those with health conditions like heartand lung disease, kidney disease, any kind ofweakened immune system - you're more risk of developing moresevere complications from influenza. every year thousands ofpeople in the united states die from influenza and many more

hospitalized. so the flu vaccine - it's the... it's not perfect, i know that, but it'sthe best protection that we have against the flu and it also helps prevent the flu from spreading from person to person.after you get the vaccine it takes about two weeks for your protection to develop and the vaccination, it'll last for several months to a year - about six months or so ofthe year. the flu vaccine is made to protectagainst three or four

strands of the virus that are likelyto cause disease that year and like i said, flu vaccine cannot prevent all cases of theflu, but again, it's the best defense that we have against it. so i highly recommendgetting your flu shot every year. there's many different kinds a flu shotsand there's like a trivalent and a quadrivalent, there's nose spray that i get my son because boy, will he fight me tooth and nail to

get him a poke, but there's also ones thatare formulated without the egg protein if you have egg allergies, there's cost - there's ones that are cost differences as well as age differences, and also for the... for the olderpopulation - if you're 65 and older there's a special flu vaccine made justfor you. it's called the fluzone high-dose and it hasfour times the amount of antigen as the regular flu shot and as we get older our immune systemswane

and this just kinda builds up uphigher immunity for you to get. so... it's also covered by medicarepart b. when you have these... special sessions where people can get flu shots, if you're over 65, do they have the fluzone that you need? yes. we... (and you have to ask for that) yes. (or do they give it to you automatically?) i would... i don't think we do it automatically butwe, we really try to - if you're 65 and older - we really recommend that you get the high-dose flu vaccine. yes.

alright. so now i'm going to talk to you about pneumonia and individuals between 19 and 64 years old who have some kind of lung disease -if they smoke or have asthma, they should be getting a dose of... pneumonia vaccine. also anyone when you, you know, if you go in to the doctorand say oh you're 65. you should get the pneumonia vaccine and thats when it's

recommended again is when you're 65. now, the recommendations have recentlychanged. you may or may not have heard of these, butthere's now two pneumonia vaccines. one is the pneumovax, which if you've gotten the pneumonia vaccine, this is the one thatyou've probably gotten. now the recommendations are to add there prevnar 13 vaccine. pretty much the rule of thumb thatwe go through at the pharmacy is to wait basicallya year.

the reason behind that is for you to get abetter immune response and also medicare will pay for one pneumovax and one prevnar if you're 65 andolder, but they were only pay for them acertain amount of time away from each other. yeah, it gets crazy. so, but we can always look intothat. yes ma'am? (how often do you get these?) it's recommended that you just get so what the - if you've gotten it your pneumovax, but you areyounger than 65 years old

and then you turned 65, you should begetting another pneumovax, but five years after your first one. if you have notgotten a pneumovax, when you turn 65, you should get theprevnar, a year later get the pnemovax. ifyou've gotten a pneumovax, some years ago but it's been over a year, get your prevnar. if you've turned 65 get the pneumovax again. we can totallydiscuss all this if you come to the pharmacy. it's... it's a little mind-boggling, butand

(...annual booster, or...) it's pretty much after you're 65 it'sa one shot deal for each. (you don't get any more?) not with the recommendations. i have had some people come in and saymy doctor is really recommending me get, you know, a pneumonia shot everyfive years i don't really think it's gonna hurt ya, but... i, you know, i can just tell you whatthe recommendations are. so, this is

just an illustration of what happens inpneumonia. so, up at the top circle this is what yournormal air sacs look like - your normal alveoli - and then in ammonia they'll start filling up with fluid, so it can be very painful and definitelyhard to breathe and coughing up all that stuff can be very difficult. so i'm just gonna talk briefly abouthepatitis b and hepatitis a. hepatitis b - it's a serious infection that affects the liver. eachyear about two to four thousand people

die in the united states from cirrhosisor liver cancer. hepatitis b can cause either a short term or a long term infection and people who are chronically infectedthey can still pass the virus along even if they're feeling totally healthyand not showing any signs or symptoms. so, the hepatitis b virus is easilyspread through contact with blood or other bodily fluids from an infectedperson. and i'm kind of a germaphobe in wheni was reading this

i got really creeped out, but and peoplewho are infected with... people can be infected fromcontact from the hepatitis b virus that's on a surface and it can live on a surface forup to seven days, and that just... that just gives me the hibbie jibbies. so those that should be vaccinated probably more for thispopulation, if you are six - little bit younger than 60 - and you have diabetes, i woulddefinitely recommend it.

you know, you're checking your blood allthe time, the doctor's they're probably drawing more blood samples. it's just a good idea. ipersonally think that everybody should be vaccinated against hepatitis b because why not? the effects that canhappen from getting this virus are just, just so outweigh the risk of getting the vaccine. also if you're doing any kindinternational traveling it can be recommended withdifferent places that you're going.

so again, that's just something that i recommend.typically it's a 3 dose series given at zero one in six months. so get up here doing them internationaltravel it's a good idea good idea and plan a little bitbeforehand if you are wanting to get back to me didn'thave the full course of therapy. so, this is jaundice that's caused byhepatitis and jaundice is the yellowing it affects the bilirubin in yoursystem and it can just yellowing of the skin and

eyes cuz you're just - you're having just - your liver is not functional well at allwhen this happens. (sorry. with hepatitis b, if you had the series-) you're good. (you're good? you don't need a booster?) correct. now, you can always have a titer done, like when i started working at fredmeyer, they were like, "oh you're gonna give shots. you have to - you're a healthcare professional,you need to make sure you're vaccinated against hepatitis b." well i didn't want togo through a whole new series of vaccine, so i just had my doctor draw atiter

and i was fine. (you do have to complete a series though?) to get the maximum benefit, yes. so hepatitis a, again, is another serious liver disease. this is found in the stool of infected people. so this is the one that you hear aboutmaybe in some restaurants, that kinda thing, that it can be spread by eatingcontaminated food or water. so you just wanna make sure you washyour hands before and after you're

eating. so... it causes a flu-like illness. again it can cause that jaundicethat you saw previously, severe stomach pains and diarrhea. those it should be vaccinated - it's verysimilar to the hepatitis b population... kind of a different little bit of a populationare people who are planning to adopt achild or care for a newly arrived adopted child from a country wherehepatitis a is common,

such central or south america, mexico, asia, africa, eastern europe, they shouldalso get vaccinated. so it's a two dose series that's given six months apart and also the hepatitis a and b vaccine these can also be combined into one shot given in a three dose series as well. (audience question) i have heard that. so... (what was the question? i couldn't hear it.) if you're traveling like in the bush in alaska,sometimes it can be

recommended - depending on whereyou're going - to get vaccinated against hepatitis a. it's - again it's one of thosethings that why not you know and if you're ever interested in thevaccines but you're not sure if your insurance pays for it or not, let us run a test claim and we'll tell youright then and there if your insurance pays for these. (and the three dose series, is that over a year's time span then?) no, it's... it's, again, given at zero, one, and six months. so and i wasn't really gonnatalk about the mmr which is the measles,

mumps, and rubella, but then... (i have a question about hepatitis. i have a question on that because just recently, i've been seeing ads that are addressing hep c and it's a capsule that they have developed that says that they can take, i think it's 12. one each week for 12 weeks.) so, there is not a vaccine against hepatitis c. there's a hepatitis a, b, c... and i'm not sure if there's more, but there's not avaccine against hepatitis c, but they have come out with these newwonderful, extremely expensive medications

to help treat hepatitis c and from the reports that i've been readingis these medications are so wonderful that their vaccine load in some of these patientsthat they're seeing is is almost none, so it's - they're consideredalmost in a sense, a cure. (are the symptoms pretty much the same? and the cause?) yeah, you know, it's, i'd... yeah. with the hepatitis c, getting it is, you know, the sharing of bodily fluids,

illicit drug use, you know, all thatkind of thing that can - the multiple sex partners, all thatcan make that the virus can be spread and ifanybody in your household has this disease, you just - it's a goodidea to be any of the household members shouldbe vaccinated against hepatitis a or b, you know, if... you know, you're living with your sister, she has it type of thing, you should be vaccinated against it

and you wanna do things, you know, don'tbe sharing toothbrushes or even razors in the shower cuz it's, it's a potentialto spread the virus. so. yes ma'am? (you said hepatitis c is a...?) the two vaccines that i talked aboutare hepatitis a as in "apple" and b as in "boy" and thenshe was asking about hepatitis c as in "cat." so... so like i said, an adult with recent travel to

central asia developed measles. fairbankshad their first measles cases to that we've seen inthe past 10 years. so, measles is a highly infectious viralrespiratory disease and it spreads via the airborne route and directcontact with respiratory secretions and just simply being in the same room assomebody with measles is enough to get the disease. it's one of the most virulent diseases that you can get. so symptoms are a fever

up to 104 degrees, runny nose, cough, redeyes and sore throat, and it's followed by a rash that typically starts, like, on the face and then the hairlineand then it kinda travels down and maybe you've seen a lot of measles, but a lot of... a lot of doctors these, this day andage, they don't see it. it could be totally misdiagnosed almost just becausewe don't see it a lot so the incubation period typically startsto appear about eight to ten - in eight to twelve days after exposureand the rash typically onsets about 14 days

and the infectious period is four daysbefore the rash even starts. so you may be - think you're sick, but not know you havemeasles and you could be infectious because therash haven't even started and up one of the reasons why measlescan just run rampant so and then you're also infectious for four days at leastuntil after the rash onset. and like i said before, if you think youhave it just definitely don't go into hugely populated areas. call

you know, you're supposed to call thedoctor's office first and they'll more than likely send somebodyout to see you versus you going to an area and potentially exposing people. so, if you were born prior to 1957,you're pretty much presumed immune because you're probably more than,at one time or another, exposed to the live virus and then adults born during or after 1957, if you don't have any evidence thatimmunity against measles, then you should at least get one mmrbooster dose. i have been giving

mmr at the pharmacy, not as much asi was expecting, which i think is hopefully good didn't but so, and then... (i was born in '49 and to volunteer at the hospital, they wanted me to have a shot or a test.) (they tested me and i was not immune. so i had to have an mmr. so that's true, but not completely?) correct, and even when i... so i was living down in pharmacy school in colorado and then i moved to wyoming and from wyoming moved to anchorage and before i started working at providencehospital, i...

i was one of the pediatric clinicalpharmacists, so they are making darn sure that i had my mmr up-to-date everything and sothey drew a titer even though i had documentation that i've had my mmr and i even, i can't recall whichcomponent was, but i'd - i wasn't immune to one of the components andthen they gave me an mmr and now when they draw titers, i'm immune to all three but, so yes. you know, people can get all up in armsabout all these anti-vaccers and blah blah blah, but

you know, in reality, it just maynot make a difference some people don't seroconvert. so... yes ma'am? (i was born in '47 and when i was a junior in high school, we got all those vaccines.) (...whole class, and we were all born about the same year, so we were not immune to it.) (if you have... are you immune to measles or are they two different viruses?) it's all different so (and i don't have any record of having an mmr. should i get one, do you think?) so i... (i imagine i got one at some point, but i...)

right, and you can always ask your doctor todraw a titer and then, you know, or you can... you can come in and get a booster. you know, it's either or. when i talk to the health department,they were saying, you know, if you, if you really don't have documentationbut you think you were exposed, then they're airing on the side of cautionand come in and get a... a shot. so... (would they do it in three separate vaccines in the old days?) i don't think so. i think it's always been an mmr.

(so a tighter shows all of your immunities?) so i know when they drew a titer on me, they looked specifically for the rubeola, mumps, and rubella. i don't know - i would imagine you wouldhave to ask for them to draw for... (ok, we don't know what a titer is.) (laughter) so, you basically go in for a blooddraw and they'll draw a tube of blood from you and... however they do it, they - they're looking at, like, the

the antigens and you immunity in the blood, but it's essentially just going in for a blood draw. (where does word come from? how did it start?) titer? t-i-t-e-r? (okay) but again, i... okay, so, in just briefly mumps is - particularly when you would see thatit's the inflammation of the salivary glands and is extremely painful and then rubella is the german measles,or sometimes they call it the three-day measles. it may not be as

as severe as the typical measles that youwould see, but the rubella is the one that is most detrimental to pregnant women. it could cause her to have a miscarriage or herbaby could be born with serious birth defects. so, this is typically what measles looks like and then this is mumps, just with the reallyswollen salivary gland. and then, so on the left, this is rubella - the german measles -

but to me, that rubella and the rubeola, or the measles, and this is roseola. there is novaccine for roseola, but kind of a childhood one, sometime you'll see itgo through day care centers, but they all look pretty darn same to me (when they look very severe, is there a gradation to the ... ) there is. when i was, you know, looking atpictures and stuff, there's all all kinds of severity and some of the rashes will be really itchy, some of them won't, and

that kind of thing. so, this is just - i know this ishard to read - this is just the 2015 recommended immunizations for adults and it's based on age. typically, ifyou're like 65 and older, pretty much this is just sayin get your yearly flu shot, get at least one dose of the tdap. if you're over 60, get your shingles. actually, in the state ofof alaska, shingles is approved for 50 and above.it's just that some people's insurances may not pay for it whenyou're 50. they will sometimes

make you wait till you're 60, likefred meyer insurance but again, if you're ever interestedwe can always run a test claim and let you know if yourinsurance will pay for it or not. (i'd like to make a point about that. you usually have to pay for it, but take my word for it. after having the shingles, it's worth the 200 or whatever it costs.) thank you. (laughs) (it's really worth it.) so yeah, i had - i got bronchitis not too long ago, but i...

i could've sworn it was pneumonia and i really wish i could just get a pneumonia shot, but with my age, they were like, "well, we don't recommend it," and i'm like, "i don't care, i just want it!" briefly i just wanted to... talk about what we offer at fredmeyers and of course we will fill your prescriptions for you. we also offer these mtmservices and mtm stands for medication therapy management.some people might know them as like a a brown bag event where - we did these a lot in pharmacyschool - where we would get people bringing an all their medications thatthey have, everything that they're taking

or not taking, put it in a brown bag, bring it to us, andwe sit down with you and we go through everything. we look at drug interactions,making sure you know what medication is used for, are you experiencing really bad sideeffects, are there any holes in your therapy, you know, if you're... if you're a patient who is diabetic, you should probably be on amedication for cholesterol as well just to help prevent these potential outcomes that can happen -

the coronary syndromes that can happen - you know, we just kinda sit down and see if there's any issues that we can look at, making sure that you're on amedication that is - that you have a clinical indicationfor basically. so we also do screen services. ican check blood pressures, i can check your blood glucose, if you're diabetic i can also check your a1c and you knowmost people think that you can only get this done at your doctor's office. it's avery quick

finger poke. i can do a1c. your bmi is your body mass index - i can also check cholesterol panels.we have the machine that it's just afinger stick and we can check your cholesterol panel. i also do coaching services fordiabetes management and care. fnw stands for fitness nutrition weight and heart healthyis more for hypertension and cholesterol issues andi also do smoking cessation.

again, we do all immunizations as well astravel consult. so we'll do, if you're traveling the world,we can do japanese encephalitis, rabies, typhoid, polio, we can do everythingbut yellow fever. but that's going to bechanging. so... it's a mosquito-borne illness, but it's... but it's only seen like in certaincountries but... (... hadn't heard about it.) it's a mosquito-borne illness.. (is it like.... fever... ?)

i've only given once - i have to re-read it. but it's.... yes. yes. i'm pretty sure it's different but it's, you know, we can always take a look, see where you'retraveling and if it's recommended because it's recommended in some areas but notothers so we can - so, i can do travel consults. i know in town, at certain doctor'soffices, they'll charge you about two hundred andforty dollars just to do a travel consult. our fee is fifty dollars

but, you know, if you even wanna hop on thecdc website you can... you can check, you know, you can put inyour itinerary and see which vaccinations that you should get and it'll save you fifty bucks, so... but again, you know, call me up - wecan always discuss it. let's see... we also do diabetic food tours and this is a new thing thatwe're doing. we just had our first one a few months ago, but they're led by a dietician and it basically if you have diabetes oreven

somebody with diabetes and your family,we do an overview of diabetes but then we walk the food aisles and it's patient-led and they ask questions of the dietician, findingout what is a better bread, how to count carbohydrates, that kind of thing.and we got really good reviews from it, so we're waiting to do our next one. so and i just wanted to tell you alittle bit about the fairbanks health department. they do allchildhood vaccinations up until

18, but for adults i know a vaccination can potentially of a lot of money. i know that. my goal is for you to get what you need to makeyou as healthy as possible. so, the fairbanks health department, they will do adult vaccinations, but only some.they will do the tdap, they will do the tetanus and they'll do the pneumovax, but they don't dothe new prevnar. and then they will only do shinglesfor ages 60 to 64 - something with their grant, that's onlywhat they're able to vaccinate for -

and they also do the hpv vaccination,with it which is that human papillomavirus one, but it's only... it's only for that age group which is like to 26years old or something. so, the cost at the fairbanks health department, it's $27.44 for your first vaccine and fifteendollars for each additional vaccine. so if you're really strapped for cashand you fit within these parameters, by all means, go see them at the fairbanks health department.

they are very, very wonderful there so. the tdap is the tetanus, diphtheria, and pertussis. so, these are just my take-aways.. and the biggest piece of information that i want you to take away from this is just know the potential hazards of poly-pharmacy and how to help manage it, also keeping a current list if yourmedications with you that you take with you to each and every doctor's appointment and... and again that should include yourallergies, name dose, how you take it, and what it's used forand then also knowing which vaccines are

right for you. and you can also go to the cdc website.that website is pretty phenomenal. you can take like alittle test where you plug in your age and gender and answera few questions about your lifestyle and health conditions and it will pop out what recommended vaccinations you should get. so, and again if you're ever curious, youknow, talk to your doctor, talk to your pharmacist, and we can always go through that, evenif you don't have a record of your

vaccinations, probably getting an extra one is not gonnahurt you. so and again, just one of the mostimportant things is just help us help you and be active in your own health care.ask questions and be an informed consumer because the most important person inyour health care is you. so, any additional questions? (laughter and applause) sorry, i know i ran a little bit over and i tried to pare it downapparently

i can really talk. yes sir? (this concerns medications. if you're traveling, specifically out of the country, and your medications are expired or lost or stolen or damaged or something like that, are things on medications pretty much standardized and how would you go to a foreign pharmacy and say, "i need this?" so, medications are not the same. like, i don't know if it's canada or europe acetaminophen, which is tylenol, it goesby paracetamol. it's one of the fairly more common ones that i know of,

but i would definitely now there's - but there's references that we can pull up online - i'm assuming theycan also do that there - that you can look for medications that are out of your country or... i'm trying to think of the word that i'm trying to say, but there's... there's references that youcan look up, like, okay i'm on this - what is your version of it and are thereare ways to look at that and you know, try to at least go to ahospital or a pharmacy and see.

you know, there's a ton medications thatare you can buy at a pharmacy elsewhere that you can't buy here. they may be able to definitely get you what you need or something hopefully similar. (should you get a doctor's or pharmacist's from this country or.... ?) like here in the united states we, we cannot take prescriptions fromelsewhere, from out of the country so it's... right. like, i mean, in canada you can get musclerelaxers over-the-counter, you can get

all kinds of stuff over-the-counter. (so you can talk to the pharmacists and they are very knowledgeable and they will come to, you know, they look at the ingredients and at what you're taking.) right. and i would, you know, i would say it try to go tolike a hospital type of place... they have national health in a lot of the countries they're pharmacies are not our pharmacies, they're not drug stores...) right, correct. like i know down inmexico - i was born and raised in el paso, texas. you just walk right across the border and you're in mexico and, boy, youcan go to the pharmacies, you can get

antibiotics, if you can get - they may go by a different name but it's,you know, you can get a lot more that's essentially over-the-counter that thepharmacist will get you that that you couldn't get here in the states. but i would definitely, when you're travelingmake sure you keep those on your, your carry-ons - don't put it in your luggage. yeah. so... yes ma'am? (recently.... had an influx of people.... thousands of people who have come into this country

and nobody knows what they had or haven't had. what is being done - do you know - about this?) i don't know exactly what is being done do you know, tiffany, anything at all? (... i'm not, but that's a very good question.) hope that you know some kinda itgovernment regulated but again, i don't know forsure. any other questions? (sometimes if you get behind or skip something, they say when you're trying to get a prescription refill

and you skipped two or three days, my impression is you're supposed to take all of those two or three days to catch up.) no, i would not. if you missed three days of medications, especially like diabetes medication, iwouldn't take, you know, three pills of metformin you're gonnabottom not your blood sugar, so i would start - you know, you shouldn't double up on a medication. take it as soon as you remember, but don't double up on a medication. well thank you everybody. (applause)

i talked to leah oh my goodness, was this back in september or october to do this presentation because as a dietician and working in a hospital, the list of medications, and i mean, i have to take a few medications and just knowing that my synthroid has to be on an empty stomach, before i eat, you know, i have to take it every day, myrefills, and that's just - those are two medications. and i can't imagine having more than that and the scary reality of what happen if youforget to take your medication and so

i'm so thankful for your advice and justthat medication she - i mean, we get prescribed medications and wetrust that the doctor knows what they are for us, but when you have multiple medications it's important that you... that you know what they are, what they do,when they look like, and if you're - my husband is notorious, "well i know that it's almost expired, but weshould keep it just in case." yeah, no no no. if it's expired, throw it away. and in just a little blurb on getting rid of your medications if you don't use them or they're expired,

some people here... a number of people, they're just like, "no i don't wanna flush it down the toilet because the fish," or you know, and that is hunky-dory fine and dandy. what you should do is if you have coffee grounds or kitty litter, get your medications thatyou aren't using grind it up, mix it with something likekitty litter or coffee grounds that makes it unappealing to somebody digging throughyour garbage

and then put it in a sealed baggie andthen you just throw it away. that is typically what you're supposedto be doing. (they also have the....) yeah, drug take-backs. now... yeah, i... yes but i... i am not positive on this, but i don't know if they're doing that anymore. and which is a complete shame. (prescriptions... has a bin...) here are you third

(it's a new service and some of the pharmacies are subscribing to it. it's a take back and it's in a sealed container and it's sent to a company that's...) yeah, and i know we sell these bags. yeah, we sell these bags that you can put them in and then seal them up and i think it's even free shipping and ship it off to somebody, but... (i think the coffee grounds and the kitty litter idea is better because you can just put it in a ziploc and put it in with the rest of your...) (the other thing, you know, i'm a pharmacist too and so i really appreciate what you've said and the most important thing

to me is get your prescriptions at one pharmacy please because we don't - we talk to each other - i'll talk to leah if my computer's not functioning so i don't have a record. when i was working, i didn't have a record of what you had filled yet, at fred meyers, safeway, and a the emergency health center.... so it's really important that this is great, that's the best thing of all but just get everything filled at one place and figure out which is the most convenient or best for your particular... if you shop at fred meyer all the time, that's the best place, or safeway good yeah really

and it's really best to keep everything in one spot.) im (so, do any doctors not approve of you changing to generic when they become available?) they will specify - like they will put a daw in, which means dispense as written. there's a few eye doctors that they really want certain particular brand-name eye drops, or it's pretty rare. we have some patients on like their duragesic pain patches and by golly they have to have brand-name

on all their pain meds. they can't have generic and they'll raise a huge stink if they don't get brand-name but it's, you know, we see itwith classes of drugs but doctors for the most part, they don't really mind.... (but your insurance minds.) right. insurance - if there's a generic available yourinsurance wants to pay for the generic. they don't pay for the brand (yeah, i'm also on synthroid and i have to take the brand.) now, there are certain class.... right, there are certain...

right, there are certain drugs that, by golly, if you are on the brand, stay with the brand. and those would be things like coumadin, the blood thinner, but if you take warfarin, then stick with warfarin. if you're on synthroid, stay with synthroid andbecause if you're flip-flopping back and forth that can have a tendencyto mess with your inr or your levels... what's another one... (...and the doctor needs to write it on the prescription and oftentimes i have to remind the pharmacist...) yes. (... do generic, and i realize that...)

yes, yes. and sorry! (laughs) if you take more than one medication, it would be very helpful if medications were sold like, in either 90 pill sized containers, instead of some come with 90, some come with 100, so you can't keep them together because if you want them refilled, all of a sudden you're getting them too soon for the one prescription. so here's the deal with that. some certain doctor's offices will either write for 30 pills, they'll write for a month's supply with

11 refills for your year or they'll write for 90 tablets plus 3 refills for a year. now, at a pharmacy we can only... we can only bill an insurance company what that prescription says. if you're - if we're gonna bill it to insurance and ifyour doctor wrote it for 90 tablets, we will put it in, we will charge the insurance companyessentially for 90 tablets and then they'll send us back a reject saying,

"well, our plan only pays for 30 pills." so then we change it to 30 pills if you want it on insurance. now if the doctorwrites for only 30 tablets even though your insurance company will pay for a three-month supply, it... it's insurance fraud if we change that to90 if the prescription is not originally written for 90 tablets. it's something that is so minute and so ridiculous, but it's insurance fraud. and so if we get audited, and we've bill them for 90 tablets but

the perception is only written for 30,we'll get humongous fines. so it yeah so we will... we encourage doctors and patients to, gosh, you know, just write for those 90 tablets you know, and we'll take it fromthere. we will bill it for 90 but even if yourinsurance company only allows a 30-day then okay, we'll fill it for 30, but for those patients who allow a thirda 90-day supply a you know, please just let us do that.

it's just, you know, it's something that's so little, but it really affects a lot of patients ifyou can just... yes, i agree. (is the use of next med md pretty common? i've ordered my pills and i'm reminded of my 90 days, when i ask for a refill.) is that something through your doctor's office? (audience speaking) oh, it's like where you can send them emails and stuff yeah, and i'm military, and so... and i know that that is coming about where it... and it

makes it much easier for patients, you know,if you have a question for the doctors, nurses, you know, something like that, you could just shoot them off an email versus making a phone call and waiting three days for them to finally call you back and by golly, you think you have trouble getting a hold of your doctor? we do it all day long. so... yes? (i had a funny situation where...) yeah, it all is based on your insurance company and the drug. they you know, they... sometimes they'll pay for a 30-day supply, but boy,

sometimes they'll really stick it to you, you know, for certain medications. no, and to tell you the truth, doctors have no idea what medications cost. i don't even think they care - i mean, theydo, but i mean, essentially they have no ideahow much something costs. we, you know, we get patients all the timelike, "you're kidding me, that antibiotic is eighty dollars! i don't have insurance.i can't pay for that!" you know, when when whatever they're being treated forcould be treated with

amoxicillin almost just as effectively, you know, that is pennies compared to what they're on. so it's... you know, if that's an issue, you know, we will call. we will... say you know, either the patient isn't gonnapick up this medicine because they can't are please call in something that theycan afford so we can cure their infection. you know sometimes arm you know we do that with your dropsand eye drops a lot to you i'm can the other currently

and homeless arms so and you know it you feel he well no him wrong and your here hit you know i kitty have to fire missus and they pretty much they just let thediet

let the doctor diagnosed patients andlet us treat the peace you hit no it doesn't but ok but yeah it would be a wonderfulworld if that happened you but yep me he had called it's not called leah the police %uh taking it next week acupuncture andoriental medicine so it should be another interesting upinteresting lectures i appreciate your time tonight and ifyou like update as well and

michelle are let well and %um email what's coming up out for summer sessionthank you very much well little yet excellent lindon okay k the keeper setting only employees you know little i go to just one good girl i cary mullis not know paul hunt it's just really important like poultryshe ate stress

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