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Monday, November 19, 2018
  • Monday, November 19, 2018 4:00 AM
    The cold weather is finally arriving and it’s time to prepare for the flu. Most people us the term “flu” in a very generic sense, meaning anything from cold symptoms to having a case of vomiting and diarrhea. The “flu” in this column refers to respiratory influenza. Since 2010, the number of deaths from influenza has ranged from 12,000 to 79,000. Hospitalizations have been between 140,000 and 960,000 and total cases between 9.3 and 49 million.
    Influenza is caused by viruses with Type A and Type B causing the majority of infections. Type B typically does not cause severe disease, whereas Type A can be lethal, particularly in the young, elderly, and those who have compromised immune systems.
    Type A virus can be broken down further into different subtypes or “serotypes” based on which proteins are found on the surface of the virus. When you read about influenza virus with a name like “H3N2,” the “H” and “N” refer to the different proteins on the surface and the numbers refer to the serotype. The serotypes are also often given common names, usually from their region of origin, such as Influenza A “Hong Kong.”
    Influenza viruses are constantly changing or mutating slightly so that each flu season brings new serotypes. Scientists make an educated guess each year on what serotypes of virus might occur the following year and formulate that year’s vaccine accordingly.
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  • Monday, November 12, 2018 4:00 AM
    A patient whose mother is having hearing difficulties asked me to write about the best way to choose someone to fit hearing aids. I’d like to begin with some background on hearing.
    It goes without saying that hearing is one of our most important senses. It is critical for our quality of life as well as for safety and social interaction. There are an estimated 30 million Americans who have some degree of hearing loss, 65 percent of whom are younger than 65 years of age. It’s very concerning that one in 14 younger adults and one in 20 adolescents have measurable hearing loss. Since 1971, the number of Americans over three years old with hearing disorders has doubled.
    The primary cause of hearing loss is environmental noise. The louder the volume (measured in decibels or dB) and/or the longer the exposure, the more likely it is for damage to occur. Repeated exposure to noise over 85 dB, produced by things such as lawn mowers, truck traffic and shop tools, can lead to gradual hearing loss.
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  • Monday, November 5, 2018 4:00 AM
    Winter cold & flu season is starting to gear up. This week, I’d like to talk about a different kid of flu, “stomach flu.” I have to start by dispelling a common misconception that all flu is the same. “Stomach flu” is not caused by the same viruses as “respiratory flu.” Flu shots, given to prevent respiratory influenza, will not protect you against viruses affecting the gastrointestinal tract that cause infections known as viral gastroenteritis.
    Noroviruses are the number one cause of acute viral gastroenteritis in America, with an estimated 21 million cases per year with about 70,000 hospitalizations and 800 deaths. The name norovirus is derived from a virus that was first identified as the cause of an outbreak of illness in a school in Norwalk, Ohio in 1968. They are a very sturdy group of viruses, able to withstand freezing and temperatures as high as 140 degrees. They can survive steaming when cooking shellfish and are even resistant to the levels of chlorine found in our municipal drinking water.
    Typical symptoms of norovirus infection include the sudden onset of nausea, vomiting, diarrhea and abdominal pain/cramping. Diarrhea is particularly common in children. These symptoms can lead to dehydration, especially in the young and elderly.
    Noroviruses are commonly the responsible pathogen in outbreaks of gastrointestinal illness on cruise ships. The viruses are highly contagious and spread rapidly in close quarters such as day cares, schools, nursing homes, hospitals, restaurants and ships. The vomit and diarrhea of norovirus sufferers can contain billions of viruses. A person need only ingest 100 of these agents to become infected.
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  • Hey Doc, My Head is Spinning
    Monday, October 29, 2018 4:00 AM
    This week I want to address a specific variant of a condition that I’ve been seeing a fair amount of lately – dizziness. Primary Care doctors in the U.S. see about six million patients a year with dizziness. 
    Dizziness means different things to different people and can be a symptom of many different medical conditions. People usually describe being dizzy when they either feel faint or lightheaded or when they feel like their environment is spinning. This latter sensation is called vertigo, from the Latin vertere meaning, “to turn.” 
    I want to touch on the most common cause of vertigo, known as benign paroxysmal positional vertigo or BPPV. Benign means the condition is not dangerous, paroxysmal indicates it occurs in a recurring pattern for short periods of time, and positional refers to the vertigo being brought on by changes in position. 
    I have to open the anatomy and physiology books to explain what causes BPPV. Hopefully many of you recall from junior high science that the organ that allows us to maintain our balance is the vestibular apparatus found in the inner ear. This is a truly remarkable and complex organ. I’ve included a diagram to hopefully help you visualize what I’m describing.
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  • Monday, October 22, 2018 4:00 AM
    This week I’d like to write about a problem that costs taxpayers billions of dollars each year – Medicare fraud and abuse. Medicare paid out $702 billion in payments for services and medications in 2017, accounting for 15% of the federal budget. The Office of Management and Budget (OMB) reports that 4.5% of those payments were “improper,” meaning the services were not necessary, did not meet Medicare guidelines, or were downright fraudulent (a slight decrease from 2016).
    Medicare fraud refers to individuals or companies who obtain payments from Medicare under false or illegal pretenses. The OMB has been making a concerted effort to limit Medicare fraud, but Medicare is an easy target since it is such a complex program. It’s like playing the lottery for those who are intent on defrauding the government, but with a much higher chance of a payoff.
    There are three major categories of Medicare fraud: phantom billing, false patient billing, and upcoding, also known as upbilling.
    Phantom billing involves a provider billing Medicare for equipment or procedures that were not necessary or were never provided. Billing for medical equipment falls under this category. I see this type of fraud frequently when companies bill Medicare for equipment or services for my patients that they never requested or that I did not prescribe.
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  • Tuesday, October 16, 2018 4:00 AM
    I’m frequently asked by patients to comment on the use of “non-traditional” treatments or remedies they have heard or read about. I usually have to respond that I have limited knowledge about the product, but I will sometimes try to help the patient research the product or its ingredients.
    The business of complementary and alternative medicine or “CAM” is booming. This is largely an outgrowth of patient frustration with traditional medicine, as well as the ease with which CAM is promoted and sold via social media and the Internet. People are fed up with the high cost of medications and other treatments as well as the perceived loss of empathy in the American health care system. 
    Many are looking for less expensive “natural” ways to deal with illness and health promotion. However, a government survey in 2012 revealed that Americans spent $30.2 billion on CAM treatments in the preceding 12-month period. This accounted for 9.2 percent of out-of-pocket health care spending and 1.1 percent of total health care spending. 
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  • Wednesday, October 10, 2018 4:00 AM
    Someone told me the other day that they thought “restless leg syndrome” (RLS) was a condition made up by pharmaceutical companies to sell more medications. You may have seen the commercials for Requip® and Mirapex®, both drugs used to treat this condition.
    People have described symptoms suggestive of restless legs since the 17th Century. The Swedish neurologist Erik Ekborn initially coined the term in the 1940’s. It is estimated that between ten to fifteen percent of Americans suffer from restless leg syndrome to some degree. The incidence in women is about twice that of men. About 40 percent of people develop symptoms prior to age 20. Since symptoms tend to be mild initially and worsen with age, most sufferers are not diagnosed for 10 to 20 years after they start having symptoms.
    The symptoms of RLS are highly variable, but most people describe a bothersome, irresistible urge to move their legs (and sometimes the arms). This urge to move the legs is worse during periods of inactivity and often interferes with sleep. About 85 percent of sufferers have difficulty falling asleep. Stress and fatigue can also exacerbate the symptoms.
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  • Tuesday, October 2, 2018 4:00 AM
    I’m starting to see a few cases of head lice now that kids are back in school. Head lice are white, and about the size of a sesame seed. They are known as "obligate ectoparasites." Obligate means they require a placental mammal host to survive (i.e. humans) and ectoparasites means they live outside the human body. They must feed on the host’s blood to survive, and can't live off of a body for more than a day or so. Lice are spread by direct contact of a person's head or hair with an infested individual or through sharing personal items such as hats, towels, brushes, helmets, hair ties or even car seat headrests. They do not jump or fly and are not transmitted by pets.
    Adult lice survive on a person for about one to three months. A female louse lays about three to five eggs, known as "nits," each day and glues them to the hair shafts of the host, close to the scalp. The eggs require the warmth of the scalp to incubate. A louse may lay up to 300 eggs in her adult life. The eggs take about ten days to hatch and the new lice need an immediate blood meal to survive. They then take another seven to ten days to mature to the point they can start laying eggs.
    Lice typically are not harmful to their human host. There is recent evidence that the head louse is genetically identical to the body louse that is known to carry the organisms causing typhus, trench fever, and relapsing fever. There is some concern that as lice become more resistant to chemical treatments that they will become more prone to spreading disease, but this is currently not a concern in America.
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  • Monday, September 24, 2018 4:00 AM
    “All parts of the body if used in moderation and exercised in labors to which each is accustomed, become thereby healthy and well developed, and age slowly; but if unused and left idle, they become liable to disease, defective in growth, and age quickly.” - Hippocrates
    Few things benefit the body more than maintaining physical fitness. While doctors routinely recommend exercise for younger patients, we’re realizing how important it is for our older patients as well. Regular exercise, even in one’s senior years, can still reduce your risk of a number of health conditions, particularly heart attacks, strokes, and falls. It also may be one of the few things to slow the onset of dementia.
    Most communities are blessed to have many options available for exercise, especially programs that are supervised. I prefer these activities because a trained professional typically leads the group. This person can make recommendations to get the most out of a program in the safest way possible.
    Why is regular exercise so important for seniors? You may have noticed that as our bodies age a number of physiologic changes occur. We lose muscle mass and tone that leads to weakness, and problems with balance. Flexibility becomes an issue (the most common cause of night time leg cramps). Our bones become weaker from a lack of weight-bearing activity. Balance problems and weak bones lead to falls and fractures. Our hearts and lungs can get out of shape, resulting in reduced stamina and difficulty breathing with activity. This leads to an overall reduced level of confidence & independence
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  • Monday, September 17, 2018 4:00 AM
    The title of this column, a quote from comedian W.C. Fields, refers to his penchant for drinking alcohol. So what do alcohol and W.C. Fields have to do with my topic of rosacea? Read on. 
    Rosacea is a common skin condition usually found on the face, which can be a great source of consternation. It is a disease with various clinical signs. These can include redness/flushing, coarse skin, and bumps and pustules resembling acne. It may also present with visible superficial blood vessels called telangiectasias. 
    The condition is found three times more often in women and usually presents between 30 and 60 years of age. It is also more common in fair-skinned people of European and Celtic origin. One of its nicknames is the “curse of the Celts.”
    The diagnosis of rosacea is made on clinical grounds (i.e. signs and symptoms). There has to be a persistent rash on the central part of the face for at least three months to qualify as rosacea. Classifying rosacea is important in determining the best treatment. 
    The exact cause of rosacea is not well understood, though there are numerous factors that likely play a role. The flushing associated with rosacea is thought to be due to the increased number of blood vessels that are close to the skin surface as well as the increased sensitivity of the vessels to heat. Sun exposure may play a role based on the location of the rash, though some studies refute this.
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  • Can you prevent Shingles?
    Monday, September 10, 2018 4:00 AM
    I’ve had requests to re-run my column on shingles. I think the increased interest has been brought on by the television ads for the vaccine to help prevent shingles, which are quite accurate and compelling. I’ve had quite a few patients who have recently been suffering from this malady, two quite severely.
    Shingles is caused by the Varicella-zoster virus (VZV). The virus is also known as chickenpox virus, varicella virus, and zoster virus. It is a member of the herpes virus family, of which eight strains are known to infect humans. 
    The biology of herpes viruses is very interesting. They infect humans through the skin and mucus membranes that line body openings. The initial or “primary” infection results shortly after exposure to the virus. This usually causes itching and redness of the skin followed by development of small fluid-filled blisters known as vesicles. Some readers may have seen chicken pox, though it is becoming a very rare disease since the advent of the childhood vaccination to help prevent the disease.
    Interestingly, herpes viruses are never completely cleared from the body. Once the initial infection has subsided, the viruses travel to parts of the nervous system called ganglia that reside deep in the body. The viruses are quite happy playing Rip Van Winkle until they are awakened from slumber at some point in the future.
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  • Red Eye can spread easily if you aren’t careful
    Tuesday, September 4, 2018 4:00 AM
    Now that school is back is session and child day care services are in full swing, the incidence of “pink eye” is starting to pick up. This is a very common condition that accounts for over 30 percent of patient visits for eye problems.
    Conjunctivitis is the medical term for “pink eye.” The conjunctiva is the continuous connective tissue membrane that covers the inside of the eyelids. It then folds back on itself to cover the front of the eyeball up to the edge of the cornea (where the white part of the eye meets the iris or colored part of the eye).
    The purpose of the conjunctiva is to provide a barrier to keep infectious organisms from entering the eye tissue itself. Conjunctivitis results when there is an irritation or breakdown of this defensive layer, a change in the normal organisms inhabiting the eye, or trauma that breaches the membrane.
    There are a number of causes of conjunctivitis. The most common are bacteria, viruses, allergies, fungi, parasites, and chemicals. These irritants cause varying degrees of redness, discharge, irritation and perhaps even pain on exposure to bright light, known as photophobia.
    It can be difficult to tell the exact cause of conjunctivitis unless the doctor has special equipment. Ophthalmologists and optometrists have slit lamps that can help differentiate the cause. A slit lamp is the instrument that you rest your chin on where the doctor sweeps a bright light across your eye
    Doctors without special equipment can sometimes get clues to the cause of the inflammation. For instance, people who have had a recent cold are more likely to be suffering from a viral conjunctivitis. Viruses are also more common from early spring through late fall. Bacterial conjunctivitis is more common in the winter and spring. Patients usually recall exposures to things that might cause chemical or allergic conjunctivitis.
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  • Sunday, August 26, 2018 10:57 PM
    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 from 2016 showed 127 confirmed cases in Indiana.
    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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  • Sunday, August 19, 2018 10:40 PM
    Health care at the end of life has been a popular discussion topic over the last few years. It has come up for discussion as we continue to search for ways to deliver compassionate, more cost effective care. Excellent books such as Dr. Atul Gwande’s book, Being Mortal: Medicine and What Matters in the End, have also popularized the topic.
    As a family physician, I see it as my professional duty to discuss end of life planning and care with my patients. In fact, when appropriate, I would consider it negligent to not hold these discussions. 
    To put this discussion in financial perspective, about 30 percent of Medicare expenditures are paid out in the final six months of Medicare recipients’ lives. This equates to about $6 billion a year. This would be money well spent if it went to improving health or quality of life, but most of it does not.
    However, this should not be a simple dollars and cents discussion. Determining a patient’s wishes regarding end of life treatment is both sensible and humane. Forcing patients to have treatments to keep them alive against their stated wishes is irrational and degrading.
    I suppose I have served on numerous “death panels.” I am guilty of having guided my patients and their families to help them recognize the importance of advance planning as well as carrying out those plans when the time came. It can be heart-wrenching for patients, families and their doctors. Allowing someone to die with dignity is aptly described in the modern Hippocratic Oath: “I will keep them [the sick] from harm and injustice.”
    To help patients put their wishes on paper, I want to briefly describe the advance directives that are available in the State of Indiana. Everyone should have one or more of these documents when they feel the time is appropriate. I like to start the discussion when my patients turn 50 or even younger, particularly if they have other chronic diseases.
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  • Monday, August 13, 2018 4:00 AM
    I recently had to remove some toenails. Why on earth would someone want that done? Because they were infected with fungus. The medical term for a fungal infection of the toenails or fingernails is onychomycosis (OM).
    This condition is generally more of a nuisance than a real health threat. However, infected nails can become quite enlarged and painful. Diabetics and people who have poor immune function need to be concerned about OM. Infected nails in these folks can lead to inflammation of the skin around the nails and entry of skin bacteria that can lead to serious skin and even bone infections.
    Most people visit their doctors for OM because of the ugly nails. It is the most common nail disorder in adults and affects up to 13 percent of North Americans. It is 30 times more common in adults than children.
    OM is caused by three types of fungi. The vast majority of these infections are caused by fungi that invade and feed on hair, skin and nails. These organisms are called dermatophytes and account for 90 percent of OM. Trichophyton rubrum (70 percent) and Trichophyton mentagropytes (20 percent) are the most common dermatophytes.
    Yeasts and molds cause the remaining cases. It’s often difficult to tell what organism is causing the infection without doing a culture in the lab which is usually recommended prior to starting treatment.
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