'Tis the FLU SEASON

It's that special time of year again...so please give yourself (and your family) 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?
As with last 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.

Didn't I hear that the flu vaccine this year doesn't match the strain that is going around? 
Well...unfortunately, yes. We are early in the season, and the CDC is seeing that most of the diagnosed cases are a result of the H3N2 strain (as opposed to the H1N1 that was so devastating several years ago), and although that strain is included in the vaccine this year, there has been a mutation in roughly half of the circulating virus that makes it resistant to the vaccine. The take-home message, however, is that even if the vaccine is LESS effective, it is still the best protection that we have AND it should still reduce the severity of the infection if you happen to contract one of those mutated strains.

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:  Your best gift for good health this season is the FLU VACCINE!

More Dancer Problems...

Dancers pretty much abuse their feet, with repetitive forces in unnatural poses, so it is no surprise that they end up with stress fractures in their feet. When we think about broken bones in the foot, most of us picture a broken toe or a large bone in the middle of the foot (the metatarsals). However, there are two tiny pea-like bones that can also be broken- the sesamoid bones. These little bones are embedded side by side within the tendon that is in the ball of your foot, just beneath the base of your big toe. They act like pulleys, allowing the tendon to slide more easily as you bend your foot, pushing off with running, jumping or walking. Stress fractures of the sesamoid bones show up as gradually increasing pain every time you put pressure on them, especially with the act of bending and pushing off. The pain tends to stay very localized, is relieved with rest, and the maximal tenderness to touch is underneath the base of your big toe.

How are these fractures diagnosed?
Sesamoid fractures, like all stress fractures, may not show up on x-rays till they have been present for a couple of weeks. A dark line is seen within the white "ball" that is the sesamoid bone. Occasionally the sesamoid bone will be completely broken into two parts, and these fractures may require surgical correction.

What is the treatment?
There is no quick fix for this problem, much to the dismay of dancers (and runners). The treatment is to stop bending the ball of your foot, most easily accomplished with a firm walking boot. How long? Typically a minimum of 3 weeks, but more often roughly 6 weeks. Upon return to activity, the key is to "start low and go slow"- do NOT jump back in to full workouts!

BOTTOM LINE: For deep, persistent, worsening pain under the ball of your foot, consider the possibility of a stress fracture of your sesamoids- head to your family doctor for an exam and possible X-ray.

Dancer Problems...

Have you ever had a plantar wart? These are the warts that show up as a painful bump underneath your foot. These unwelcome growths often show up at the site of "trauma", so dancers obviously most frequently develop them on their feet or toes. Warts are incredibly common, with a prevalence of up to 10% of Americans. In fact, the vast majority of us will develop at least one wart somewhere on our body during our lifetime.

Are warts dangerous? Not really. Warts do not turn in to cancer, and in fact, untreated, will eventually go away on their own. The problem is that "eventually" could be years. Since warts are rather unsightly, and obviously plantar warts can be painful (picture having a pebble under your foot as you walk), most people do not choose to do nothing and simply wait out the wart.

How can you get rid of a plantar wart?
There are many different remedies out there, most of which have some success- including the perennial favorite, duct tape. Over-the-counter fixes may work as well as treatments in your doctor's office. None are perfect. One relatively recent study from 2011 again demonstrated that home daily self-application of salicylic acid yielded the same results as a physician treating in the office once with cryotherapy (liquid nitrogen). EVerT: cryotherapy versus salicylic acid for the treatment of verrucae--a randomized controlled trial.

My personal favorite treatment for plantar warts is a non-prescription product called Curad Mediplast. This stick on product is a combination of higher dose salicylic acid (the active ingredient in most OTC liquid wart removers) and, well, tape. You simply cut a tiny piece large enough to just cover your wart, and stick it on your freshly washed, but thoroughly dry wart. Leave it on for 24 hours. Take it off, scrub your wart a bit with soapy water and a pumice stone or washcloth, then let dry for 10 minutes and place a new one on. Repeat this for ONE week. Then, do nothing for two weeks (you can continue to use the pumice stone if you want, but don't be tempted to start digging around with sharp objects. Repeat the week-long cycle again. Smaller plantar warts like the one pictured above may resolve after only one cycle, while larger ones may take three or more. Just remember- one week of treatment, then two weeks off. Is this 100% evidence-based practice? No, but it has been successful for my patients, and correlates with clinical studies using similar protocols.

BOTTOM LINE: Think you have a plantar wart? Head in to your family doctor to confirm the diagnosis and start on a treatment that will get you back to action as quickly as possible.

Is it Ebola? Or "just" the FLU?

You have a fever, chills, sore throat muscle aches, headache, nausea and vomiting…is it Ebola Virus? Or perhaps that new respiratory virus (Enterovirus 68)? While technically speaking, it is possible for your illness to be caused by one of these dreaded agents, the odds are very much against it. However, you very well may have the FLU.

NOW is the time to get your flu vaccine- please! The flu vaccine is recommended for EVERYONE aged 6 months and older (who does not have a contraindication for the immunization.) We are already seeing cases of flu here in Austin, as others are across the United States. Instead of fretting about the two cases of Ebola virus here in Texas, recognize that last year in Texas alone, twenty children died from the flu. Twenty. Children. Gone. And, according to the CDC,  across the United States we have over 23,000 deaths and over 200,000 hospitalizations from influenza.

"But Dr. Grimes, the flu shot always gives me the flu!"
No, it does not. The flu shot does NOT contain live virus- it is not capable of causing influenza. In randomized, blinded studies the only difference between people who got a placebo (salt water) vs those who receive the actual flu vaccine is that the real vaccine makes your arm more sore for a few days.

There are no absolutes in medicine, but I will share that in my 20 years of practice, 99% of my patients who have actually HAD a real case of influenza make it a priority to get a flu shot each year so they don't have to experience the flu again. This is not a perfect vaccine, but annual flu vaccines greatly reduce your chance of getting the flu, and definitely decrease the severity of the infection if you end up with influenza.

BOTTOM LINE: The CDC recommends ANNUAL FLU VACCINE for everyone* over the age of 6 months. I got mine- did you get yours yet?

(*Flu vaccine is not indicated for the minority of people with "severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine. This might include gelatin, antibiotics, or other ingredients. ")

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!

 

Jellies!

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.

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.) 

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!

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.)

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!

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.

Summertime & SUNBURNS: Just Say NO

Happy June 1st! With summer here, it's time for my annual post on SUNSCREENS. Remember that "base tans" are a medical myth- no pre-tanning helps prevent sunburns. Period. As for 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 Sport or "Baby" lotions. 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.

It's a NEW MONTH- CHANGE those AIR FILTERS!

A Doctor's Travel First Aid Kit

Packing up for your summer vacation? If you are driving and have the luxury of a bit of extra space, you may want to consider packing a first aid kit to take with your family. If you already keep one in your car (hello, fellow soccer/dance/volleyball moms!) then let this be your reminder to pull that kit out of your car, CHECK EXPIRATION DATES, and replenish all your used up supplies.

What's in my kit? A handful of medicines have earned their way into my ever-ready first aid kit.  Here is my top 10 list:

1. Ibuprofen- for headaches, muscle aches, fevers or menstrual cramps.
2. Tylenol- to supplement the ibuprofen if the ache or fever is severe.
3. Antacid tablets (TUMS or Rolaids)- still the fastest relief from heartburn/stomach acid.
4. Hydrocortisone cream (steroid such as Cortaid)- for anything that itches (bug bites, allergic skin reactions.)
5. Triple antibiotic cream- for cuts/scrapes (after washing with water.)
6. Bandaids- the GOOD kind that really stick, with specifics for knuckles, knees, and most commonly, HEELS (for those blisters!)
7. Benadryl tablets- for an intense allergic reaction to food, stings, etc; also may be used to help nausea.
8. ACE wrap- handy to limit swelling of a sprained ankle, knee or wrist.
9. Aspirin- honestly, I only keep this in case an adult has symptoms of a possible heart attack.
10. Imodium- I do NOT recommend this to stop infectious diarrhea (so do not take if you have a fever), but if you get a "nervous stomach" with the thought of flying, driving, or simply being cooped up in a car with your relatives, consider this medication to calm down your bowels.

BOTTOM LINE: These few basic first aid supplies should get you through 99% of the illnesses and injuries that crop up on your trips. Remember the creams may count as "liquids" so slip them into your airline-specified ziplock baggie if you are flying!

Relief for Allergies!

Rainy days in May mean high mold counts on the Austin allergy scale.  A nonstop sneezing reaction of my own has prompted me to blog about some belated good news for allergy suffers. Late last fall (October 2013), the FDA approved the first OTC nasal steroid for seasonal allergies- Nasocort AQ...and there was much rejoicing! I have maintained for years that I wished the nasal steroid sprays would have gone over the counter before the non-sedating antihistamines (like Zyrtec, Claritin & Allegra) primarily because the nose sprays have far fewer side effects.

People frequently initially cringe when I suggest a nasal steroid spray for their seasonal drippy nose, sneezing and congestion- for a couple reasons. One reason is that many of us hate even the thought up shooting something up our noses. Rest assured, using a fine mist from these sprays is NOTHING like getting water forced up your nose from jumping into water! If that is your (or your teenager's) primary concern, try a sample before you rule out this treatment option. The second main issue is a global distrust or fear of STEROIDS. Again, relax- you will not be morphing into Arnold from THESE steroids. Nasal steroids are not muscle-building anabolic steroids, but a separate class of drugs called glucocorticoids, which decrease inflammation. Additionally, these nasal sprays are very minimally absorbed into your body, but instead work more locally in the nasal membranes.

BOTTOM LINE: If you have been prescribed nasal steroids for your seasonal allergies, know that there is now a full-strength over the counter option. 

(Disclaimer- I have no financial ties nor investments in Nasocort or any other medications, but like all practicing clinicians, I have my own clinical preferences...and this is one of them.)

Can Healthy Lungs "Collapse"?

My last blog entry talked about costochondritis, a common frustrating but benign cause of chest pain in young people. Today I would like to talk about a much less common but potentially far more serious cause of chest pain in young adults- pneumothorax, more commonly known as a "collapsed lung".  If images of television's Dr. McDreamy dramatically inserting a chest tube into an ER patient pop up in your head, please keep in mind that this medical issue only occurs in just over 1 in 100,000 people in the United States per year. In my private clinical practice, I saw less than an average of one per year, despite seeing innumerable patients with chest pain. Now working in an urgent care setting, I definitely see this more often but it is still relatively infrequent (I diagnosed three in the last six months, only one of which required surgical intervention.)

Wouldn't you know if you had a collapsed lung? Shouldn't you be gasping for breath? Well, not necessarily. Most of what we see outside of hospitals is much more subtle, and typically involves a very small portion of the lung. (I should clarify that I am talking about primary spontaneous pneumothorax here, where the person has no known underlying lung diseases such as pneumonias, tuberculosis or cystic fibrosis.)

Who gets this? The classic body type we think of as a risk factor is a very tall, thin, frequently athletic person. Smoking is also a risk factor, but is not necessary. 

What does it feel like? The pain is typically very sudden, sharp, and one sided, often near the shoulders or neck (not towards the heart or breast bone). Pain is worse with a deep breath or cough. Often patients think they "pulled something" in their back/chest/neck. 

How can the doctor know if the lung is collapsed? When the doctor listens to your heart and lungs with her stethoscope, she may be able to hear a discrepancy in your breath sounds- the side with a partially collapsed lung may have softer (or absent) breath movement than the other side. However, when the portion collapsed is very small, there may be no obvious findings on the physical exam.  In the schematic above, my balloons are demonstrating a fully inflated lung on the image right hand side, with a partially deflated "lung" on the left. On regular chest x-rays, the outline of the shrunken lung can be identified as an opaque shadow, leaving the remaining "empty" part of the chest cavity that an inflated lung would normally fill looking darker black than the other side. Chest X-rays are typically the only imaging necessary, though occasionally a CT scan is needed to identify additional lung pathology.

What is the treatment?  The treatment for pneumothorax is highly dependent upon the size of the collapse as well as physical symptoms. Larger or recurrent collapses may require chest tube placement to re-inflate the lung, and/or surgical intervention to prevent additional lung collapses.

BOTTOM LINE: Most sharp chest pains in otherwise healthy young adults are NOT from the lungs, but partially collapsed lungs do occur and are not always dramatic. See your doctor if you have any concerns about your chest pains, even if you are not short of breath (and even if you are otherwise young and healthy.)

Chest Pain in a Teen or Twenty-Something?

In otherwise healthy young adults, chest pain is rarely a serious medical problem. The vast majority of the time, chest pain is coming from the chest WALL, not the heart- which is typically the concern of the patient or his/her family. This chest wall pain is medically labeled as "costochondritis." We see this more in young females than males, most often between the ages of 20 and 40 years, though younger teenagers may have this as well.

What causes costochondritis?
Sometimes the cause is obvious, such as a new weight lifting regimen or workout routine, or perhaps after a lingering upper respiratory infection that left you coughing for a month. Often, however, we cannot identify a trigger or likely cause.

What does it feel like?
As opposed to the squeezing or pressure sensation that we associate with cardiac pain, chest wall pain tends to be more achy and actually tender to touch. Although the pain may be in multiple locations, it is typically one-sided and often right along the junction of the ribs with the sternum (your breast bone).

Do you need a chest x-ray to diagnose costochondritis?
While chest x-rays may be ordered to rule out other causes of chest pain, there is no specific clinical finding that you can see on a chest X-ray film to "show" costochondritis. Along the same lines, there is no blood test to prove or disprove this diagnosis.

How do we treat costochondritis?
Topical ice massage, stretching and anti-inflammatory medications such as ibuprofen, or straight pain-relievers such as acetaminophen (tylenol) may all be tried to see if they offer improvement. Often people with this complaint are less concerned about making the discomfort go away, but are seeking reassurance there is not something wrong with their heart. The symptoms of costochondritis have an annoying tendency to wax and wane over weeks to months, regardless of what intervention is  attempted. Changing behaviors is also critical if there is a concern of an overuse injury as a cause.
The good news is that this is not a medically dangerous condition that leads to scarier diagnoses, and while the symptoms seem to hang on "forever", the vast majority of the time the symptoms seem to fully resolve by the end of a year.

BOTTOM LINE: Chest pain that is actually tender to touch in an otherwise healthy young person is often "costochondritis", a benign but annoying chest wall problem that tends to last for weeks to months, then spontaneously resolve. 

Is This Strep Throat?

Are you worried you might have "strep throat"? How can you tell when it is time to head to your family doctor for a sore throat? Certainly the majority of sore throats are not caused by the streptococcus bacteria, and do not require antibiotics. In fact, seasonal allergies often cause extremely painful throats, but do not involve bacterial infection at all. While there is very little in medicine that is completely black and white, there are several clues to clinicians that a particular sore throat may be caused by strep (and therefore, respond quickly to antibiotics.)

Typically with strep infections, we see a combination of fever, a sore throat (that looks beefy red, with or without white pus on the tonsils and often with the red spots on the top part of the mouth), with tender, swollen glands (lymph nodes) in the front part of the neck, and LACK of a cough. The presence of a cough almost always excludes the possibility of strep, so if you are coughing, chances are greater that you may have a viral or other cause of your sore throat.

Other symptoms that are common with strep throat infections are headache and stomach ache, with or without nausea and vomiting.

How helpful are the rapid strep tests? Very- if they are positive. A positive test has a 95% chance that you do, indeed, have strep. However, not all types of strep are identified with the rapid test, only Group A (which is the classic "strep throat" that can lead to scarlet fever). Other types of strep (Groups B, C, D, and G) can also cause throat infections, but will not be identified with the rapid strep test. A false negative test may also be the result of a suboptimal swab, which can happen if the patient has an overactive gag reflex (which raises the tongue and blocks the tonsils). There is a 3-10% false negative rate (meaning you test negative, but you do have strep.)

A throat culture- where that same swab is placed on agar to actually see what bacteria grows- takes a couple days to yield an answer, but it is 99% specific.

What can you do to feel better? Happily, strep is a bacteria, so antibiotics due indeed cure this problem. In addition to taking the antibiotic that your doctor prescribes, taking ibuprofen or acetominophen typically helps with the pain and fever. I am a big advocate of salt water gargles (for the first day or two) to ease pain. For this, my advice is to put a couple tablespoons of salt into a standard 8 oz glass of warm water- it won't all even dissolve, but the point is to make the gargle solution extremely hypertonic (very salty), which appears to aid both in numbing the throat as well as helping to fight the bacteria.

BOTTOM LINE: Signs of strep throat that should signal a diagnostic trip to your family doctor include fever, sore throat, painful & swollen lymph nodes (glands) in the front of your neck, and NO COUGH.

Painful Ankles...to X-Ray or NOT?

Image: http://www.bmj.com/content/326/7386/417

This month I am talking a bit about bone fractures and x-rays. As we try to "do no harm" in medicine, leading physician groups have been taking a closer look at procedures that have become automatic, and determine whether or not they are medically necessary- do they IMPROVE outcomes? One such procedure involves imaging ankle injuries. Both clinicians and patients often expect that a painful joint needs an x-ray as part of a thorough evaluation. When SHOULD we order an x-ray for a painful ankle? Current evidence suggests the answer to that question- at least for adults- lies in the "Ottawa Rules", a guideline to help clinicians decide whether or not a fracture is truly likely, and therefore, whether or not to order an x-ray.

First, questions for the patient:
When the injury happened- could you bear weight immediately? 
Could you bear weight when you reached the medical facility? 
                     If the answer to both of these is YES- you could definitely bear weight and walk on the ankle- it is less likely to be fractured.

Then, questions for the doctor as she examines your ankle: 
Is there pain at the bottom, back edge of your ankle bones, both on the inside and the outside? (in medical terms, the distal 6 cm, posterior edge or tip of the lateral or medial malleolus).
Is there tenderness at two different spots on your foot (the navicular and 5th metatarsal bones)? 

The majority of ankle injuries are sprains, not fractures, which involves the ligaments attaching the bones to each other- not the bones themselves. As such, x-rays will not "show" ankle sprains- they are diagnosed by clinical exam. Ankle sprains can be very serious injuries that require splinting or even casting, but they do NOT necessarily require imaging with x-rays.

BOTTOM LINE: Not all ankle injuries need to be x-rayed; an open conversation with your physician about utilizing the Ottawa Rules may save you some unnecessary radiation and expense. 

Do I Need An X-Ray?

Image: B. Rushing

When you hurt your back (or ankle, or wrist) and head to the doctor, should you expect an x-ray? In my last post, I mentioned that the only way to be certain whether or not a bone is broken is with imaging, and that is true. However, not every painful joint NEEDS to be x-rayed. I find that many patients are surprised or disappointed if I do not insist on an x-ray for an acute injury, but they are simply not always necessary, and radiation is not without harm.

XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue.  (As a quick aside,  a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking x-rays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries. Stay tuned for more on those rules in my next post.)

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

Spring Break: Alcohol 411

Spring Break is nearly here, and students everywhere are gearing up for a week-long party. Alcohol is often a large part of these festivities, so I think this is a great time to review some facts about alcohol dangers. In recent years, studies show that about a third of college students admit to binge drinking (consuming 5 or more drinks in a row.) The good news is that this number is down over 15% from over the last two decades, and actually, drinking trends in ALL categories are decreasing- whether the measurement is annual consumption, monthly, weekly or number of binging episodes. A great website to educate yourself (or your favorite college student) is  http://www.b4udrink.org/statistics - complete with a virtual bar where you can enter in your gender, age and weight, and then "pour" yourself drinks and watch your blood alcohol levels rise...

Another wonderfully informative program/website is Aware Awake Alive. Check out their table with drinks/blood alcohol concentrations, and SHARE THIS WITH YOUR FRIENDS. Ultimately, know that if you have a THIRD drink, you are most likely legally drunk. AND, please note, this is a third drink measured by the book (not a "college pour" of alcohol into a plastic red cup- those cups hold several servings in just one glass). The biggest mistake friends make is leaving their intoxicated friends alone to "sleep it off".  If someone has "passed out," they NEED supervision. The alcohol level in their bloodstream will continue to rise, which can cause them to either vomit (and potentially choke, because their gag reflex is dulled by the alcohol) or to stop breathing. If their breathing is less than 8 breaths/minute, CALL 911 immediately.

Pain killers often find their way to spring break as well, whether that is courtesy of a knee injury skiing, or simply part of someone's personal medicine cabinet. Please take note: Pain Killers (narcotics- think codeine or vicodin) + ALCOHOL= DEATH. This combination accounts for far too many accidental suicides per year- don't do it.

BOTTOM LINE: Enjoy spring break, but if your festivities include alcohol, make sure you know your limit AND know exactly what to do if one of your friends drinks too much. 

"Don't Let the Frostbite BITE"

Who doesn't love FROZEN? Our family can't stop singing the award-winning songs from Disney's latest musical hit, so I couldn't resist borrowing a line for my blog title today...However, frostbite is no laughing matter, and with the record low temperatures we have had this year, I thought I should say a few words about this cold weather danger.

What is frostbite?
Frostbite occurs when ice crystals literally form within the tissue in our fingers and toes and noses, damaging and often completely destroying the cells in the skin. Frostbite shows up when it the thermometer reads in the negative in Celcius or below minus 17 in Fahrenheit. Remember, though, that wind chill can push the "real" temperature below the numbers you see on your favorite weather app!

Risk factors besides the extremely low temperatures include alcohol use, smoking, diabetes, previous cold injury, low calorie intake, lean body mass and history of Raynaud's phenomenon (where the blood supply to the hands gets restricted and your hands turn red/purple and ache terribly.)

What are the signs and symptoms?
Frostbite manifests as very painful, severely cold, and initial white and numb areas that progress to blotchy, swollen redness in the tip of your nose or the ends of your fingers and toes. While the affected areas hurt, they are also typically numbed (you can't feel someone touching the end of your finger/toe, but you have pain in that area). With second and third degree frostbite, blisters and "blood blisters" appear, and in fourth degree frostbite there is actual gangrene (rotten, dead tissue).

PREVENTION is KEY
Dress your core in LAYERS, cover all exposed areas, avoid alcohol (or any drugs that can alter mental status), and stay inside if the temperature is below negative 10*. HOWEVER, be aware that if you try to layer socks or gloves, you may end up with excessively tight, constrictive layers that can actually make you MORE likely to get frostbite. Also, remember to remove rings (fingers and toes) before skiing or other cold weather activities.

What is the Treatment? 
Remove any jewelry if present. Immerse the affected areas in warm water and take NSAIDS (ibuprofen) and quickly SEEK MEDICAL CARE. Do NOT rub affected areas, as this may actually increase tissue damage.

BOTTOM LINE: Watch the temperatures, especially if you are traveling to an area that is much colder than you are used to experiencing, and make sure you have gloves, socks, and face gear that is made for sub-zero weather challenges if you plan to be outdoors in below zero weather!

What's Hookah?

What's Hookah?? In the past few years, instead of asking my patients "Do you smoke?" I have learned to ask  "Do you smoke? (pregnant pause)...ANYTHING?" I found that asking in that manner greatly increases my yield. Couple that with Colorado's legalization of marijuana, and more people are freely sharing the full extent of their substance use with their doctors. Which left me asking the question, "what's hookah?" (I could add here that I was also asking "what's shisha" and "what's snus"?)

Hookahs are water pipes used to smoke flavored tobacco. The flavors are often sweet- chocolate, cherry, licorice or fruit flavored. The heat source is charcoal, and the vapor/smoke goes through a water basin before being inhaled. A common misperception is that this "purifies" the tobacco, so that the smoke is no longer harmful. Hookahs can have multiple tubes allowing several people to inhale at one time, or users can pass around the mouthpiece and take turns inhaling (obviously sharing germs as well as the hookah vapor).  Hookah bars seem to be multiplying across the United States, especially in college towns. Austin, Texas, is no exception. A 2013 study of 7 large universities showed that 1 in 10 college students used hookah.

Although hookahs has been around for centuries, we certainly do not have a plethora of double-blind, placebo-controlled meta-analysis studies to clarify exactly the specific health risks of long term use of hookah. What do we know?

• Hookah smoke is "at least as toxic as cigarette smoke" (CDC, 2013)
• Hookah tobacco and vapor contain the same poisons that cause mouth, lung and bladder cancer
• Hookah sessions are usually much longer than cigarette breaks- often up to an hour, increasing the toxin exposure up to ten times higher than traditional smoking
• The nicotine in hookah tobacco and vapor is very addictive (just as in cigarettes)
• Smoke from the heat source, charcoal, can cause carbon monoxide poisoning
• Gum disease is 5 times more common in hookah users than cigarette smokers

BOTTOM LINE: Hookah (water pipe) smoking is NOT a "safe" alternative to cigarette smoking- don't take up this habit! 

CVS Quits Smoking!

Congrats to CVS pharmacy for taking a stand for HEALTH and announcing that they will completely quit selling tobacco products by October 1st of this year! While, yes, consumers can choose to walk across the street and head into another store to purchase their cigarettes, I am hopeful that other major pharmacies and grocery stores will consider this same step. As people have heard me say repeatedly, there is NO amount of tobacco that we believe to be actually GOOD for your health.

Every single day in the United States, there are over 1300 deaths attributed to smoking. How can you picture what that means in terms of human tragedy? Imagine two enormous jumbo jets colliding- which would mean approximately 1200 people dying...and think about how many times we would see that ghastly image on our computers and televisions. I want young people starting to smoke to have THAT image printed on their brains, rather than associating smoking with fun, alcohol and parties.  Did you know that the vast majority of long-term smokers began the habit before the age of 21? I cannot tell you how many soccer moms my age, as well as professionals of all sorts, are still closet smokers- hating their addiction and wanting to quit. Many picked up "social smoking" in college fraternities and sororities, thinking it was no big deal...and that they would stop that habit after they graduated. Now it is ten or twenty years later, and they are hiding this addiction from their peers and especially their children. I believe it may be easier for people who smoke openly to quit, because at least they can enlist the support of their friends and family!

If you are still smoking, please talk to your family doctor about all the medical options to help you quit, and think about setting a quit date in 2014. Your habit didn't form over night, and the average serious smoker takes 7 tries to quit for good. Nicotine replacement medications (gum, patch, nasal sprays, inhalers and lozenges)  have been shown to increase your chance of successful smoking cessation by 50-70%. Other medications such as Chantix & Zyban double or triple the success rate as well.

BOTTOM LINE: Smoking doesn't "just" cause lung cancer (and many other cancers), it causes heart attacks, strokes, and really crummy quality of life with chronic bronchitis and COPD (Chronic Obstructive Pulmonary Disease). If you still smoke, please make an appointment to talk to your family doctor about quitting. You CAN do it!

Sugar for Your Sweet Heart??

As Valentine's Day approaches, our thoughts turn to HEARTs, right? And maybe chocolate? Perhaps...but we also need to think about the heart muscle keeping us alive right now, and we have yet another medical study that shows the EXCESS SUGAR in our diets is taking a toll on our heart health.

The recently published Journal of the American Medical Association report, "Added Sugar Intake and Cardiovascular Disease Mortality Among US Adults"  confirmed that American adults consume too much added sugar (such as the sugar we directly add to coffee and foods, as well as the "added sugar" in sodas, fruit juices, pastries, and chocolate) with 10% of us getting over one fourth of our daily calories from this category! In addition, people whose diets have over 21 % of their calories from added sugar have a significantly increased risk of heart attacks and strokes- DOUBLE the risk of those who limit these sugars to less than 10% of their diet. If you bump up the daily percentage of added sugar to over 25% of the daily calories, that risk almost TRIPLES.


Now this may seem fairly obvious, because we know obesity is linked to cardiovascular disease, but the interesting part to me is that this increased risk held true even when factoring in our known risk factors such as  obesity, low physical activity, and high cholesterol. 

Additionally, this study noted that those of us drinking a sugar-sweetened beverage every day (more than 7/week) also have an increased risk of cardiovascular disease compared with those who do not. Keep in mind, a soft drink at a restaurant is usually TWO servings, not one, so even one of those every other day would count. I would also like to take this opportunity to point out that drinking one regular (not diet) soda per day will add on 15 pounds per year...so there is definitely some benefit to changing this habit! Sodas are not the only culprit, of course, please note that fruit juice is on the list (yes it has some vitamins in it, but you are better off eating the whole fruit) and the daily coffee addiction can add tremendous numbers on the scale if you are not a "black coffee" kind of person. But I digress...

BOTTOM LINE: Let's become conscious of the "added sugar" in our diet, and make it less of a habit and more of a treat...and our HEARTS will thank us!

Can't Stop Sneezing?

Ah, the beautiful golden mist floats above our Austin trees...ACHOO! It's cedar fever time in central Texas, and many of us are suffering. Itchy eyes, runny nose, sneezing, stuffy nose, ear pain and very sore throats are all part of the package. Often people are afraid they have the flu or strep throat, because their symptoms are so intense, but one clue with allergies is the LACK of a fever- while you might have an elevated temperature of 99-100*, allergies don't cause the 101-104* fevers and chills that infections can trigger. That being said, some of the most PAINFUL sore throats can come from "just allergies"...so be sympathetic to your suffering friends and family.

What is the best treatment for seasonal allergies? 
First line treatment for seasonal allergies includes both oral non-sedating antihistamines (like brand names Allegra, Claritin & Zyrtec, now all over the counter) and nasal steroid sprays (such as Nasonex, Flonase, Veramyst, etc.- require a prescription.) My personal preference for someone who truly has daily symptoms during a given season, especially with significant nasal congestion, is to start with these nasal steroid sprays. These are not "pump you up" steroids, but anti-inflammatory steroids that only act locally in the nasal membranes, creating sort of a protective barrier in your nose; blocking irritating pollens from ever causing that release of histamine that triggers all the itchy, runny, drippy symptoms. When I see a patient who suffers from nasal congestion, drainage, etc., "every" winter or spring, my plan is to get them started on these nasal steroid sprays a week or so before that season the next year, in the hope of preventing symptoms from ever starting.


There are also prescription nasal antihistamine sprays, which are very effective in drying up dripping noses, but are limited in many people by a rather nasty aftertaste. (Leaning forward as you use this type of spray can greatly reduce this side effect).

Another oral medication that works very well for seasonal allergies (when taken daily throughout a particular season) works by targeting the immune response via a "leukotriene antagonist"- don't worry about the specifics here, but know this pill effectively limits the body's allergic inflammatory response. The trade name of this drug is Singulair, and it is used both for seasonal allergies and for asthma. Many physicians use this drug as a second line of defense when the daily nasal steroids are not enough, especially if people are having too much sedation or dryness as a result of oral antihistamines.

Allergy shots from an allergist may also be a very effective option, but because they require a significant time and financial investment, we reserve this treatment for patients more severely affected.

BOTTOM LINE: If you have had a stuffy nose for weeks or are having fits of sneezing or itchy eyes, ears or throat, talk to your family doctor about treatment options both NOW and in anticipation of your next allergy season.

Gardasil- What's Up Down Under?

The HPV (Human Papilloma Virus) vaccine, Gardasil, was FDA approved in the United States for use in young women in June, 2006, then extended for males in October, 2009. In October of 2011, the Advisory Committee on Immunization Practices (ACIP- the group that creates our national guidelines that you see posted on your doctor's office walls) extended their official recommendations to include ROUTINE VACCINATION of both boys and girls at age 11-12 years, with "catch up" immunizations for those youth  ages 13-21 who had missed getting this vaccine series.

Why are we vaccinating?
We vaccinate primarily for CANCER PREVENTION. Each year in the United States, we have over 33,300 cases of HPV-related cancers (data from CDC, 2012). About 2/3 of these occur in women, primarily with cervical cancers, but also other genital, anal and oral cancers. In men, the majority of HPV related cancers are oral, but they, too, can have genital and anal cancer, though it is less common than in females.
Gardasil also protects against the two strains of HPV that cause 90% of genital warts, and with over one million cases of this malady each year in the US, you can see what an impact prevention can make here!

How well are we doing?
Not as well as we could do...because national immunization surveys have shown that in teenagers 13-17 years old, only 53% of young women had started the series, and only 1/3 of that group had completed the series. A bit more encouraging is an improvement in the very low percentage of teenage males getting the vaccine, which was at 8% in 2011 (the first year it was considered a "routine" universal vaccine) and more than doubled to over 20% in 2012.

How effective is this vaccine? Here is the GREAT news- the HPV vaccine is unbelievably effective when given to young adults not previously exposed to HPV (with no prior sexual intimacy). The CDC's data demonstrates efficacy nearing 100% protection for women in preventing cervical, vulvar & vaginal cancers and genital warts, and 90% efficacy in men for genital wart prevention and 75% efficacy preventing early anal cancers.

What happened down under? 
From 2007-2009, Australia provided the HPV vaccine free of charge to all young women ages 12-26, and had extremely high vaccination rates as they utilized the school system to give out these shots. Follow up studies in 2011 and 2012 showed dramatic results, with 92% decline in genital warts in young women (< 21years old),  72% decline in women ages 21-30, and interestingly...an 81% delicate in young (< 21) heterosexual men and 51% decline in men ages 21-30. This is interesting because the young men saw improvement not because they had been immunized, but simply from the widespread immunization of all the women. Pre-cancerous cervical abnormalities also markedly declined in this short time period, and since cervical cancer typically is very slow growing, we expect to see dramatic falls in cervical cancer rates in the next few years and certainly, in the next decade.

BOTTOM LINE: HPV vaccination SHOULD BE a routine immunization for our sons and daughters- talk to your family physician about it at your next visit*

(In this day and age, I feel compelled to add two things: one, I in no way financially benefit from the makers of the Gardasil vaccine; two, yes, we chose to vaccinate our daughters.)