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Sunday, July 22, 2018

  • Monday, July 16, 2018 4:00 AM
    I saw a young athlete two weeks ago who complained 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 and 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 9, 2018 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 involuntarily 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, causes deep, severe, unrelenting pain known as ureteral colic. Stones may also cause blood in the urine.
    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 minerals and molecules 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 2, 2018 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 8 - 13 years. Therefore, generics often aren’t even available until 7 - 12 years after the name brand hits the market.
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  • Monday, June 25, 2018 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.
    If the urethra is the only part of the urinary tract involved, the condition is called urethritis. This can be caused by colon bacteria, but may also be caused by sexually transmitted organisms. The infection can progress up the urinary tract causing infection of the bladder (cystitis) or one or both kidneys (pyelonephritis).
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  • Monday, June 18, 2018 4:00 AM
    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 11, 2018 4:00 AM
    The mother of one of my patients asked me to write about meningitis. Meningitis is a very rare condition. The incidence of all types of bacterial meningitis in the United States is about two to three cases per 100,000 people per year, while viruses cause about 11 cases per 100,000 per year. I frequently witnessed the devastation of meningitis during my training in the late 80’s. However, with the advent of vaccines to prevent the most common causes of bacterial meningitis, physicians rarely see a case today.
    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, usually through some type of trauma.
    Meningitis, especially bacterial, can be very serious, if not diagnosed and treated promptly. Depending on the cause, 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. 
    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, and HIV.
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  • Monday, June 4, 2018 4:00 AM
    Summer is just around the corner which means I’ll start to see patients complaining of “swimmer’s ear.” Doctors 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 not 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.
    The majority of cases of swimmer’s ear are caused by too much wax. This allows water contaminated with bacteria or fungi to enter the ear canal and invade the broken down skin. Since swimmers often swim in contaminated water, they are more prone to develop this problem.
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  • 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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