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Thursday, August 17, 2017

  • Get a better understanding of Lyme Disease
    Monday, August 14, 2017 4:00 AM
    The arrival of warm weather each year means we have to start worrying more about Lyme Disease. Most people are aware of the association between tick bites and Lyme disease, but few know exactly what Lyme disease is or what causes it. Indiana has seen an increasing number of confirmed cases of Lyme disease, particularly since 2013. The most recent statistics showed 102 cases in Indiana in 2015.
    Lyme disease received its name in the late 1970s when a number of children around Lyme, Connecticut developed arthritis. The actual disease has been described since the early 1900s. It is mostly found in New England as well as Wisconsin and Minnesota. When a case does occur in Indiana, the news spreads rapidly, sometimes inciting panic. Most infections (85 percent) are seen in the spring and summer with the remainder in the fall. 
    Ticks do not actually cause the disease, though they do carry the organism that does cause it, the spirochete Borrelia burgdorferi. Spirochetes are bacteria that have a spiral shape. Another common misconception is that any tick can spread B. burgdorferi infection, when in fact only Ixodes (deer) ticks carry the organism. The accompanying photo shows a deer tick on a fingernail – they are very small.
    The B. burgdorferi organism, during its various life stages, mainly infects field mice and white tailed deer. Humans are innocent bystanders when we wander into deer habitat. The ticks lie in wait on the tips of grasses and shrubs and crawl onto us as we brush by. They then crawl about until they find a nice tender spot where they attach and begin to feed.
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  • It’s that time of year: Leaflets three . . . let it be!
    Monday, August 07, 2017 4:00 AM
    We are in the middle of summer and people are still out puttering in their yards. Predictably, this has resulted in a lot more cases of contact dermatitis showing up in my office, most of which were likely caused by poison ivy. Poison ivy is one of three plants in Indiana in the genus Toxicodendron. This genus also includes poison sumac, commonly found in central Indiana, and poison oak that is an infrequent offender.
    The physical appearance of the poison ivy plant is highly variable, though it always has leaves in sets of three (see illustration). Boy Scouts learn a little mnemonic to recall what it looks like – “leaflets three let it be, berries white a poisonous sight.” The white berries can sometimes be seen in wintertime. The plant is small and low to the ground when young. As it grows, it can be found in various sizes all the way up to a thick vine attached by small red roots to trees or other structures.
    The rash of poison ivy, like most contact rashes, results from the immune reaction to a foreign compound on the skin. The compound binds to skin cells, is recognized by the immune system, and attacked. When dealing with poison ivy, sumac or oak, it causes a typical rash, known as “rhus dermatitis.” 
    In the case of poison ivy, oak and sumac, the offending chemical is the plant resin or oil urushiol. Interestingly, urushiol is also found in mangos and the shells of cashew nuts. This oil can remain active for years after a plant dies. 
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  • Monday, July 31, 2017 4:00 AM
    The joy of summer sports and yard work has resulted in a number of patients coming to see me complaining of sore shoulders, elbows, hips and knees. Many of these folks have been suffering from bursitis. Most people have heard of bursitis, but what is it really? 
    Any time a medical term ends in “itis,” it indicates inflammation of the tissue or organ involved. In this case, bursitis is an inflammation of a bursa (pleural bursae or bursas). Bursa is Latin for purse, a very good descriptor of what it looks like – a small sac made of connective tissue. 
    A bursa is lined with a synovial membrane that secretes fluid, filling the sac. This turns the bursa in to a little pillow filled with a slippery liquid that helps cushion structures around it. It also allows these structures to glide more easily over each other. Here’s a fun activity for the kids; make your own bursa by putting just a little water in a small balloon. Then put an object like a book on top of it and roll it around on the table to get an idea of how bursae work. 
    There are many bursae in the body. The ones that cause the most problems are found in the shoulder, elbow, hip, and knee. These joints are fairly complex and have many bones, tendons and ligaments that intersect and move over each other. Without the aid of bursae, these structures would rub together, causing a lot of pain as well as wear and tear.
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  • Monday, July 24, 2017 4:00 AM
    I continue to be amazed that, when asked what the number one killer of women is, the majority of women respond, “breast cancer.” While breast cancer is the number one cancer killer of women, and is estimated to have claimed about 40,000 women last year, it is not the biggest threat women face. It’s estimated that ten times that many women - 400,000 died of heart disease in the same year.
    Cardiovascular disease is arguably the most important women’s health issue that is largely preventable. How can women be so unaware that they have a one in 31 chance of dying from breast cancer but a much higher one in three chance of dying from heart disease? Could it be that breast cancer gets so much more coverage in the popular media? Is breast cancer generally more frightening & potentially disfiguring? Is heart disease just plain boring to talk about?
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  • Monday, July 17, 2017 4:00 AM
    I saw a young athlete last week complaining of shin pain. He had been upping his running mileage; the pain was due to a stress fracture. It is estimated that between five and 30 percent of athletes and military recruits develop a stress fracture each year. Briefhaupt first described the condition in 1855 when examining military recruits.
    Everyone is familiar with bone fractures, especially those that result from acute trauma. These fractures are usually easy for an untrained person to see on an X-ray – the bone looks like a broken stick. Stress fractures, however, can be much more difficult to diagnose.
    Stress fractures result from repeated stress on the bone. This repetitive microtrauma causes disruption of the microscopic structure of the bone over time that eventually exceeds the bone’s ability to heal itself. A tiny crack subsequently develops in the bone that may or may not be obvious on an X-ray. Think of bending a piece of metal over and over. Eventually it weakens, cracks and eventually breaks.
    Stress fractures typically occur in bones that are prone to repetitive stress based on particular sports. The fractures can involve any bone, but the most common locations and their associated sports include the leg, hip and foot (runners & jumpers), the spine (gymnasts, divers & volleyball players), arms (throwers), and ribs (rowers). The forces experienced by bones in the feet and legs can be up to twelve times a person’s weight. Stress fractures are one of the five most common injuries in runners and account for up to half of injuries in soldiers.
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  • Monday, July 10, 2017 4:00 AM
    Kidney stones are a topic near and dear to my heart as I’ve had the distinct pleasure of passing four of them. Stones are also known as calculi, from the Latin for pebble. They can form and stay in the kidneys (renal calculi or nephrolithiasis) or move down the ureters, the tubes connecting the kidneys to the bladder (ureteral calculi or urolithiasis). Stones may also be found in the bladder.
    The ureters are very small tubes that contain smooth muscle cells. These cells contract to help move the urine from the kidneys to the bladder. When a stone is too large to pass down the ureter, it can partially or completely block the flow of urine, causing pressure to build up. This pressure, along with contractions of the muscles in the ureter, results in severe pain called ureteral colic.
    The peak onset of kidney stones is in the third and fourth decades. It is rare after age 60. Men have about a 12 percent lifetime chance of developing a kidney stone while women have a seven percent chance. Interestingly, stones are more common in the Southeast United States. The chance of developing a recurrence of stones is 14 percent at one year, 35 percent at five years, and 52 percent at ten years.
    Stones form when the urine becomes supersaturated. This means that compounds in the urine become so concentrated that they start to form crystals. These eventually grow to form stones. Maintaining adequate fluid intake to keep the urine diluted is therefore very important in reducing the risk of stone formation. Other types of stones may be formed by infection in the kidneys.
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  • Monday, July 03, 2017 4:00 AM
    This week I want to tackle the subject of generic vs. name brand medications. There are a number of reasons this topic is important. First of all, medications in general are becoming prohibitively expensive for many patients. Insurance companies are also pressuring patients and physicians to prescribe generics whenever possible to reduce health care costs (not necessarily a bad thing, but certainly a pain in the rump at times).
    I receive many questions about generics in the office. People want to know why every medication doesn’t have a generic substitute and if not, how long will it be until one is available. They also want to know if they are safe and effective.
    First let me describe what generic and name brand drugs are. Generic drugs are chemical compounds that either never received patent protection or the patent on the name brand drug has expired. In contrast, name brand drugs are protected by a patent, meaning no other companies can produce or sell that particular drug. 
    This brings me to the answer for one of the most commonly asked questions – when will the generic version of a drug be available? When a drug is patented, the patent on the specific formulation is in effect for 20 years. Patents are granted shortly after the drug is discovered in the research lab. This is usually long before it is even tested in clinical trials in humans, which can take between eight and 13 years. Therefore, generics often aren’t even available until seven to 12 years after the name brand hits the market.
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  • Monday, June 26, 2017 4:00 AM
    Urinary tract infections (UTIs) account for about eight million visits to physicians each year in the United States. These infections are much more common in adults, particularly in women. Children account for one to two percent of all UTIs, but their infections are often more serious. About 40 percent of women and 12 percent of men have a UTI at some time in their lives.
    The urinary system or “tract” is composed of the kidneys, ureters, bladder and urethra. The kidneys filter waste products from the blood and produce urine that passes down the ureters to the bladder, where it is stored, before passing out the urethra. An infection can involve one or more parts of the urinary tract.
    Bacteria that normally inhabit the bowel and live around the anus are the cause of most UTIs. The gut bacterium Escherichia coli (E. coli) is far and away the most common offender. Bacteria cause UTIs by making their way to the opening of the urethra where they can enter and start to grow anywhere in the urinary tract. 
    The two most common ways bacteria enter the urinary tract in women is through improper hygiene (wiping from back to front after a bowel movement), and sexual intercourse. Older men are also more prone to UTIs because their bladders may not empty completely due to obstruction from enlargement of the prostate gland.
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  • Monday, June 19, 2017 4:00 AM
    Summer barbecue season is in full swing and it’s a good time to review food safety. Food-borne illness is something that almost all of us have experienced at some point in our lives.
    Food-borne illness is defined as more than two people having a similar illness with evidence of food as the source. The overall rate of these illnesses has gone down drastically in the last century with improvements in food handling and sanitation. However, we still hear about illness outbreaks.
    There are approximately 76 million cases of food-related illness in the United States each year. There are also about 325,000 hospitalizations and 5,000 deaths. Underdeveloped countries, as a group, experience about one billion cases annually and four to six million deaths.
    The Centers for Disease Control estimates that 97 percent of all cases of food-borne illness come from improper food handling. Most of these (79 percent) are from commercial establishments, while the other 21 percent originate in the home.
    There are a few common denominators that account for most cases of food poisoning. Leaving foods at temperatures that allow bacterial growth is a frequent cause, especially in the summer months when food is left out in warm weather. This can result Staphylococcal food poisoning that is usually seen in foods like potato salad and pies that are high in salt or sugar content.
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  • Monday, June 12, 2017 4:00 AM
    The mother of one of my patients asked me to write about meningitis. First of all, I want to state that meningitis is a very rare condition. The incidence of bacterial meningitis in the United States is about two to three per 100,000 people per year, while viruses cause about 11 cases per 100,000 per year. It used to be much more common when I did my training in the late 80’s, but with the advent of preventative vaccines, the incidence has dropped dramatically.
    Meningitis is a condition that causes inflammation of the meninges, the coverings surrounding and protecting the brain and spinal cord. Most of the symptoms of meningitis are caused by the inflammatory reaction of the body to infection by viruses and bacteria, and rarely fungi or parasites. These microorganisms reach the meninges either through the bloodstream or by direct contact of the mininges with the nasal cavity or skin.
    Meningitis, especially bacterial, can be very serious if not diagnosed and treated promptly. Death from meningitis occurs about 20 percent to 30 percent of the time in infants, about two percent in older children, and from 19 percent to 37 percent in adults. The risk is much higher in those who have other co-existing medical problems.
    Viruses are the most common causative agent in meningitis. Viral meningitis is usually caused by enteroviruses, herpes viruses, varicella (chickenpox) virus, mumps virus, measles virus or HIV.
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  • Monday, June 05, 2017 4:00 AM
    Summer is just around the corner which means we’ll start to see patients complaining of “swimmer’s ear.” We tend to see more of this malady in hot, humid weather, but it can also be brought on by other conditions as well.
    The medical term for swimmer’s ear is otitis externa, indicating inflammation of the external ear. This is in contrast to the more common otitis media, or infection of the middle ear (the air filled cavity just behind the ear drum).
    The number of people who suffer from swimmer’s ear is about four per 1,000 per year, or about three to five percent of the population. It afflicts males and females in equal numbers and tends to present between seven and twelve years of age, though older folks can certainly be afflicted.
    The wax (cerumen) that everyone is always trying to get out of their ears is actually there to protect the external ear canal. There exists a delicate balance of too much or too little cerumen. If there is not enough present, the ear canal can dry out, crack and develop infection. If there is too much, the ear canal can become too moist. This leads to swelling and breakdown of the skin lining the ear canal.
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  • Monday, May 22, 2017 4:00 AM
    Despite not getting to Memorial Day yet (thanks to all those who gave the ultimate sacrifice), it’s time to start thinking about the dog days of summer. Although I don’t see a significant number of heat-related emergencies in my office, many patients do end up in emergency departments suffering from exposure.
    Deaths from heat-related illness range from 300 to several thousand per year in the U.S. The number is increasing with our warming climate and is markedly increased during heat waves. There are tens of thousands of visits each year to doctors’ offices and emergency rooms.
    Risk factors that make one more prone to heat-related illness include being elderly, very young or obese. Some prescription or even non-prescription drugs, particularly alcohol, cocaine, antihistamines, beta blockers, diuretics, ADD/ADHD medications, and some psychiatric medications can increase the likelihood of heat illness. Workers like firefighters, who have to wear heavy clothing, are also at very high risk.
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  • Monday, May 15, 2017 4:00 AM
    Readers have asked me to address more summer safety issues. It’s great to see kids and adults out on their bicycles now that the weather has warmed up (especially kids who aren’t sitting on the couch). This will undoubtedly result in more bike accidents. Some of the saddest experiences I had during my Family Medicine residency were to have to take care of kids who were brain injured as a result of a bike accident.
    In 2014, there were 726 deaths from bicycle accidents in the United States. Most of these deaths were the result of head injuries from people being hit by or running into automobiles. Bike accidents account for about half a million visits to emergency departments each year and account for over $10 billion in health care costs.
    While most kids own bike helmets, often they tell me they don’t wear them. Parents often bring up the fact that they never wore a helmet when they were kids. Most of the time, the reason is because helmets did not exist when they were kids.
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  • Monday, May 08, 2017 4:00 AM
    This past weekend’s sunny (yet chilly) weather reminded me it’s time to starting thinking about summer. This week, I want to briefly review some sun and water safety tips.
    Most people enjoy a good day in the sun. Whether it’s lounging by the water or working outdoors, we all get our fair share of sun every summer. Everyone knows you can get a burn if you’re out in the sun too long. However, many people don’t realize that you can still get a burn in the shade or on a cloudy day. Ultraviolet rays come in two forms: UVA and UVB. UVA accelerates aging of the skin, while both UVA and UVB can cause skin cancer.
    Sunscreen lotions work by absorbing the UV rays before they penetrate into your skin and cause damage. They can be effective, but only if used properly. Dermatologists will all tell you it’s safer to use physical blocking agents like widely available sun-protective clothing and wide-brimmed hats.
    Sunscreens are rated using the “SPF” scale. Don’t bother with lotions with an SPF below 15. An SPF of 15 theoretically allows you to stay in the sun 15 times longer before you burn. However, the effectiveness does not last near that long since the lotion usually wears off from sweating, swimming, or friction. They should be applied liberally (at least 2-3 tablespoons per application) before going out in the sun. They need to be re-applied at least every two hours. It’s important to get a broad-spectrum lotion that absorbs UVA and UVB.
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  • Monday, May 01, 2017 4:00 AM
    I had a request to write about lupus. Lupus is the common name for Systemic Lupus Erythematosus. It is an autoimmune disease first described by the physician Rogerius in the 12th Century. There are many opinions regarding the origin of the name. One of the most popular is that the rash on the face of many lupus sufferers resembles a wolf’s face. Lupus is Latin for wolf.
    Autoimmune diseases are a group of illnesses caused by a person’s immune system attacking their own cells. In the case of lupus, the immune system makes antibodies against proteins in the nuclei of cells, the part of the cell where the DNA is found. It is believed that people who develop lupus have an underlying genetic predisposition to the disease. There is no single “lupus gene.” Like most genetic diseases, it appears to involve problems with multiple genes and interactions with the environment.
    Certain environmental factors are felt to trigger damage to cells that results in exposing proteins, normally hidden in the nucleus, to the immune system. Some of the factors causing damage are thought to include ultraviolet light, stress, medications, and infections, likely by viruses. Drug-induced lupus usually goes away when the offending medication is stopped.
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