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Sunday, May 27, 2018

  • Monday, May 21, 2018 4:00 AM
    As we approach Memorial Day (remembrances 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 heat exposure.
    Deaths from heat-related illness range from 300 to several thousand per year in America. 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.
    Absorbing too much heat from the environment or producing too much heat internally can lead to heat illness. The two main types of heat illness are heat exhaustion and heat stroke.
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  • Monday, May 14, 2018 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 2015, there were 818 deaths from bicycle accidents in the United States, an increase of over 12 percent. 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.
    Helmets really do work – wearing one decreases the chance of a serious head injury by over 50 percent and serious face & neck injuries by 33 percent. Those wearing helmets have less than a 17 percent chance of dying from a bicycle accident – a marked improvement from pre-helmet days. Deaths for persons under 20 years old have decreased 88 percent since 1975.
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  • Tuesday, May 8, 2018 4:00 AM
    It’s finally getting warm outside – 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.
    Sun intensity is highest between the hours of 10 a.m. and 4 p.m. so try to minimize exposure during those hours. Sunburns suffered in childhood are a major risk factor for skin cancer later in life, so model good behavior and tell your kids the importance of protecting themselves. Regular use of sunscreen in kids can lower their risk of skin cancer by almost 78 percent.
    Don’t forget your sunglasses! While most folks apply sunscreen to their skin, they forget to protect their eyes. UV radiation can cause damage to the lenses in your eyes and lead to cataracts. Be sure and read the tag on the glasses to make sure they’re rated to block 99 to 100 percent of the UVA and UVB rays. Wraparound glasses are the most effective.
    If you’re in the sun, water often isn’t too far away. An estimated 260 children under age five drown each year in residential swimming pools and spas. Another 3,000 are treated in emergency rooms for submersion accidents that often lead to permanent brain damage. Nationally, drowning is the fourth leading cause of death in children under five.
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  • Monday, April 30, 2018 4:00 AM
    The summer sports season will be starting soon as will gardening and other outdoor chores. If they haven’t already, weekend warriors will soon be doing all sorts of things to keep doctors who treat musculoskeletal injuries busy. I want to give everyone some pointers in how to take care of the inevitable sprains and strains of summer.
    It’s interesting to me how many people come to my office after suffering an injury and don’t have any idea how to do some initial first aid. It’s extremely important to treat injuries immediately to prevent additional damage and disability.
    When a musculoskeletal structure is injured, a biochemical chain reaction is triggered to attempt to heal the injury. Injured cells release various messengers that start the process, but this also results in pain and swelling. The intent of this inflammation is to get the person to rest the injured area so it can heal. However, for an athlete or anyone trying to get back to play or work as soon as possible, this can prolong the time it takes to get back to normal function.
    The goal of orthopedic and sports medicine is to promote healing of an injury, but to also speed up the recovery process. The best way to do this is to prevent or slow the normal inflammatory chain reaction. It’s very simple really. The only memory aid you have to recall when you are injured is the word “RICE.”
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  • Monday, April 23, 2018 4:00 AM
    It’s once again time to run my annual column on allergies. Many of our readers are probably already cursing the annual return of allergy symptoms. The pollen levels in Indiana are already ramping up as spring (hopefully) arrives for good.
    Allergies are a major problem for many people. When allergy sufferers are asked about their quality of life, they generally rate allergies as more bothersome than heart disease and sometimes even cancer. There are many causes of allergies, but I want to focus on the seasonal type.
    Seasonal allergies are caused by pollen. Pollen actually contains a plant’s male DNA; it is analogous to sperm in animals. The goal of any biologic organism is to spread its genes as far and wide as possible. Pollen is the perfect vehicle to accomplish this task. 
    There are two main categories of pollen – anemophilous (wind-loving) and entomophilous (insect-loving). Anemophilous pollen is very lightweight, which allows it to move great distances, particularly on windy days. In fact, engineers have used the geometric shapes of some of these pollen grains to design golf ball dimples to help the balls fly farther. Anemophilous pollen is produced by trees, grasses and weeds.
    Entomophilous pollen is produced primarily in plants that bear flowers. It is much heavier and stickier, allowing it to be picked up and spread about by insects. These pollens are much less likely to cause human allergies since they are not typically blown into noses by the wind.
    Plants produce and release pollens at various times of the year, hence the “seasonal” nature of allergies. Trees in Indiana start pollinating in late February and usually end sometime in May. Each species of tree pollinates for around one to two weeks. Right now, the predominant pollen in central Indiana is from Maple, Ash and Birch trees.
    Grasses start pollinating in April and continue on through May. Hoosiers then get a break until about mid-August when ragweed starts up and continues until some time in October. The allergy season has become longer over the past two decades, starting two to three weeks earlier and lasting two to three weeks longer. This is most likely due to warming from climate change.
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  • Monday, April 16, 2018 4:00 AM
    I’ve received a request to write about thyroid gland problems. Thyroid problems are common in a family medicine setting. For those who don’t know what the thyroid gland is or does, keep reading.
    The thyroid is an endocrine gland found in the front part of the neck below and to the sides of the larynx or Adam’s apple. Endocrine glands make hormones that are secreted into the bloodstream. The hormones then travel around the body and interact with cells in different tissues, like tiny fingers that flip switches on cells to tell them to perform particular functions.
    The primary job of the thyroid gland is to control metabolism (energy use) in our cells. It does this by producing two hormones, T4 (thyroxine) and T3 (triiodothyronin). Both of these hormones contain iodine which is why iodine is so important in our diets.
    Our cells have hormone receptors on their cell membranes that act as sensors to constantly monitor body functions and tweak them to maintain “homeostasis,” a balanced internal environment. Biochemical systems that maintain homeostasis are extremely elegant. Some work like a furnace thermostat that turns the furnace on or off based on the temperature in the room. Instead of using wires and electricity to communicate, the body uses the circulatory system and hormones as chemical messengers.
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  • Monday, April 9, 2018 4:00 AM
    Snoring can certainly be annoying, but it doesn't always indicate a serious medical problem. This week, however, I do want to focus on a harmful condition that can be associated with snoring – sleep apnea.
    Sleep apnea is a condition where people have pauses in their breathing while sleeping. Most people have pauses to some degree, but people with sleep apnea have much longer pauses, sometimes lasting up to 30 seconds. These long pauses cause the level of oxygen in the blood to drop and carbon dioxide to rise. These changes can be very hard on the body, especially the heart and lungs.
    There are two main types of sleep apnea – central and obstructive. Central sleep apnea is a problem with how the brainstem sends signals to the breathing muscles. It is not a very common cause of sleep apnea in adults; obstructive sleep apnea (OSA) is seen much more often.
    Obstructive sleep apnea is caused by any type of obstruction to the flow of air in and out of the lungs. This usually occurs in the back of the throat when excess or loose tissue collapses into the throat when the throat muscles relax during sleep. This is why OSA is much more common in obese individuals – they have a lot of extra tissue in their throats.
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  • Wednesday, April 4, 2018 4:00 AM
    I’m running through my list of suggested topics from readers, and this one goes out to a reader from Sheridan. It’s a common problem, but one of those topics that doesn’t usually come up in casual conversation - constipation.
    There are three common times in a person’s life when constipation can become a problem. The first is during early childhood, the second when a person has decreased activity for some reason, and the last is during the elder years. Each one has different causes.
    First, I have to deliver yet another lesson in basic anatomy and physiology. When we eat, food travels through the following structures: mouth, esophagus, stomach, small intestine and finally, the large intestine. This journey is facilitated by peristalsis, a process where involuntary muscles in the wall of the digestive tract contract to move food from north to south.
    While constipation can involve trouble anywhere along the way, the vast majority of problems occur in the colon. One of the main jobs of the colon is to reclaim water from the stool. If the stool is slowed down in its transit through the colon, more water is absorbed, making the stool firmer.
    Young children can develop problems with constipation when they put off going to the bathroom for various reasons. When this happens, they can retain incredible amounts of stool in their colons. This stretches the wall of the colon to the point it weakens the muscles responsible for peristalsis. 
    Eventually the colon dilates to the point where the muscles are not able to push the stool out and the child may lose the urge to have a bowel movement. These children may pass very large bowel movements and may have a great deal of pain when doing so. They also may have accidents, passing semi-solid or liquid stool that has leaked around the blockage. Painful movements lead to the child not wanting to have a bowel movement and the cycle repeats itself.
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  • Tuesday, March 27, 2018 4:00 AM
    Last week I tried to explain the very complex non-Hodgkin lymphomas (NHL). This week I want to cover Hodgkin’s lymphoma, more commonly known as Hodgkin’s Disease (HD). It gets its eponymous name from Dr. Thomas Hodgkin, who first described it in 1832.
    Hodgkin’s is a potentially curable malignant lymphoma and carries a much better prognosis than non-Hodgkin lymphomas. It is a very specific type of lymphoma that is defined by its microscopic appearance and by specific proteins that are found on the cell membranes of the tumor cells.
    The estimate for 2017 was that there would be 8,260 new cases of Hodgkin’s Disease (4,650 men and 3,610 women) and 1,070 deaths (630 men and 440 women). It is more common in whites and slightly more common in men, except in childhood where 85 percent of the cases are found in boys. The disease has what is called a bimodal age distribution, with occurrences between the ages of 15 and 34 or over age 55.
    The cause of HD is unknown. It’s hypothesized that a viral infection, perhaps Epstein-Barr virus (EBV) may cause HD. This is the virus that causes mononucleosis (mono). EBV is found in half of HD tumors in people with normal immune systems and 100 percent of the time in people infected with HIV. One percent of people with HD have a family history of the disease. Siblings of a person with HD are about three to seven times more likely to develop HD themselves.
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  • Monday, March 19, 2018 4:00 AM
    One of my patients asked me recently what lymphoma is. I must admit my knowledge of the subject is limited; it’s a medical condition I’ve tended to avoid because of its complex and changing nature. It can, however, be a very interesting disease and a type of cancer that is illustrative of where cancer treatment in general is heading in the years to come.
    “Lymphoma” is a broad term used to describe a large number of “lymphoid neoplasms.” A neoplasm is an abnormal growth of cells that can be benign (not usually dangerous to one’s health) or malignant (cancerous). Lymphoid neoplasms are composed of cells found in the lymph system. This system is responsible for filtering out and killing foreign things in our bodies, especially infectious agents.
    The lymph system contains two types of specialized cells that can kill these foreign invaders either directly (T cells) or indirectly (B cells). B cells produce antibodies that bind to the germs to help remove them from the body. It is these B and T cells that multiply out of control resulting in lymphomas. 
    The various types of lymphomas are named using a complex classification system based on cell morphology (what they look like) and lineage (their genetic makeup). Lymphomas are broadly classified into Hodgkin and non-Hodgkin lymphomas (NHL). Non-Hodgkin lymphoma is further divided into B-cell and T-cell types. B-cell lymphomas account for about 80 percent of NHL.
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  • Wednesday, March 14, 2018 4:00 AM
    I’ve seen a lot of patients this year with concussions. Usually this is an athletic injury, but it is frequently seen in others as well. Concussions have always been a part of sports, especially those involving high-energy collisions, most notably football, soccer, hockey and basketball. Intensive research, along with lawsuits like the NFL Players Association vs. the NFL is causing research to move rapidly to help us get a firmer grasp on how to prevent and manage concussions.
    A concussion is a trauma-induced alteration in mental status that usually does not involve a loss of consciousness and does not have to be a result of a blow to the head. In fact, only ten percent of concussions are associated with a loss of consciousness.
    A concussion is the result of soft brain tissue moving violently inside the bony skull. It is important to realize that this movement can result in varying degrees of microscopic injury to the brain, the majority of which do not show up on radiology imaging studies like CT or MRI scans.
    You may have seen headlines last month like this one from the New York Times: “Concussions Can Be Detected With New Blood Test Approved by FDA.” Unfortunately, this is totally inaccurate. The test was developed to detect two proteins released into the bloodstream that indicate there is bleeding in the brain, NOT to aid in the diagnosis of concussion. The test will be used primarily in emergency rooms to determine if a patient needs a CT scan to evaluate for a brain bleed. The diagnosis of concussion remains a clinical one, based on the history, physical exam and some additional tools.
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  • Monday, March 5, 2018 4:00 AM
    Last week I hope I answered the first part of our reader’s question about how DNA can be used to treat inherited conditions. This week I want to focus on stem cells - what they are, where they come from, how they might be used to treat disease and finally the social and ethical challenges surrounding their use.
    Stem cells are cells that have the potential to change into other more specialized cells in the body through a process known as differentiation. By definition, stem cells have to exhibit two properties: (1) they must be able to divide multiple times and remain unchanged, and (2) they have to have “potency,” the ability to differentiate into other cell types.
    There is a hierarchy of potency in stem cells that is important in determining what they are capable of doing. Totipotent cells have the capacity to differentiate into any of our 220 cell types. Pluripotent cells can differentiate into nearly all cells, while multipotent cells can become only cells of a closely related family of cells. There are additional levels of potency that produce even fewer cell types.
    There are two types of stem cells in humans – embryonic and adult. Embryonic stem cells are derived from embryos that are 4-5 days old. Embryos at this stage contain about 50-150 cells, some of which are pluripotent and can propagate indefinitely.
    Adult stem cells are found in most tissues in the body and are multipotent. They are typically able to generate all of the cell types of the organ where they reside. They can also be found in umbilical cord blood. These cells exist to replace and repair tissues. It is also hypothesized that they may bear some responsibility for developing into cancers.
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  • Messrs. Mendel, Watson & Crick
    Monday, February 26, 2018 4:00 AM
    I received two queries from readers asking me to address how DNA and stem cells might be used to treat inherited medical conditions. That’s a tall order for the space allotted, so I’ll tackle DNA this week and stem cells next week. 
    Modern genetics started with Gregor Mendel’s work on the inheritance of various traits in pea plants in the mid 1800s. A century later, James Watson & Francis Crick (with a lot of help from Rosalind Franklin) determined the structure of DNA in 1953. There is no doubt that the expansive scientific knowledge borne from the discovery of the structure of DNA will continue to revolutionize medical science.
    DNA is an extremely elegant molecule that carries all the information needed to construct a living organism. The structure of DNA is described as a “double helix” which can be represented by imagining a ladder that has been doubly-twisted along its length (see diagram).
    The “rungs” of the DNA ladder are comprised of chemical units called base pairs. Each half of a rung is comprised of a base (also known as a nucleotide) that binds in the middle of the rung to the base on the other side. DNA contains four different nucleotides. The genetic code contained in the DNA molecule is determined by the sequence of these nucleotides.
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  • Monday, February 19, 2018 4:00 AM
    Last week I had a young patient ask me what the difference is between an MRI and a CAT scan. Not long after that, I noticed an error in a newspaper article that mixed up the two technologies.
    Radiologic imaging of the human body has revolutionized the diagnostic accuracy of physicians. However, it has also had the negative effect of reducing our reliance on a good medical history and physical examination.
    There is also a real concern about patients receiving too much radiation over their lifetimes as a result of having too many CT scans (more below). This is particularly concerning in children who may receive numerous scans over their lifetimes that may increase their risk of cancer.
    We are the only country in the world where a CT and/or MRI scanner is in the neighborhood of virtually every citizen. While this is convenient, it leads to over-utilization of these very expensive and sometimes unnecessary technologies.
    CAT (CT) scanners have been around longer than MRI scanners. CAT stands for Computed Axial Tomography, but we typically use the shortened abbreviation CT for Computed Tomography. This test uses ionizing radiation (X-rays) to produce the medical image.
    When performing a CT scan, the patient lies on a table that is surrounded by a big ring called a gantry that contains an X-ray tube that rotates around the patient. As the tube is spinning around the patient, the table moves the patient through the ring.
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  • Monday, February 12, 2018 4:00 AM
    Sometimes I get asked questions in unusual places. A few months ago at church I was pulled aside and asked if I could write my column on that malady of menopausal women – hot flashes.
    Hot flashes are usually described as a feeling of intense heat, usually with sweating and a rapid heartbeat. They can last a few minutes up to a half hour or so. The feeling usually starts on the face or upper chest but can also be on the neck and even spread over the entire body. Many women experience flushing of the skin over the involved area, hence the alternate name hot flushes. 
    Interestingly, some women never experience them. There is no hard and fast rule when or if hot flashes will develop. Some women are fortunate enough to have them for only a few months, while others (up to 45 percent) may suffer for five to 10 years. Some may have infrequent episodes while others may have them numerous times a day.
    What causes hot flashes? The primary culprit is a woman’s lack of the hormone estrogen that is made primarily by her ovaries. The production of estrogen gradually tapers off as a woman ages. If a woman has undergone surgical removal of the ovaries, the estrogen level drops rapidly and she develops “surgical menopause.”
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The Paper of Montgomery County,
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