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Tuesday, July 29, 2014

Shake, Pump & Fives!

The American Journal of Infection Control has the media world abuzz with talks of fist pumps vs. handshakes today, as they released a recent study confirming that a quick greeting of fist pumps "substantially reduce" the transfer of bacteria between people (compared with shaking hands.) This investigation confirms previous similar studies, such as the 2013 report from the Journal of Hospital Infection, Reducing pathogen transmission in a hospital setting Handshake vs. fist bump: a pilot study.
We know that fist bumps (and high fives) are typically very brief- less than a second, versus hand shakes that can last for several seconds. Additionally, there is less skin to skin contact in a fist bump. However, these studies have shown that hand shakes pass more bacteria from person to person than you would expect simply based on time and area of contact. Fist pumps, it turns out, are up to 20 times more hygienic than hand shakes.

As a primary care physician, I have long greeted children with high fives, and switched to fist pumps as they became trendy over the last few years. With adults, I have primarily used the traditional handshake- but I literally wash my hands in the exam room in front of the patient (to ease any concerns they might have of me bringing in germs from the patient before them.) Everyone knows that washing hands reduces the spread of germs, and most people are vigilant about this within the health care setting or in restaurants. However, what about the rest of our busy lives? If you bump into a friend or business partner at an event, and they introduce you to the group of people they are with, what is the healthiest way to greet these new people? Do you shake hands, but then whip out your hand sanitizer and pass it around? Or perhaps, based on these studies, do we replace the handshake with a fist pump? There are, indeed, researchers suggesting "handshake-free zones" in healthcare settings.  And what about hugs? Does this more intimate gesture pass more germs, or because we are only touching clothing (and avoiding skin-to-skin contact,) is that safer?

Personally, I think the real take home message here is a reminder about the importance of HAND WASHING. Choose high fives and fist pumps (or smiles and nods) when those are socially acceptable alternatives, and especially if you are feeling ill. If you have the opportunity to wash your hands, don't skimp! How long should you wash? 20-30 seconds (much longer than the usual speedy dash of hands through the water en route to grabbing a paper towel that we see in public restrooms.) Use soap and make it foam up, scrubbing especially under rings and around the finger nails. If you use sanitizer, be sure to use enough that you still have 20-30 seconds of "scrubbing".

BOTTOM LINE: Good hand hygiene is the MOST EFFECTIVE way to limit the spread of germs from person to person- choose fist pumps or high fives before handshakes when appropriate, and mainly, remember to wash your hands early & often!


Monday, July 21, 2014


My last blog was about INVISIBLE things that sting, but this one is all about much larger and visible stingers- JELLY FISH. We all know what they look like- bell-shaped, primitive looking soft tops, with variable amounts of tentacles streaming below. Swimmers typically stumble upon these creatures at or near the surface of the water, or washed up along the beach. Do NOT make the mistake of thinking an obviously dead jelly fish washed up on the shore is harmless! The stingers (nematocysts) in the tentacles will release their toxin and sting you- whether the jelly is dead or alive. 

Most jellyfish stings around the United States are an uncomfortable nuisance, but not life-threatening. The box jellyfish of Australia, however, can be lethal, and so these are a true medical emergency.

What happens with a jelly fish sting, and what should you do?
Stings cause immediate pain, redness and swelling. Severe stings can cause more bodily reactions, including, nausea, vomiting, headache, muscle aches, and fever/sweats/chills. Immediately wash the stung area in SALT WATER- stick it in the ocean. If you rinse with fresh water, remaining nematocysts will discharge, which means you will immediately have many more stings! If you have quick access to vinegar, pour that over the sting (because vinegar helps neutralize the toxin and prevents further release of more toxin.) Stings typically involve extremities, but if your eyes or mouth are involved with the sting, seek immediate medical attention. For the eyes, flush with a gallon of fresh water before heading for help. 

If the tentacles are stuck on you, pour vinegar over them, then make a paste with mud (or if available, with baking soda or shaving cream) before you try to remove the tentacles with tweezers or a knife/razor. Flush the area again with vinegar after removal. 

Topical steroid cream or ointment may help reduce discomfort and swelling after the initial first aid.

BOTTOM LINE: If you are going to swim in an area known to have jelly fish, make sure everyone knows not to touch "dead" jellies, and add a bottle of vinegar and a box of baking soda to your family beach bag.

Monday, July 7, 2014

Invisible Things that Sting...

The crystal clear waters beckon you, and you blissfully leap into the water ready to search for playful Honu (sea turtles) and brightly colored fish. Suddenly something stings your arm...and then your leg and your other arm. Are there jellyfish? No. In fact, you see absolutely nothing, yet SOMETHING or things are continuing to sting you. Have you baked your brain in the sun too long?

The picture above is from the Na' Pali coastline in Hawaii. While snorkeling there, a small group of the swimmers (including myself and one daughter) were bothered enough by invisible "stings" to get back on the boat. Meanwhile the majority of snorkelers were completely fine, despite swimming right next to other people who were being stung. Back on the boat, mosquito bite-looking lesions appeared everywhere we felt stings, with some people having a great deal of surrounding redness and swelling. The red bumps continued to sting like a moderate bee sting for ten minutes or so, then simply seemed to react like a mosquito bite- more itchy than painful. Our mystery stings lasted a few days, then disappeared.  

There are numerous names for rashes that crop up after swimming- sea bather's eruption, ocean itch, and my personal favorite, sea lice, to name a few. What causes these invisible stings?  Ultimately, some type of larval parasite burrows into a human instead of reaching its desired host (usually a water bird).  These larvae come from corals, sea anemones and thimble jellyfish. These parasites cannot live, grow or reproduce in human skin, so they die. Unfortunately, in many people, their presence sets off an allergic reaction- hence the red bumps and itch. With more intense allergic reactions, swimmers can develop headache, body aches, GI symptoms and fever. Primarily what is seen, however, are itchy red bumps or blisters.

The medical name for this type of rash is cercarial dermatitis. If the stings occur on exposed areas, there are typically fewer total red bumps. However, often sea bather's dermatitis shows up beneath where a swimsuit covered the skin, because the larva can get trapped in the fabric. Swimmers can have literally hundreds of bites covering their torso.

What can you do? If you start to feel bites, remove your suit BEFORE you shower- fresh water often triggers the larvae to sting. Vinegar may neutralize the toxin and reduce additional stings- apply to your body and rinse your swimsuit in the vinegar as well.

Additional treatment is targeted at the allergic reaction. Consider taking an oral antihistamine such as Benadryl, Claritin, Allegra or Zyrtec, and apply topical steroid cream or ointment on your torso or extremities (not on the face or genitals). Cool compresses may also help ease the itch or burn.

Is this rash contagious? Absolutely not- each bump is an allergic reaction to a larva burrowing into the skin, and the larva cannot be spread from one person's body to another. However, if you borrowed a wet swimsuit from a friend, any larva trapped in the suit material could certainly sting you.

BOTTOM LINE: Itchy, burning stings or bites after swimming is a frustrating allergic reaction, but only rarely medically "scary"- simply remove your suit as soon as possible, rinse with vinegar if available, take an oral antihistamine and/or use topical steroid cream on torso or extremity lesions and your symptoms should resolve within days to a couple weeks (depending on the severity.) 

Wednesday, June 25, 2014

Worried about Dementia? Try Something New...

This week, JAMA Neurology offered an encouraging study for our aging population which demonstrated that continuing to stimulate your brain through intellectually challenging work or leisure activities (such as playing a musical instrument, using a computer or reading) can postpone the onset of dementia. The investigators utilized nearly 2000 participants in the Mayo Clinic Study of Aging, specifically enrolling people aged 70-89 years old, and identifying whether or not they had APOE (a genetic marker linked with increased risk of Alzheimer's disease) and assessing their baseline cognitive performance.

People who had less mentally challenging occupations, less late-life intellectual stimulation and/or weaker educational backgrounds scored lower on the baseline cognitive assessment. Those people with more advanced degrees or continued late-life education scored higher, creating the anticipated advantage of "cognitive reserve"- in other words, they start with more brain power, so they can afford to lose more brain function before dementia is diagnosed. (For the visually-minded, imagine that dementia is diagnosed when the elevator gets below the 10th floor. If you are starting at the 21st  floor, you get there much later than someone who's elevator started at the 11th floor.)

The surprising good news from this study is that regardless of your baseline brain power, life vocation or genetic predisposition for Alzheimer's disease, everyone's memory power benefits from intellectual stimulation after age 40. In fact, this study showed that the intellectually stimulated people postponed the onset of dementia beyond 7 years compared to their peers who did not mentally push themselves.

Of note, there were observed positive snowballs- the more education a person has on the front end, the more likely he or she is to continue a lifetime of intellectual stimulation.

Does it matter what type of intellectual stimulation? We don't know for certain, but psychologists will be the first to tell you to pick what you ENJOY, because you are far more likely to keep it up. Remember that what you enjoy may or may NOT be what your aging friend or parent enjoys…so whether it is learning to knit, playing the piano, learning a new language or even learning how to text on an iPad- push yourself to learn something that sounds interesting to YOU.

Special kudos to my amazing mother-in-law, Bene, for not only continuing to reading medical articles long beyond her nursing career, but for her constant willingness to learn anything! She texts faster than most adults (with far fewer spelling errors than the rest of us), and even learned to add emoji's last month. Pictured above is the two of us taking a "selfie" from her iPad.

BOTTOM LINE: Until we have a cure for Alzheimer's on the treatment end, the "ounce" of prevention  we all need is to STIMULATE our brains…and never stop!

Tuesday, June 24, 2014

The Gift of a Complete Smile

Mariza (needed lip revision)
Steven- showing off his cleft palate
Joseph- Dimples and all!

Mariza,  Joseph, and Steven are just three of many precious children that our Austin Smiles team enjoyed meeting and helping last week in El Salvador. Cleft lips and/or palates occur in the United States at a frequency of roughly 1 in 700-1000 births (roughly 7000 babies per year) making them one of the most common birth defects. However, these problems arise with more than twice that frequency in Central America and in some Asian countries. Why? We are not completely sure. Scientists continue to investigate the various contributing roles that genetics, nutrition, toxins, and environment play in creating these defects, hoping to find ways to prevent their occurrence. Meanwhile, plastic surgeons, dentists, orthodontists, cranio-facial surgeons, anesthesiologists, primary care physicians, speech pathologists and speech therapists are all working together to help re-align lip, nose, mouth, and palate muscles and other tissue that never came together, as well as using mouthpieces and tongue/muscle/speech exercises to improve tone and clarity of speech. The clefts can be on one side or both, and can involve the nose, the teeth, the jaw and the palate. The defects range in severity from a mild tenting of one side of the lip, to severe clefts extending through the nose and the entire roof of the mouth, leaving a gaping hole where there should be protective tissue. The costs of cleft lip and palate defects are measured not simply in dollars or time spent in medical care, but in emotional trauma as well. Many of these children and their families are shunned by their peers, and the mothers of these children may be inappropriately blamed for causing the disfiguring defects. You cannot imagine how much gratitude and tears of joy these families heaped upon us when we simply played with and LOVED their children. We praised the parents for their dedication, extra attention and efforts. One seven month old girl, Angelica, had a facial defect so incredibly severe that there was only a hole in the center of her face where the upper lip and entire nose should be. Her mother had to literally drip formula from a bottle one drop at a time on to her tongue to feed her, yet this child was well above average weight and height for her age. Think about the emotional and physical fortitude it must require to care for this baby. I could barely speak to this amazing young  twenty-two year old mom without tearing up, because I cannot imagine facing such an intense challenge. Our family is truly honored to be part of the Austin Smiles team, and to have met such inspiring individuals and families in El Salvador. Bottom line: Cleft lip and palate defects are common and CORRECTABLE, given adequate resources and funds. Please consider supporting Austin Smiles with a donation of your time, talents or treasure.

Baby Taylor- cleft lip & palate
Taylor after his lip repair
 (He should be big enough for a palate repair next year.)

Saturday, June 14, 2014

Planning International Travel? Check out the CDC!

I am  so excited to be heading to El Salvador today with Austin Smiles, a wonderful organization that gives the gift of a beautiful smile to people born with cleft lips or palates. Check out our blog and Facebook page!

If you are planning to international travel, start your medical planning for the trip well in advance- ideally six months ahead, and check out the CDC Traveler's Advice page.  Simply select your destination country, and you will see all the current medical recommendations for your travel. Please note that often vaccinations are recommended that may require more than one dose, so you may need to get started on your shots 4-6 months before you leave! For example, if you are headed to Central America and have not been immunized against Hepatitis A, this vaccine is given in two doses, six months apart.

In addition to vaccine recommendations, the CDC also gives you a handy medical check list that includes site specific prevention for issues such as travelers diarrhea, malaria, and altitude sickness. Advice for lodging and general safety issues (depending on the political climate, etc.) are also included.

Remember to see your family doctor well in advance of your trip, so you can have plenty of time to get any prescriptions you might need- whether it's medication for motion sickness, flight anxiety, or traveler's diarrhea. Think about the timing of your regular prescriptions, especially if you have medications that are filled monthly at your local pharmacy. Especially in summertime (on Fridays, at 4:59pm!) primary care doctors are swamped with panicked phone calls from patients requesting medications to be called in urgently to pharmacies, from birth control to blood pressure to actual travel destination-related antibiotics or other drugs...and that doesn't work well for anyone. Medical planning should happen at the same time you secure your passport, because neither of these processes can or should be rushed in the final hours.

BOTTOM LINE: For international travel, START EARLY with planning your medical prevention!

Monday, June 9, 2014

Nervous about Flying?

Do you have travel plans for the summer? Any fear of flying? If you do, you are not alone. Many people, especially since 9/11, are very nervous flyers. I know that I never had any issues about flying until I became a mother, at which point suddenly I was emotionally convinced I would die in a plane crash and orphan my child (despite the logical part of my brain telling me it's far more dangerous to drive on Saturday nights.)

So, what can you do? Well, there are many choices, but suffering in silence should not be one of them. First off, arm yourself with the facts that you are over thirty times more likely to have a fatal car accident than die in a plane crash. Most of the fear is not rational, however, so if the facts don't calm you, keep looking.

Plan ahead- create a diversion packet for yourself with an engaging book, music, or DVD. Get noise-canceling headphones (or at least good earplugs). It's amazing how when you can close your eyes and not hear the plane noises, you can relax much more easily.

Avoid stimulants like caffeine and decongestants
- no need to ramp up your heart rate before you even get on the plane!

If you have the luxury of time before you travel, consider biofeedback, hypnosis, or meditation training.

I mentioned yesterday that you might want to talk with your doctor. What can she offer? We have several choices, actually. For long flights, I will frequently prescribe a "sleeping pill" such as Ambien or Lunesta. Some patients do very well with medicines that simply control your heart rate, such as metoprolol (a beta-blocker). Others with more intense anxiety respond well to a rapid and short acting sedative such as Xanax.

Bottom Line: Fear of flying is common- plan ahead and talk to your doctor if you would like to consider a medication to lesson your stress.