Signs & Cure for Skier's Toe

Downhill skiing is a ton of fun, but there are several common injuries that crop up with this sport. Perhaps the most common is the infamous skier's toe. Typically discovered at the end of the day, "skier's toe" shows up as a very painful BLACK TOENAIL- usually the great toe. The medical term is a subungual hematoma, which simply means below the nail bleeding.  This can occur from a single instance of trauma like dropping something on your toe, or from small, repetitive trauma like a too-small or too-big (so your foot slams back and forth) ski boot. As the tiny amount of blood builds up under the nail, the pressure escalates and the toe throbs.

The good news is that this can be quickly remedied in a clinic if you head in within hours or a day of noticing the black nail. If you wait several days trying to tough it out, we have less success treating the nail. The doctor typically burns a tiny hole in the nail, which allows the drop or two of blood to come out. (Sorry for the yucky description, but that's what we do.) Ski resort doctors usually have a cool handheld device that does the burning, while other doctors (and D-I-Y's, though I do NOT recommend this- partly because many people faint at the sight) use an unfolded paper clip with a heated end from holding it in a flame.

The BETTER news is that again, PREVENTION is key! Make sure your ski boots fit properly- don't cram your foot into a friend's boots- and be sure your socks are not bunched up. This painful injury does NOT occur if your shoes/boots fit correctly!

BOTTOM LINE: Make sure your ski boots and socks fit properly to avoid getting skier's toe, and if you DO get it, seek treatment as soon as possible!

PS And please, don't forget your HELMET when you SKI!

Snowboarding Can Be a Pain in the Rear...

Some time ago, I thought it would be great fun to learn how to snowboard. And it was...until the third day, when I was gathering speed linking my self-proclaimed awesome S turns (instead of my falling leaf) and I had to stop suddenly for a youngster that cut across my path and BOOM- I slammed right down on my rear. When the stars faded from my vision, the throbbing in the seat of my pants had my full, undivided attention- I had fractured my tailbone. For the next several months, my days were filled with apologies to our patients for appearing rude by not sitting as I listened to their concerns...but I could only sit on an inflatable "donut" that I was too vain to bring into each exam room.

Tailbone (coccyx) injuries are some of the most common snowboard injuries, although certainly they occur in other situations. Whether it is a bruise, dislocation or fracture, these injuries are caused by self-induced trauma such as falling hard on your rear end, a direct blow (your friend smashing in to you on their skis, or perhaps a contact sport like football), childbirth, or repetitive strain (such as bicycling). A bruise may or may not be visible, and the pain is typically worse when sitting or if you press on the affected area (either topically or via a bowel movement or intercourse.) X-rays can be tricky to interpret, often requiring both sitting and standing views for best accuracy.

Treatment is largely avoidance of pressure on the area, as obviously casting is not practical! Avoid prolonged sitting, and use an inflatable cushion if possible (the donut). Avoid constipation so you don't get additional pain from a hard bowel movement (so eat high fiber and drink lots of water!) Anti-inflammatory medications such as ibuprofen can help reduce pain, and using ice packs for 10-20 minutes several times per day the first few days will also help. If your pain is not controlled by these methods, it's time to head to see a doctor. They will not have a miracle cure, but can offer further diagnostics (to be sure you don't have a displaced fracture) and possibly stronger pain medications.

BOTTOM LINE: Protect YOUR "bottom line" by using padding if you are learning to snowboard and exercise caution by wearing "gripping" shoes on icy surfaces to avoid falling, and again, remember to protect your HEAD with a HELMET!

An Altitude Adjustment

Going skiing for winter break? Mountains are my favorite destination, but...please remember that the high altitude can come with a couple medical challenges. First of all, don't be fooled that cool weather means no sunburns! Check out this blog on sunscreen so you don't end up with a high altitude burn. Secondly, be aware of signs and symptoms of "mountain sickness" (aka. altitude sickness).

HOW HIGH do you have to be for altitude sickness?
There is not a set elevation for typical mountain vacations that affects everyone. Symptoms are uncommon at altitudes below 5000 feet above sea level, and fairly common above 8000 feet. If you fly to a higher elevation (such as above 8000 feet), wait a day to acclimate before you start hiking the high peaks nearby.

When does it start?

Symptoms usually within the first 24 hours, and often as early as the first few hours after arrival.

What are the common signs?

• Mild to moderate: HEADACHE, decreased appetite or nausea, insomnia, and lightheadedness
• Severe:  All of the above plus vomiting and shortness of breath

Treatment?

Ultimately, going to a lower elevation will relieve symptoms, but rest and hydration will alleviate most mild symptoms. For persistent or worsening symptoms, head to a clinic for possible oxygen and medications.

PREVENTION:

• Hydration and avoidance of diuretics like CAFFEINE and ALCOHOL, especially the first few days.
• SLOW ASCENT if possible (driving up to the mountains is lower risk than flying).
• If you have had altitude sickness previously, especially if it has occurred on multiple trips to the same elevation, see your doctor and consider prophylactic medications (acetazolamide or steroids).

BOTTOM LINE: Don't let the mountains literally take your breath away- plan ahead to prevent altitude sickness!

We Should All Be #FacingAIDS

Today (and every December 1st) is World AIDS Day. Do you know anyone living with HIV disease? Or anyone who has died of AIDS? With over a million Americans living with HIV disease, odds are good that someone in your life either has or will be affected by this infection. The scary part is that only 5 out of 6 infected individuals are aware of their HIV status...which means ONE in SIX people infected with HIV are completely UNAWARE they carry and can spread the disease.


This silent presence of HIV is the very reason that back in 2006, the CDC changed screening recommendations to state that EVERYONE aged 13-64 should be tested once for HIV, regardless of perceived risk factors. People at high risk should be re-screened annually, which certainly includes sex workers  and injection drug users, but ALSO includes both gay AND heterosexual people "who themselves or whose sex partners have had more than one sex partner since their most recent HIV test." Let me say it again- even if you have had only one new partner since you were last tested, it's time to get tested again this year. 

HIV is not tucked away back in some dark corner of our society with drug addicts and prostitutes. Heterosexual transmission is the primary source (84%) of new infections in American women, causing nearly 7000 new cases in 2010. 1 in 4 new HIV infections occurs in young people (ages 13-24). If you are sexually active, it is imperative to know YOUR HIV status, and that of any potential new partners.

I love the  #FacingAIDS campaign, because putting familiar faces on unfamiliar diseases is a terrific way to promote awareness and remove stigma. By the way, the #FacingAIDS pictures do not at all imply these people have HIV disease- simply that they realize that the "face" of HIV can look like ANYONE, and this picture is to encourage everyone to get tested and be certain they know their HIV status. HIV doesn't care how much money you make, where you live or how you dress...it is an equal opportunity virus.

On this World AIDS Day, please make a commitment to know your HIV status.

BOTTOM LINE: Every American aged 13-64 should be tested for HIV disease- if you have not been checked, get tested!

Got Asthma? Get this Vaccine!

This month I am focusing on vaccinations- the FLU vaccine, Tetanus, Pertussis, and now...the "pneumonia" vaccine.  This vaccine works against Streptococcus pneumonia, the "pneumococcal bacteria" which causes hundreds of thousands of cases of pneumonia, sepsis and meningitis in the United States every year. Before routine childhood immunization against this bacteria, there were also over 5 million ear infections per year caused by this organism. This bacteria has developed quite a bit of resistance to antibiotics, and the more serious pneumococcal diseases have a very high mortality rate ranging up to 37%, so everything we can do to prevent pneumococcal disease saves innumerable lives.

Recommendations for this vaccination USED to only be for adults over 65 or those adults who had their spleen removed or had severe immune-compromising illness. However,  in 2008, the ACIP (Advisory Committee on Immunization Practices) realized that the scientific evidence showed that adults who smoke or have asthma are at much higher risk of developing pneumococcal disease, and CHANGED the RECOMMENDATIONS to include ADULTS WHO SMOKE or HAVE ANY TYPE OF ASTHMA (exercise-induced,

There are two types of pneumococcal vaccine:  PPSV23 and PCV 13, which target the specific subtypes of this bacteria that cause the most disease.  Children receive PCV13 (trade name, Prevnar), as part of their infant series at 2, 4, 6, and 12-15 months of age.


ADULTS (19 -64) should receive the PPSV23 (trade name, Pneumovax) pneumococcal vaccination if they are a SMOKER; if they have ASTHMA or  DIABETES;  or if they have chronic lung, heart, liver or kidney disease, cochlear implants, a missing (removed) or non-functional spleen, or an immuno-compromising illness such as cancer or HIV disease.

ALL ADULTS over the age of 65 should receive a PPSV23 pneumococcal vaccine as well. If they already had a pneumococcal vaccine before the age of 65 (because they are asthmatic, or a smoker, or diabetic, etc.) then they need a BOOSTER  second vaccination at 65, or as soon as it has been at least 5 years since they received their first pneumococcal shot.

Adults with some of the more serious conditions that affect their immune system should receive both types of pneumococcal vaccine (for more details, see the CDC's Pneumonia Vaccine Q&A).

BOTTOM LINE: If you are over 65 or if you are aged 19-64 and you have asthma, diabetes or have not yet quit smoking, please talk to your doctor about getting the "pneumonia vaccine"! 

Did I Hear a WHOOP?

As a Texas Aggie, I generally love to hear a "WHOOP" (especially during football season- gig 'em, Ags!) However, as a doctor, the word or sound "whoop" triggers concerns about Pertussis, the bacteria that causes whooping cough, which has been unfortunately on the rise in our community and across the United States.

What is whooping cough?

This highly infectious respiratory disease only infects humans, and causes nearly 50 million cases of disease each year. In the United States, we only see around 40,000 documented cases/year, but certainly have many more infections that are not recognized and treated.  Smokers, asthmatics, infants, pregnant mothers and people with compromised immune systems are at the highest risk for catching pertussis, but we are also seeing outbreaks in healthy, previously immunized populations (whose immunity has worn off over the years since their last booster vaccine.)

There are several stages of whooping cough infections. The first stage is like a common cold- stuffy, runny nose, low grade temperature and a slight cough. However, the second stage is what sets this disease apart. Instead of a mild lingering cough, the cough becomes more frequent and can be intensely severe- causing fits and spasms of coughing so hard that you vomit, and occasionally creating a "whoop" sound as you suck in air after a fit of coughing. Typically people describe this as the "worst cough" they have ever had. Finally, there is a several week convalescent stage where the cough gradually decreases and fades away.

How is pertussis diagnosed?

For a variety of reasons, doctors do not often test for pertussis. The test for pertussis requires a specific nasal swab that should be immediately sent off to the health department lab for evaluation. Blood tests can help to confirm an acute case as well (checking antipertussis toxin IgG levels).

How is pertussis treated?

Short courses of azithromycin or erythromycin will eliminate the virus from the upper respiratory tract. More serious infections (especially in infants) may require hospitalization for more aggressive treatment.

Why can't I get a zpak for my cough?

The vast majority of coughs are NOT pertussis, and in fact, are not caused by ANY bacterial source. The zpak, or any antibiotic, will only help improve coughs caused acutely by a bacterial infection (such as a pneumonia). The good news here is that although coughs can hang on for up to six weeks after a viral infection or with allergies, we do have other (non-antibiotic) medications such as broncho-dilating inhalers that can help clear them up.

How can I prevent pertussis? 

In a flashback to the previous blog on TETANUS, here is your answer: All children should receive the combination vaccine DTaP (diphtheria, tetanus and pertussis) five times in early childhood, at 2, 4, 6, 15-18 months, and age 4-6 years. Then, at 11-12 years, they should receive a BOOSTER combination vaccine, called Tdap (which has lesser, booster-level doses of the diphtheria and pertussis portions, noted with the lower case letters). Finally, everyone over the age of 19 who did NOT receive that Tdap during adolescence should get a one time vaccination with Tdap "now", regardless of the interval since their last tetanus booster, which was most likely simply a Td (tetanus/diptheria booster).

What's that little "a" for in Tdap and DTaP? 

That little "a" is for "acellular" pertussis. There were concerns about side effects from the original whole cell pertussis vaccines, so scientists were able to develop a newer version of the vaccine that only used a small portion of the pertussis cell. This section of the bacteria is still "large" enough to trigger a robust immune response, yet has fewer side effects.

BOTTOM LINE: Adults who have never received a tetanus booster that contains pertussis should update their immunizations at their next check up!

When was Your Last Tetanus Shot?

Since it's time for everyone's annual FLU VACCINE, I thought I'd take a few posts and reflect on a couple other vaccines. Today, let's talk about the TETANUS vaccine.


What does the tetanus vaccine do? Most people have heard that if you "step on a rusty nail", you should make sure you are up to date on your tetanus booster. Actually, this should be true for any significant breaks in the skin such as burns, puncture wounds or "road rash".  The tetanus vaccine boosts our immunity to the bacteria called Clostridium tetani, an organism that lives all around us, but especially in the soil, dust and any areas that my be in contact with manure or saliva.

What is tetanus (the disease)? Tetanus used to be called "lock jaw", and even Hippocrates knew about this disease nearly 30 centuries ago! This disease causes intense spasms of skeletal muscles, especially the neck and jaw muscles (making it impossible to open your mouth or to swallow). The infection can be very severe, and has a high mortality rate in children (1 in 5 cases.) We rarely see this disease in the United States now, thanks to routine vaccinations, but it still occurs in roughly one million people each year around the world.

The tetanus vaccine is the "T" in the DTaP series (Diptheria, Tetanus and acellular Pertussis.) All children should receive 5 routine doses- 2, 4, 6, 12-15 months, and 4-6 years. The next recommended booster comes at 11-12 years (or up to age 18) and is a slightly different preparation, the Tdap. The Tdap is still Tetanus, diptheria and pertussis, but the diptheria and pertussis (marked by the lower case letters) are reduced strength boosters since adolescents and adults no longer require the full strength childhood versions.

New changes in Tdap recommendations are the result of recent pertussis outbreaks in the United States, and include routine vaccination for all adults ages 19 and older with a single booster of Tdap (unless the individual received Tdap as an adolescent), as well as every pregnant women in her third trimester (for each and every pregnancy).

To clarify, after the basic 5 childhood immunizations of DTaP, an adolescent should receive one Tdap (the booster vaccine) between the ages of 11-18, then simply the Td (Tetanus/diptheria) booster every ten years. All adults who have only received the Td booster should receive one dose of Tdap now, regardless of how long it has been since their last Td shot.

BOTTOM LINE: Talk with your family doctor and check to see if your immunizations are up to date!

Restless Legs Keeping You Awake?

Do your legs ache, squirm, feel antsy and seem to want to MOVE to get comfortable when you try to go to sleep at night? How about during the day- do you need to get up and walk around to relieve that same irritating sensation in your legs when you are supposed to be sitting in a meeting or parking yourself in front of a computer? Does walking around or at least moving your legs relieve the discomfort? If so, you may be one of the estimated 3-15% of the population with a disorder known as restless leg syndrome (RLS).

This disorder can be a sign of underlying issues such as iron deficiency, pregnancy, kidney problems or  drug side effects, but also may be an isolated medical problem. About half of the time, there is a family history of other blood-relatives having the restless leg syndrome. The incidence increases with age, and is more common in Caucasians.

How is RLS diagnosed?
Restless leg syndrome is primarily diagnosed by your history, with focus on four issues:

• Strong urge to move your legs
• Symptoms worse at rest
• Symptoms worse at night
• Urge relieved by movement, but come back quickly with rest

Your doctor may need to do blood tests to determine if you have a low iron level (ferritin) and/or low red blood cell count (anemia), and occasionally a formal sleep study may be necessary to fully identify RLS.

How is RLS treated?
If there is an identified cause, such as a medication or iron deficiency, then the treatment obviously targets that trigger. Medications that are more likely to cause RLS include antihistamines and decongestants, antidepressants, anti-nausea medications, seizure medications and stimulants.

If no cause can be identified, then there are several different medications which your doctor may try.
For very intermittent symptoms, a drug traditionally used for Parkinson's disease (Sinemet) can be taken on an "as needed" basis. For people who suffer from symptoms the majority or every night, other neurologic medications (Requip, Mirapex, Neurontin, Lyrica, or Neupro) may be tried on a nightly basis.

What about alternative therapies? There's always SOAP...

BOTTOM LINE: If your squirming legs are keeping you from restful sleep, don't suffer in silence- talk to your doctor and find out if you have restless leg syndrome!

Can't Sleep? You're Not Alone...

One in ten American adults have suffer from insomnia (defined as inability to adequately sleep for at least fourteen consecutive nights). Whether it is trouble with falling asleep or difficulty staying asleep (waking up either multiple times or simply way too early), this lack of restorative sleep leads to more than simply daytime fatigue. Sleep deprivation causes trouble with concentration and memory, irritability and other mood disturbances, and actually can lead to higher rates of infection, diabetes, heart disease, and cancers. As such, I'm going to spend the next several blog entries talking about insomnia issues and solutions.

While some sleep disturbances (such as sleep apnea and restless legs) will definitely require medical interventions, the good news is that a great deal of sleep issues can be significantly improved or solved with some behavioral modifications. What can you do?

Sleep Hygiene Improvements:

• Eliminate or greatly reduce caffeine- even morning coffee affects the quality of your nighttime sleep. (You can keep the coffee- but wean to decaf!)
• Exercise in the morning (or at least a few HOURS before bedtime)
• Avoid "screen time" in the two hours before bed- do your dishes/laundry/non-screen chores if necessary, read a book, play with your pets or enjoy the lost art of conversation
• Take a warm shower or bath just before going to bed
• Use ALL your senses to relax during that bath- smell, sight, sound (think lavender soaps, soft music or nature sounds, and candle light- there is a reason SPA's use all these!)
• Go STRAIGHT to bed after the shower- don't get sidetracked by housework or electronics
• Make your bedroom dark and cool (consider blackout shades and ceiling fans)
• COVER THE CLOCK (no peeking at your phone or clock to watch the minutes tick by one after another!)
• Until you are sleeping WELL again, move the pets OUT of the bedroom. 

BOTTOM LINE: If you suffer from insomnia, talk to your family doctor to try and identify the cause, and include these sleep hygiene tips along with any necessary medications to maximize your long-term success.

I Got Mine! Did You Get Yours?

As we zip into the holiday season, give yourself the GIFT of a flu vaccine NOW so you are not struck down with this illness at the busiest time of year! Flu shots have been available for a few weeks and seem to be available everywhere.  Clinics, schools, grocery stores, pharmacies and many employers are all offering flu shots these days. Add a flu shot to your grocery list- I'll bet the pharmacy there is stocked and you won't even have to add an extra stop on your weekly errands.

Who should get the flu vaccine?
The Center for Disease Control and Prevention (the CDC) recommends annual flu vaccines for everyone over the age of six months.

What is different this year?
This year, we have quadrivalent vaccines (that include protection against four strains- 2 influenza type  A strains, and 2 influenza type B strains) in addition to the usual trivalent vaccines. Pick one or the other, you don't need both. If you have egg allergies, make sure to ask for the trivalent vaccine that is egg-free.

But I hate needles...no problem, just ask for the vaccine that is delivered via a nasal spray! The only caveat here is that this is a live vaccine, so there are some restrictions: you must be age 2-49 years, not pregnant, have no major problems with immunity (such as having AIDS or cancer), not take aspirin daily, and not have asthma.

Hate needles and have asthma? There is also a trivalent shot that has a tiny needle which is injected just below your skin, rather than into the muscle.


What is FLU? Influenza is not a simple cold, nor is it a twenty four hour stomach virus. The flu causes fever, chills, cough, runny/stuffy nose, muscle aches, headaches, fatigue, and sometimes involves vomiting and diarrhea (more often in kids). Colds and allergies tend to bother you from the neck up- stuffy, sore throat, headache- but don't knock you down for the count, and coughs are generally less bothersome.

How is the FLU spread? This virus is spread from infected people when the cough, sneeze or talk, via tiny respiratory droplets, and the scary part is that you are contagious a full day BEFORE you develop symptoms (as well as for about a week after you feel sick.)

How can you prevent the FLU? Get vaccinated. Get vaccinated. Get vaccinated! 

Who should NOT get vaccinated? Those with bad reactions to vaccine in the past; infants younger than 6 months; and those people with a history of an uncommon disease called Guillain-Barre. If you are sick with a fever, wait till this illness is over before getting the vaccine.

BOTTOM LINE:  FLU SEASON has begun again- get vaccinated!

It's BA-ACK! Halloween Candy

Despite the 90 degree days we are still having in Texas, the calendar tells me it is already OCTOBER. Of course, the grocery stores have been featuring HALLOWEEN CANDY for nearly a month already! Did you resist? Or are you tossing in a bag of bite-sized candy on impulse as you check out?

If so, it's high time to realize that we are now officially in what I call the "treat yourself" season, as we hit the trifecta of food oriented holidays: Halloween, Thanksgiving and Christmas/Hanukkah. We tend to celebrate with nonstop EATING, and then what do we do every January? That's right, make New Year's resolutions where LOSING WEIGHT tops the list!
This year, let's THINK AHEAD...

Let's SAVE THE HALLOWEEN CANDY for...yes, HALLOWEEN! Start in the grocery store. Do NOT BUY the candy till the DAY BEFORE Halloween. It's way easier not to eat it when it is still sitting on the shelf in the grocery store, rather than sitting on your desk at work or your kitchen counter top. We all grab a small handful of treats when they are openly displayed in front of us.

Do the calories add up? You bet. Here are some of my favorites: Snack Size Butterfinger: 170 kcal, Fun Size Kit Kat- 50 kcal, and ONE single, plain M&M-4 kcal. Now, if you stop at ONE, it's really no big deal. but if you eat a handful of M&Ms each DAY for the next few weeks, or grab a couple fun size chocolate treats, BOOM-you will gain a pound right there. (Remember one pound is 3600 kcal- do the math.)

BOTTOM LINE: Don't wait for NEW YEARS to make a resolution for better health- start NOW by limiting Halloween CANDY to HALLOWEEN DAY!

PS. It's a new month, so CHANGE THOSE AIR FILTERS!

High Heeled Danger!

Attention female shoe lovers- if your closet is packed with high heels, especially those with pointy toes,  you may one day find yourself dealing with a medical problem known as a Morton's neuroma. A Morton's what, you ask? Morton's neuroma- a little balled up group of nerve endings (perineural fibrosis, if you want the medical lingo) along the small digital nerve as it passes between your toes, most commonly in the space between your third and fourth toes.

This malady is most common among women in their mid to late 40's. High heels cause more weight to be transferred to the front of the foot, and the pointy toes squeeze in from the sides, pinching in on the nerve, causing inflammation. Often the patient first notices the problem as a sensation of a pebble in their shoe, but typically this progresses quickly to pain, cramping, numbness or shooting sharp pains of the area with weight bearing. Can you get a Morton's neuroma without high heels? Sure- anyone who "overuses" their feet- ballet dancers, basketball players, runners- can develop this problem, but high heels greatly contribute to this problem.

How is a Morton's neuroma diagnosed? Xrays might be obtained if there is concern of a stress fracture or other bony issue, but the neuroma itself does not show up on xray films. Often this condition is diagnosed based on your history and a thorough exam, but occasionally clinicians use ultrasound to further evaluate the problem. Ultrasound is very accurate at identifying neuromas (98% sensitivity) but not always accurate (65% specificity). MRI scanning is rarely needed to help with surgical resection, for resistant cases.

How about treatment? First and foremost, it's time for "sensible" shoes- wear flat shoes with a roomy toe box. Inserts such as metatarsal pads may help ease symptoms, as well as arch supports for those people with flattened arches. Taking NSAIDS (ibuprofen or naprosyn) often will ease the discomfort temporarily, and nearly half of patients (40-50%) will respond to these simple measures within three months. The primary treatment from the medical end when conservative measures are not effective enough, however, is a steroid injection into the top of your foot (just above where the pain is located). This injection may be repeated in 1-4 weeks if there is a partial response.  Another 40-50% of patients will respond to these injections. For those 20-25% who continue to have pain despite all these measures, surgery may be indicated to go in and remove the actual neuroma and free up some space (releasing a ligament) in between the toes, and happily around 96% of surgical patients obtain relief.


BOTTOM LINE: Once again, prevention is key! Enjoy your high heels in moderation, but consider a more generous toe box and wedge (less slope) for daily use if your profession calls for dress shoes. Also, go see your family doctor when you START feeling that "pebble"- don't wait for it to become intense daily pain!

Cigarettes- the Good News & the Bad News

Let's start off with the GOOD news- the CDC's anti-smoking TIPS campaign has turned out to be far more successful than they had dared to hope! Over 1.6 million smokers had a quitting attempt, and at least 200,000 smokers DID QUIT as a direct result of the shocking pictures and stories featured in this unique national program. The Lancet published a wonderful article this week summarizing all the findings: Effect of the First Federally Funded U.S. Antismoking National Media Campaign.

I have always maintained that stories are more powerful than statistics. Sure enough, this campaign is chock-full of stories from former smokers- people sharing extremely painful negative consequences from their nicotine addiction. Virtually every complication from smoking is shared: heart surgery scars, asthma, artificial limbs (from damage to blood vessels), artificial voice boxes (from throat cancer), COPD (chronic obstructive pulmonary disease) and of course, lung cancer, to name a few. Hearing from Terrie- a former cheerleader, points out the dangers of "social smoking" in college. Likewise with Michael, who smoked in the military. Click on the TIPS from Former Smokers 2013 to hear and see more...and share with any of your friends or family or co-workers who still smoke.

The campaign goals are to increase public awareness of both immediate and long term health risks of smoking- both first-hand, and from inhaling second-hand smoke. Note that for every person who dies from smoking, 20 more Americans are LIVING with a smoking-related illness. The CDC wants to encourage and support smokers who are ready to quit, as well as encourage them to limit other people's exposure to their second-hand smoke. 

So that was the good news...now the bad. Just last week, Notes from the Field: Electronic Cigarette Use Among Middle and High School Students- United States, 2011-2012 was published in the CDC's Morbidity and Mortality Weekly Report. E-cigarettes are not a new cell phone app, they are true electronic cigarettes that are battery powered and deliver nicotine and other byproducts via an aerosol. Worse yet, they can add sweet "childhood" flavors- fruit, mint or chocolate. Really??? Does the industry have NO conscience???? Not surprisingly, they are portrayed as "safe smoking" (anyone else reminded of "safe sex" campaigns?) and teens are jumping on board. E-cig use doubled in this time period, yielding nearly 2 million (1.78, lest I exaggerate) students trying out nicotine in this delivery system last year. Please note that although we do not yet have long-term studies on the "pure" damage of these e-cigarettes, we know that nicotine is damaging to adolescent brain development and, hello- nicotine is ADDICTIVE. If you get addicted via e-cigs vs. dipping vs. "regular" cigarettes- the outcome is the SAME. You are ADDICTED to NICOTINE.

BOTTOM LINE: There is still NO AMOUNT of smoking that is GOOD for you, so please, help encourage your friends who are already smoking to QUIT, and parents, please warn your kids that e-cigarettes are NOT SAFE. NICOTINE is ADDICTIVE in ANY FORM.

Fruits Helping Diabetics?

Hooray! I was delighted to see a new study about the role of dietary fruit in diabetic patients, entitled
Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies, published this week in the British Medical Journal (BMJ).  Over the years, I have found that many of my diabetic patients purposefully avoid all fruits, fearing that the sugar in fruits will raise their blood sugar values and worsen their diabetes. However, fruits are a wonderfully nutritious part of a healthy diet, and I will forever attest that eating too many fruits or vegetables is NOT the major contributing factor to becoming diabetic or overweight.

This particular study reviewed diets (based on scheduled food questionnaires), and found that for every three servings per week of whole foods consumption of blueberries, prunes, grapes and raisins, apples and pears, bananas, grapefruit, and even peaches and apricots,  the risk for developing diabetes was significantly REDUCED!

Fruits are packed with wonderful nutrients, phytochemicals, vitamins and fiber, all of which have long been known to help prevent untoward health consequences such as heart disease and cancer. Hopefully this new study will help convince everyone that FRUIT belongs in the pre-diabetic and diabetic diet as well. The key to improving diabetes in overweight or obese people is weight loss: consuming fewer calories than you burn. Colorful diets packed with fruits and vegetables are the best way to get you moving that direction.

Of note, drinking fruit juices was actually associated with a slight increased risk of developing diabetes. Once again, we see that eating the WHOLE FRUIT is better than making it into a juice or condensing it into a pill...

BOTTOM LINE: Up your intake of whole fruits, especially blueberries, grapes, raisins, apples, prunes and pears, and decrease your risk of developing diabetes. 

Golfer's Elbow- the "Inside" Elbow Problem

Tennis elbow refers to the "outside" elbow pain of lateral epicondylitis. However, if your "inside" elbow is hurting, you may have GOLFER's elbow, known medically as medial epicondylitis. Both elbow problems are due to overuse injuries, and rarely do they occur in both arms at the same time.

Tennis elbow is much more common than golfer's elbow, with tennis elbow having a little over 1% prevalence, and golfer's elbow only 0.4%. Golfer's elbow is an overuse of the wrist as it flexes and pronates (turns palm down). Interestingly, tennis players with overly tight grips often end up with "golfer's elbow".

The main symptoms of golfer's elbow are pain on the inside (tender to touch and aches most of the time), worsened pain with resisted flexion and turning the palm downward, and worsened pain with gripping or handshake. The pain starts at the bony bump on your inside elbow and then may radiate downward to your forearm and wrist.

Once again, treatment includes relative rest (stop the repetitive activity that is worsening the problem), anti-inflammatory medications, compression wraps and icing. An ice massage is done by rubbing the ice in a wide circular motion over the painful side of your elbow for about 5 minutes. (Making the ice in a small paper cup will save your fingers from an uncomfortable session- just peel away the top part of the cup and then you have a paper holder.)

Symptoms that do not resolve within a week or two using these basic treatments may require formal physical therapy or steroid injections to fully resolve the problem.

BOTTOM LINE: Don't let overuse injuries of your elbows keep you off the courts or links- start treatment as soon as you begin to notice persistent elbow pain, and avoid developing full blown "tennis" or "golfer's" elbow.

Tennis Elbow- Racquet Optional!

Recently I talked about carpal tunnel syndrome and cubital tunnel syndrome of the wrist. Now I'd like to move up a notch and talk about issues with the ELBOW. Interestingly, we've got two different "sport" elbow problems- tennis elbow and golf elbow-and yet, you can develop either of these problems without ever picking up a racket or a club. Today, let's talk about tennis elbow.

The medical name for "tennis elbow" is lateral epicondylitis, and this occurs when the tendons on the outside of the elbow are torn or strained. Typically the symptoms begin with an ache on the outside of your elbow, that gradually worsens until it becomes an intense burning pain that is worse when you grab or twist anything (opening car doors, jars, lifting groceries, etc.)

What causes tennis elbow? Any action that causes a repetitive movement can cause swelling and pain in the joint being used, and tennis elbow is no exception. In this case, the movement is a repeated twisting of the wrist and elbow, such as in a tennis stroke. However, other activities- like hammering, sawing, giving massages or working in an assembly line-can also cause "tennis" elbow.

Do kids get this? Not too often- the typical patient with tennis elbow is 30-50 years old, with an equal distribution of men and women.

Do you need an X-ray? An x-ray will not "show" tennis elbow, but some times an x-ray is done to rule out an underlying fracture.

How is tennis elbow treated? There are multiple things to do to treat tennis elbow, but the most important is relative rest- not a cast, but avoidance of the activity that caused the problem. Additionally, taking consistent over-the-counter anti-inflammatory medications such as ibuprofen or naproxen will help reduce both the pain and the swelling. Ice packs applied a few times per day, especially after activity, will also help. An ACE wrap can help control swelling, plus serves as a reminder to you not to overdo it! If these treatments are not enough to resolve the symptoms, then physical therapy, splinting and steroid injections are the next level of treatment. Rarely, surgery is required.

Prevention: If you are taking up a racquet sport (or joining a league and greatly increasing your time on the court), make sure to maintain good strength and flexibility in your arm muscles with light weights or resistance bands.

BOTTOM LINE: If you are developing persistent "outside" elbow pain, you might have "tennis elbow"- try rest, ice, compression, and anti-inflammatories as soon as possible, but if it persists, it's time to see your family doctor.

PS- Happy August- change those air filters!

Say NO to Delivery Food!

Have your kids reached the "I'm bored" stage of summer yet? If so, why not spend some quality time together in the kitchen? Our family is challenged with one vegetarian and one GF (gluten-free) dieters, but we have found multiple menus that still please everyone. Today's meal (pictured above) was made by our younger teenage daughter, proving that 14 year-olds can definitely do more than order pizza!

Nutrition studies have found that kids are far more willing to expand their palate when they are involved in preparing the food. Fruit smoothies are probably the easiest and most delicious way to engage your child in the kitchen. Grab some frozen fruit, a banana, and some plain or vanilla yogurt. Toss the ingredients together in a blender and voila- healthy breakfast you can drink on the run as you dash off to dance camp!

My next favorite is today's dish-stir fry. This meal is simple to make vegetarian by adding your beans of choice, but can also be protein-enhanced with chicken, fish or other meats. Supervise your kids as they learn to chop up squash, zucchini, mushrooms, onions and carrots, then toss them in a large wok or pan and stir fry with olive oil. You can also add some garlic and other seasonings as they expand their palate. We serve this over rice (using the" toss in the microwave for one minute" super-fast option) or pasta or even simply over lettuce for an extra veggie load.

BOTTOM LINE: Break the pizza/burger/nachos summer habit, and substitute some healthy dishes and family fun in the kitchen!

Is this Carpal Tunnel Syndrome?

With all the time we spend at computers, I'm amazed we don't actually see more complaints of carpal tunnel syndrome (CTS), the single most common cause of peripheral nerve compression. Carpal tunnel symptoms include pain, numbness or tingling of your THUMB, INDEX, and MIDDLE fingers, and may extend to include your wrist, palms and forearms. Typically, the pain is worse at night, although that is not true for every person. Extended use of your wrists or hands- such as typing at a computer- also tends to increase discomfort.

The actual problem in CTS is pressure on the median nerve at the wrist. The median nerve only supplies the thumb "side" of the hand and fingers, which is why the symptoms do not show up in the pinky finger. (If the pinky is numb or tingling, you may be pressing on the ulnar nerve at the elbow).
The space in the wrist is limited- restricted by a ligament on the bottom and bones up above, so even general fluid retention and swelling can cause compression and lead to carpal tunnel symptoms. Pregnancy, for example, often results in enough fluid retention to cause CTS. Other risk factors include diabetes, kidney failure, low thyroid and birth control pill usage, as well as jobs or activities that result in prolonged flexion or vibration of the wrist, such as golfers, carpenters, musicians, jack-hammer operators and assembly line workers or grocery clerks.

There are a couple simple tests that doctors use to help diagnose CTS. Tapping on the underside of your wrist may cause a shooting electric pain to jump up into your wrist or palm- that is called the Tinel sign. Holding your hands together, bent downward (like reverse prayer hands) can worsen the numbness, pain or tingling in your thumb and first two fingers- this is the Phalen's sign.

Treatment obviously varies depending on the cause of the CTS. If the primary cause is fluid retention from another medical problem or medication, then treatment will target those issues. Prescription strength ibuprofen or similar anti-inflammatory medications have traditionally been used to provide relief of symptoms, although the scientific evidence is lacking to support this approach. Various splints are available and have been proven to provide some relief when worn consistently at night. Local steroid injections into the wrist have definitely been shown to be effective for at least short-term relief of symptoms (compared with placebo). Physical therapy and avoidance of behavioral triggers play a significant role in treatment. Finally, a minority of CTS cases may require actual surgical decompression to improve symptoms.

BOTTOM LINE: If you are having persistent or recurrent numbness, pain, or tingling in your thumb or first few fingers, head to your family doctor for a definitive diagnosis- don't wait until the symptoms have been stuck there for months, because the longer you've had symptoms, the more difficult it is to cure.

Is Your Pinky Tingling?

Have you ever had your pinky go numb or start tingling, especially at night? If so, did your co-worker tell you it might be carpal tunnel syndrome? Hmm...probably not the right diagnosis. Although carpal tunnel syndrome also involves fingers starting to tingle or go numb, that problem is associated with the median nerve, which supplies your thumb and first three fingers (and half of your ring finger.) If your PINKY gets involved with the tingling, that is due to the nerve on the other side of your arm- the ulnar nerve.

Cubital Tunnel Syndrome, also known as Ulnar Neuropathy, results from pressure or compression of the ulnar nerve at the elbow. Men suffer from this problem much more than women, anywhere from 3-8 times more often. What causes this? Sleeping with your elbows bent and arms overhead (scrunched up under your pillow as a side-sleeper) is a common cause. Athletes who have repetitive upper arm motions such as throwing, hitting with a raquet or skiing can also suffer from this problem.

The primary prevention is to avoid prolonged periods with pressure on your elbow. For example, if you are driving a long distance, be careful not to prop your left elbow on the arm rest (putting pressure directly on the side of your elbow) for extended amounts of time. If you are a side sleeper, try not to extend your arms over your head.

Treatment depends on the severity and duration of symptoms. Many cases can be treated with NSAIDs (like ibuprofen) or a simple steroid injection into the elbow, coupled with the avoidance behaviors noted above. Bracing at night, physical therapy and ergonomic corrections to computer desks go a long way towards correcting and preventing future injuries. A minority of cases are so severe that they do indeed require surgery, but 85-90% of all cases of cubital tunnel syndrome will resolve with good to excellent results.

BOTTOM LINE: All that tingles (in fingers) is NOT carpal tunnel- if you have persistent pain, numbness or tingling in your ring finger, pinky , or forearm, you may be suffering from another compression syndrome such as Cubital Tunnel Syndrome.

Ugh- Athlete's Foot!

Athlete's foot, known medically as "tinea pedis", is one of the most common skin infections encountered in primary care practices. With bare feet and wet public areas for summer fun, athlete's foot shows up more this time of year. This infection is caused by a fungus that can grow on skin, nails or even hair. As the fungus grows and spreads, there is typically a red edged border, with the central area clearing and looking like normal skin. On the feet, however, the fungus causes an itchy red rash with thick scaling, cracking, and redness between the toes and on the heels, sometimes accompanied by a strong, unpleasant odor. (If you have a sweaty teenage athlete who props their feet up on the couch to share their stinky feet with the rest of the family, you know the smell...) We see athlete's foot most often in young adults, aged 20-50 years old, although it can certainly occur at any age. Men seem to contract it more than women, although the reason for that is unclear.

How can you prevent it?
Getting athletes foot does not imply you have poor hygiene, but it likely does mean your feet are staying damp for prolonged periods. Wearing rubber sandals or other foot protection in community showers and locker rooms can help, as well as doing whatever it takes to keep your feet dry- from careful towel drying after getting wet, to changing socks half-way through the day if you tend to have sweaty feet.
The key is DRY.
Bonus tip of the day: to avoid spreading the fungus to other parts of your body, put on your socks before your underwear (if you have a case of athlete's foot).

How is it treated? 
There are multiple OTC sprays and creams that might help, but severe or chronic cases may require prescription anti-fungal medications that are taken by mouth. If you have already tried a full week of treatment with OTC products and are not getting significant relief (or if you keep treating it but getting it back), schedule an appointment with your family doctor to fully address this problem.

BOTTOM LINE: In moist or damp public areas such as showers, pools, and locker rooms, wear foot protection to avoid prolonged contact with the fungus that causes athlete's foot. 

Don't Forget to Book Your Back-to-School Physical!

July is here already, so before you know it, our kids will be headed back to school. Why am I bringing this somber fact up on July 1st, in the very heart of summer? Because part of back-to-school preparation is that doctor check up, complete with the mountain of forms your child's school has sent you. Whether your baby is starting pre-K or headed off to graduate school, our educational institutions rightly want to protect their students' health, including reducing the spread of preventable, communicable diseases with vaccinations. Prioritize calling your family doctor RIGHT NOW and get your kids appointments on your calendar (and your doctor's) before camps, family vacations and other summer fun fills every day.

Many people have asked me why we "make" kids to come in to fill out these school forms, so I thought I'd take a moment to explain. First of all, kids GROW. Yes, I know this is not news to you, but when the last time we saw your pre-teen or tween was 6 months ago, before his growth spurt, if we use his height and weight from that visit, we'll be off by a couple inches and a dozen pounds. Additionally, with the childhood obesity epidemic we are facing, these vital signs become even more important. I'd much rather talk to "Jessica" about food choices when she is a few pounds overweight, than waiting a year or more and then face telling a teenage girl she is 20 lbs overweight.

This "annual" exam is a wonderful window of opportunity for your physician to talk to your adolescent about all kinds of preventative issues- from helmets and limiting screen time, to diet & exercise, to dating & driving risks. Often kids "hear" their doctor's words as significant information, despite the fact that their parent has preached the same speech to deaf ears. Feel free to give your family doctor a heads up if you have concerns about your child's behavioral, dietary, or peer choices so we can better direct our discussions.

Finally, be aware that our immunization schedules are always changing. For example, HPV vaccinations are now recommended for all boys and girls at age 11-12. "7th grade" vaccinations have included the meningitis vaccine, and the booster shots for chicken pox and tetanus for several years now, but current recommendations today also include a BOOSTER Meningitis vaccine for all college students up through age 21, that must be given on or after the child's 16th birthday. 

BOTTOM LINE: Back to school preparation INCLUDES a doctor's visit for your child (unless she's recently had a checkup). Sign up now and don't forget to bring those school & sport forms to the appointment! 

PS. It's the first of the month...change those air filters!

Going Vegetarian?

I think we all know (or at least, assume) that eating more fruits and vegetables is a healthy choice. I have yet to find the person who thinks eating vegetables is BAD for you, although I do have many patients who are afraid that eating fruits will worsen their diabetes. With the recent media focus on the risks of eating red meat (and the link to increased risk of developing diabetes), many people are taking a critical look at their diet and wondering what to do.

My honest recommendation for the majority of us is to simply increase the color in our diet- focus on increasing all the fruit and vegetable servings you eat throughout the day. In addition to that, I encourage patients to try and eat at least one vegetarian meal per week- that's one out of 21- not too much to ask! More is not a problem, mind you, but getting Texans to restrict their red meat can be a challenge, especially in BBQ season...

For those of you considering jumping in full force and becoming vegetarian, there are a few things to remember.

Number one: vegetarian does not equal healthy.

Please remember that eating poptarts and chocolate chip cookies may be vegetarian, but that does not mean you are getting all the nutrients your body needs!

Number two: pay attention to PROTEIN.

When you give up meat, you need to be sure you are getting adequate protein from other sources. Some vegetarians add in seafood (pesco-vegetarians), others add in dairy and egg (lacto-ovo-vegetarians), while vegans consume absolutely no animal products. Protein is found in fish, dairy (cheese/milk) and eggs, but also in nuts, seeds, legumes (dry beans and peas) and some grains. Your daily protein needs are weight and age dependent, but women over 19 need roughly 46g of protein daily, and men >19 need roughly 56g. To give you a frame of reference, a cup of milk has 8 grams of protein, and a cup of dry beans has 21g.

If you are radically changing your diet, I highly recommend you book an appointment with a local registered dietitian to be certain your new food choices will meet all your body's needs.

BOTTOM LINE: Up those vegetables and fruits, and if you are going all-out vegetarian, pay extra attention to your protein!

Diabetes from Hamburgers?

Last week, the media was abuzz with a recent study: Changes in Red Meat Consumption and Subsequent Risk of Type 2 Diabetes Mellitus, published in JAMA. Since my last post was addressing knowing your diabetes risk, this is a nice follow up, so I will jump on the bandwagon.

The study involved several separate groups: over 26,000 men in the Health Professionals Follow Up Study, nearly 50,000 women in the Nurses Health Study and around 74,000 women in the Nurses' Health Study II. Dietary choices were tracked with validated food records updated every four years.

What did they find? People who increased their red meat intake during a four year interval had a significantly higher risk of developing diabetes in the next four years. In fact, adding only a half serving of meat per day was associated with a 48% elevated risk, and on the flip side- DECREASING your red meat intake by more than a half serving per day was associated with a 14% DECREASE risk of developing diabetes over the next four years.

Did eating those extra steaks and burgers (and maybe the baked potato and fries on the side) just make people gain weight, and because of the weight gain, then develop diabetes? Researches agree that this theory played a role, but only partly explained the significant changes.

BOTTOM LINE: Significantly lowering your average daily red meat consumption appears to decrease your risk of developing diabetes. Take it a step further, and REPLACE that red meat with some colorful vegetables, and you will really give yourself a healthy push!

Are YOU at Risk for Diabetes?

Although the internet is packed with misleading and erroneous medical advice, there certainly are a great number of medically accurate and helpful sites as well. Today I stumbled across an excellent tool to help people quickly assess their risk for DIABETES on the American Diabetes Association website:
The Type 2 Diabetes Risk Test. Their catch phrase is "It's Fast. It's Free. It's Easy."- and it IS all that!

The numbers of people being diagnosed with type 2 (adult onset) diabetes in this country are staggering. There are nearly 2 MILLION new cases of diabetes being diagnosed each year in the United States, and nearly 80 MILLION people thought to have Pre-Diabetes. To clarify, Type 1 Diabetes, previously known as Juvenile diabetes, is a condition typically diagnosed in childhood or young adulthood, when the person's pancreas is not able to produce insulin.

This type accounts for only around 5% of all diabetics. Type 2 Diabetes is the more common type, and in this disease the body makes insulin, but either it cannot make enough insulin or the cells in the body are resistant to the insulin. Either way, blood sugars rise and cause problems in the rest of the body (such as the kidneys, eyes, blood vessels and nerves) and that sugar is not being converted into energy.

Bottom Line: If you are overweight and/or have a family history of diabetes, or simply are wondering about your risk, please take a minute and jump to the ADA website and see where you stand. Then take that number with you and head to your family doctor to see how you can optimize your health and minimize your risk for developing diabetes!

Swimmer's Diarrhea?

Lovely topic, isn't it? But if you've got a persistent case of diarrhea, it's possible you picked up a parasite called Giardia during a summer swim. Giardia is transmitted by swallowing contaminated water (typically during a swim) or from other fecal-oral transmission (such as poor hand washing after changing baby diapers or using the restroom), or rarely, from contaminated food. Even if you are not a pool-water-mouth-squirter, it is very easy to accidentally swallow water while swimming- especially in a race! And diapered babies are supposed to be limited to a "baby pool" for a good reason, but think how often you have seen a busy mom change a diaper poolside (so she can multitask, watching her older child in the pool) and then hop right back in to the pool with her baby...probably thinking that the chlorine in the pool will "wash" her hands, if she is thinking about hygiene at all. Not infrequently we see clusters of giardia infections that can be traced to a public water source- a small lake or public pool, as well as deceptively pure-looking mountain streams.

Interestingly, only 25-50% of people who get infected notice any symptoms. If you do have symptoms, they tend to show up a week or two after exposure, and include persistent diarrhea (more than 5-7 days), bloating, flatulence, nausea and bad smelling stools.

Giardia infection is diagnosed most often by lab examination of stool samples, and often requires multiple samples to identify the parasite. The treatment is with antibiotics, and often people are treated based on clinical symptoms. Commonly people develop lactose intolerance following this infection, and therefore, avoiding dairy for a couple weeks after treatment is often helpful.

BOTTOM LINE: Watch your "bottom line" and remember not to routinely allow water in your mouth while swimming, plus don't count on chlorine to be your sanitizer if you have just changed a diaper.

Which Sunscreen Should I Use?

Speaking of melanoma (yesterday's blog), it's time for another review about the basics of sunscreens. Which one is the best? Sprays are so fast and convenient- but do they work? Which ingredients matter? 

Let's start with SPF. What does it mean? Sun Protection Factor is a measure of a sunscreen's ability to protect the wearer against UV radiation from UVB. Note that the sun produces both UVA and UVB, and BOTH cause damage that can lead to skin cancers. Right now, though, the SPF only addresses the UVB protection. So, SPF means that compared to bare skin, the sunscreen keeps you from burning X times longer. If it takes you a half hour to turn red with bare skin, a sunscreen with an SPF of 30 should in theory keep you from burning 30 times longer, which would be 900 minutes- 15 hours. Unfortunately, no sunscreen stays fully effective beyond two hours without re-application. Additionally, sunscreens with an SPF of 15 block roughly 93% of UVB rays, SPF 30 ~ 97%, and SPF 50 is 98%. Therefore, even with perfect application, no sunscreen blocks all UVB rays, and many block no UVA rays.

How much should you use to be effective? Surprise- would you believe it takes about an OUNCE (picture a shot glass), and that same amount should be reapplied every two hours. This means you will use roughly half of an 8 ounce bottle on ONE PERSON during a full day outdoors. (And no, I don't own stock or have financial interests in sunscreens.)

Which ingredients are important? Most dermatologists recommend combining the physical barrier ingredients that protect against the deep penetrating UVA rays, such as ZINC OXIDE & TITANIUM DIOXIDE (the ones that leave the white residue) along with the chemical barrier agents known to block UVBs, such as PABA, salicylates, cinnamates and benzophenones. Since nearly all sunscreens contain mixes of the chemical barriers, I grab a tube or bottle and scan to be sure it also lists either zinc oxide or titanium dioxide as well. Note that some people are sensitive to PABA or other ingredients, and may do best with purely barrier sunscreens and clothing (such as surf shirts.)

Back to the sprays...they are not my first choice. Why? Few have either zinc oxide or titanium dioxide, and those that do are very expensive and have these minerals broken down into "nanoparticles" to allow them to be in a light enough liquid to spray. In the medical literature, some debate exists as to whether these nano-sized minerals can potentially cause cancer, which is of course, the opposite of our intent. Regardless of these issues, probably the biggest issue with sprays is that people use TINY portions- picture that less than 10 second total body spray- and so they are not obtaining anywhere near the listed SPF. Would I prefer that over skipping sunscreen all together? Yes...which means I do keep some on hand.

What do I usually buy? Our family likes Banana Boat's "Baby" lotion. To it's credit, my kids complain that their skin is "way too white" because I never let them tan. I take that as a compliment! Probably more importantly, for extended sun exposure we all use swim shirts, and try to consistently wear hats and sunglasses.

BOTTOM LINE: Get a sunscreen that contains both chemical and barrier agents (think titanium dioxide) and realize an 8 oz tube should be used up by a family of four in ONE morning OR afternoon since each person needs ONE OZ every TWO HOURS.

Summer Skin Cancer Message

Recently a friend posted a very impactful message on her Facebook page (thanks, Lisa!) that I would like to recommend. The youtube video is called "Dear 16 year-old Me", and shows real people who lives have been deeply affected by melanoma, and the message they would love to go back in time and send to themselves (and their loved ones) before they started purposefully sun tanning to "look healthy".

Many people are unaware that the skin cancer MELANOMA is a very serious cancer. Because it looks like a simple little funny-looking mole on the skin, there is often the assumption that a quick skin biopsy will fully take care of the issue. Not so! While these cancers start in the pigment-producing skin cells, they can invade locally and then break off and metastasize to the liver, lungs and even the brain.

Melanoma skin cancers kill roughly 8000 people in the United States every year, and show up in an estimated 100,000 people annually. (Numbers on this vary greatly, partly because although melanoma cases should be reported to central cancer registries, many providers are unaware of this these reporting requirements.)  I know in my practice, I have seen younger and younger patients (not just because I am growing older!) with this scary diagnosis. Did you know that using a tanning bed before you turn 35 will cause a 75% increased risk of developing this cancer? Other risk factors include blistering sunburns in childhood, living at higher altitude (>2300 feet), family history of melanoma, fair skin, red or blond hair and more than 5 sunburns in your entire lifetime.

Remember the ABCDE's of Melanoma:
Asymmetry
Border (that looks irregular)
Color variation (including reds, blacks or blues)
Diameter (>6mm)
Elevation  (you can feel it as a bump above the skin)

And ultimately, remember this- if all your "moles" look the same, and ONE looks different- please go get that one checked out. Just like Sesame Street, if "one of these things is not like the others" then it "doesn't belong"!

BOTTOM LINE: Please, watch the video- the message is very effective. And remember to wear sunscreen and protective clothing this summer!

Modeling credit: A. Lampert (who will wear more sunscreen next time...)

Is Swimming Pool Water Safe?

Swimming season has arrived, and patients often ask me about whether or not you can catch this or that disease from a swimming pool or hot tub. First of all, let me assure you that no, you cannot catch STI's (sexually transmitted infections) directly from a hot tub...as long as all you are doing in the hot tub is enjoying the water. There are, however, diseases that can be contracted from swimming pools- typically from accidentally swallowing the pool water. How does that happen? Easily, especially for kids and adults who play around with getting mouthfuls of pool water and spraying that out like a whale (we've all seen them!)

The most common swimming pool contracted illness that we see is diarrhea, especially from the parasite giardia or the pathogenic strains of the bacteria, E. coli. Of course, there is also the potential to contract a few skin diseases such as athletes foot or plantar warts when you are hanging out in public swimming areas.

A recent study, Microbes in pool filter backwash as evidence of the need for improved swimmer hygiene-metro-atlanta, georgia, 2012, published by the Center for Disease Control (CDC) looked at the microbes collected in pool filter backwash. Over half the samples contained Pseudomonas and E. Coli. Pseudomonas  can invade ear canals and any open skin lesions/cuts/scratches- including "razor burn" areas, and is a special concern for diabetics, who can tend to develop more severe infections.  E. coli is the most common bacteria in a healthy human gut, but can also cause significant illness, as is evidenced by the food poisoning we see from time to time from this organism. Ultimately, this study reinforces the need for public awareness of good swim hygiene, which includes showering before swimming (to remove any fecal matter- the quick, already bathing-suited dash under the poolside shower does nothing for this, though it may reduce oils and residue from sunscreens) and refraining from swimming when you have a diarrheal illness. Most importantly, keep a close eye on your non-potty trained toddlers in swim diapers, making sure to check those diapers on an hourly basis.

BOTTOM LINE: Swimming is great fun and generally good for your health, but pay attention to good swim hygiene, and if you develop persistent diarrhea this summer, don't ignore it- head to your doctor and get checked out (and please stay out of public pools till you are cured.)

Cleaning Ears without Q-tips

In yesterday's blog I touched on a pet peeve of mine, asking people to NOT put Q-tips in their ears. Inevitably, the next question is, "but Doctor, if I can't use q-tips, how can I clean out my ears?"
The answer is two-fold:
Number One- most ears don't need to be "cleaned out".
Number Two- when you do have an ear wax build up, flush them out with a bulb syringe.

Ear canals, like many other parts of our body, are self-cleaning. The ear wax (cerumen) is made up of dead skin cells, hair, and other debris that enters the ear and mixes with fluid produced by glands in the ear canal. The wax is a protective feature, and usually produced and shed in the outer portion of the canal. "Cleaning" the ear canal with various objects typically results in actually pushing the wax further into the canal, eventually packing it up against the ear drum. If wax does indeed build up and block the canal at the base, you can experience a variety of symptoms including muffled or decreased hearing, ringing in your ears, or feeling off-balanced.

The best way to clean out otherwise healthy ears if you have wax build up (assuming you do not have a ruptured ear drum, ear tubes, or other prior ear surgeries) is to flush the ear with luke-warm water. Take care the water is not very hot or cold, or you are likely to experience vertigo and/or nausea. Using a baby's nasal syringe (the rubber bulb pictured above), fill the syringe with the warm water. Lean over the sink and gently pull your ear out and back, which straightens out the canal. Place the tip barely inside your ear, and squeeze the bulb, flushing your ear. Repeat multiple times (I usually say a maximum of ten times) until you see the wax come out. Afterwards, many doctors recommend placing a few drops of alcohol or a mixture of alcohol and vinegar, which will help to remove any remaining moisture.

Why not use q-tips, bobby pins, or other cleaning devices? Again, two main reasons. First of all, it frequently worsens the issue instead of fixing it. Secondly, we frequently see damage from them, whether it is minor, tiny abrasions in the canal and on the ear drum, or a serious rupture of the ear drum from over-vigorous "cleaning" or an accidental jamming that happened courtesy of a careening toddler or playful pet, a suddenly opened door, or a loud noise that causes the user to jump/startle.

BOTTOM LINE: Save q-tips and bobby pins for makeup application and hair, and keep them OUT of your ear!

Swim Season! Are Your EARS Ready?

Swim season is fully upon us, and with that comes a couple medical challenges. Today I'd like to focus on swimmer's ear.

What is swimmer's ear? 
This typically refers to an OUTER EAR infection caused by fungi or bacteria. The moisture left in the ear after swimming is fertile ground for these organisms to multiply, especially lake water.

What are the symptoms?
Swimmer's ear is PAINFUL and almost always one sided, despite the fact that both ears had the same exposure. (Differently shaped ear canals and varied amounts of ear wax are to blame for this discrepancy.) Since this is an outer ear infection, typically there are no other symptoms (such as stuffy nose, headache, or sore throat, like we see with middle ear infections.)

How quickly should you head to your doctor?
Good news here- often mild to moderate cases of swimmer's ear can be treated with over-the-counter solutions. If you are developing fever or intense pain, it's time to head call your doctor, but more mild symptoms can wait for a couple day trial of home therapy.

How is it treated?
Doctors treat these infections with ear drops that contain both antibiotics or anti-fungal medications, as well as drying and anti-inflammatory agents. However, there is a home concoction that works extremely well for prevention, and often can provide a remedy. Grab a bottle of vinegar and a bottle of rubbing alcohol, and mix them together half & half. This mixture can be spilled on to a cotton ball and squeezed into the ear canal OR my preference is to use the bottle from the over-the-counter swimmer's ear prevention product and fill it up with my "home brew". Place around six drops in each ear, and allow to drain back out- do this after every swim session, and three times/day if you develop a sore ear. Warming up the bottle in your hands will make it less irritating to your ears. The vinegar kills the bacteria & fungus and the alcohol dries up any remaining moisture. Voila! Prevention & cure- same solution.

Please remember that although this mixture will treat a large percentage of outer ear infections, if your sore ear isn't improving in a couple days, please call your doctor & let them take a look, as you may require stronger medications.

By the way, using q-tips to "clean" the ear serves to cause minor trauma to the ear canal and tends to make it easier to get these outer ear infections, so skip the q-tips, please.

BOTTOM LINE: If you (or your kids) are frequent swimmers, don't wait for a sore ear to start using swimmer's ear prevention this summer!

Staying Alive! Hands-Only CPR & AEDs

When is the last time YOU were CPR certified? Most of my friends were first certified during scouting years, then for babysitting as a teenager, then again when they had babies of their own. I know my last few certifications I did online, without benefit of the famous Annie mannequin. Last week, however, I had a recertification training that included an automatic external defibrillator (AED), and now I'm ready to light a fire under everyone I know to head to an American Heart Association (AHA) training!
There are two main messages that I would like to share:
1. You don't always need to do mouth-to-mouth to save a life- "Hands-Only CPR" is very effective.
2. Using an AED is simple. Learn it!

To expand a bit...the AHA has been emphasizing "hands-only" CPR. Far more people are willing and can feel confident about chest compressions than the full traditional CPR with rescue breathing. The message is this: IF YOU WITNESS AN ADULT OR TEEN SUDDENLY BECOME UNCONSCIOUS, CALL 911 and then START PRESSING DEEP and FAST on that person's chest. To make it even easier for us baby boomers, simply start singing John Travolta's "Staying Alive" song to get the right pace!

As for the AED, the whole key here is AUTOMATIC. Truly, once you turn on the machine (press the power button), the machine literally talks you through the procedure. You are told to open the package with the pads and plug in the cord. The pads have diagrams showing you proper placement. This modern wonder analyzes the heart rhythm then instructs you out loud if you need to press another button to administer a shock to restart the heart. Best of all, there are only two buttons on the machine, clearly labeled and the shock button lights up and flashes when it is needed. Simple, right? And did you realize that most public places have AEDs now? From sporting arenas, to schools, churches, malls, airports, and restaurants, if you or someone you love has a sudden cardiac event that leaves him unconscious, chances are high that immediately effective help is nearby...if only someone is aware and willing to use an AED. While truly this procedure is simple enough to be learned from a video, attending a training and using your own hands to walk through the actions a few times will boost your confidence to a whole new level.

BOTTOM LINE: Take less than a minute right now and click on to the AHA website to watch their "staying alive" instruction video for hands-only CPR- the life you save is likely to be that of a family member or close friend!

PS. Kudos to Ericka Holmes for being such a terrific CPR instructor!