Rocky Mountain HIGH...Altitude Sickness

Going skiing for winter break? Mountains are my favorite destination, but...please remember that the high altitude can come with medical challenges. Be aware of signs and symptoms of "mountain sickness" (aka. altitude sickness) and if you are susceptible to this issue, look closely at ski resort altitudes- there is a wide variation.

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. This is very common- an estimated 75% of people visiting mountains with altitudes higher than 10,000 feet will get some degree of altitude sickness. Note that many people have a significant difference in degree of symptoms between altitudes of 9000-13,000 feet- which may explain why they "felt fine" skiing last year at a different resort.

For Colorado skiers: 
The highest ski mountains are in Arapahoe Basin and Loveland (13K), with Breckenridge barely under at 12,993'. Snowmass/Aspen, Keystone & Copper Mtns peak at roughly 12,300-12,500', with Crested Butte and Winter Park closer to 12K. Vail is 11,500 while Durango and Steamboat are around 10, 500. To get below 10K, consider Buttermilk at Aspen (max 9900) or Steamboat Springs Howelsen Ski Area at only 7,136. Obviously the ski towns themselves are not at these peak mountain summit heights, and many resorts offer lodging at a variety of elevations- consider this factor when deciding about the convenience of ski in, ski out, as sometimes you are better off further down the mountain.

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
• Note that in severe forms, there can be brain swelling (High Altitude Cerebral Edema) and/or fluid collecting in the lungs (High Altitude Pulmonary Edema)- these are medical emergencies.

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. For mild insomnia, try over the counter melatonin.

PREVENTION:

• Increased hydration with water or sports drinks, 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!

Was My Rapid Flu Test Accurate?

In primary care offices, we do many types of rapid testing to help us diagnose and treat patients- pregnancy tests, urine tests for infection, rapid strep tests, and of course, rapid flu tests. The accuracy of these tests definitely vary by category. Since we are entering FLU season, this post specifically addresses the Rapid Influenza Diagnostic Tests (RIDTs).

If a rapid flu test is POSITIVE, it is EXTREMELY accurate- 98-99%. This means they are very SPECIFIC tests- if it says you have it, you have a 98% chance that you really do have the flu, so the likelihood of a false positive is very low. If your rapid flu test result is NEGATIVE, however, you might still have the flu...and your doctor should rely on her clinical judgement. 
The SENSITIVITY of different brands or rapid flu tests can vary, but averages about 62%, meaning about 1/3 of the time when you DO have the flu, the test could miss it.

The most recently published meta-analysis of rapid flu tests analyzed 26 different rapid test brands, but all had similar data on accuracy-http://www.ncbi.nlm.nih.gov/pubmed/22371850. Another study published in 2015 looks back at the last seven years to assess accuracy of one major brand of rapid flu tests (Becton Dickinson RIDT)- once again, confirming extremely high accuracy if positive (99%), but having a much lower sensitivity ranging from approximately 20-60% (so missing true positives roughly half of the time).

Why do doctors even use these tests if they are not super sensitive? Because it affects our treatment plan. If we have confirmation that someone has the flu (with a positive test), then we can feel more confident in NOT prescribing an antibiotic, and limit our conversation to pros/cons of taking an antiviral medication as well as medications for symptomatic relief. This step greatly reduces unnecessary antibiotics, which is critical in an era of increasing antibiotic resistance.
Additionally, knowing a patient definitely has the flu helps us advise them about returning to work/school/activities, since we know flu stays infectious for up to a WEEK. (So STAY HOME at least several days, and until you are fever-free for at least 24 hours!)

If you had the flu vaccine, will that affect your rapid flu test?  If you had a shot- no. If your flu vaccine was the intranasal spray, there is a chance that you could have a false positive test. Studies have shown that in the first several days after receiving the nose spray vaccine, people may test positive for the flu (even though they are not infected.)

The CDC encourages doctors to treat all high risk individuals with suspected flu with antiviral medications.

Who should be treated with SUSPECTED illness? Some are obvious- anyone hospitalized, patients in nursing homes, and people with immune problems, significant chronic problems (lung or heart disease, for example) or with severe illness such as pneumonia. However, HIGH RISK also includes all otherwise healthy children under the age of two years,  adults over the age of 65, and women who are pregnant or have just delivered their baby within the past two weeks. There are also other less common subgroups that are high risk such as people who are very obese (BMI >40), American Indians or Alaska natives, and youth under 19 who are on chronic aspirin therapy.

Who should be treated with CONFIRMED illness? 
Anyone in the high risk categories above should be treated with antiviral medications if they have a positive test, because treatment definitely decreases severe complications, hospitalization and even death.

Otherwise healthy, active adults who test positive for the flu should have a discussion with their physician about taking the antiviral medications. When taken within 48 hours of the onset of flu symptoms, these drugs have been shown to decrease the duration of the flu by one or two days...which may make a big difference to a student, parent or employee. However, these medications are not without side effects, and for some people, they may aggravate flu symptoms- particularly nausea. In controlled studies, the antiviral medications only cause about 10% more nausea/headaches/fatigue than placebo, but there is no doubt that in a minority of patients, the medicine causes more side effects than they are worth. However, since you have the FLU when you are taking the medications- you already likely HAVE nausea, headache, fatigue, etc- so it is often difficult to sort out. In my family, half of us can tolerate the antiviral medications with zero problems, and half...barely keep the pills down long enough to know.

BOTTOM LINE: If you have flu symptoms, get to the doctor as soon as possible (especially if you would consider taking antiviral medications), and understand that a positive test is REALLY positive, but a negative test does not definitely rule out the possibility of the flu. 

AND...that ounce of prevention...remember to GET YOUR FLU SHOT NOW to reduce your chance of getting the flu (or to at least minimize your symptoms if you do catch it.)

Roll a Mile in Someone Else's Wheels

We've all heard the expression "to walk a mile in someone else's shoes" but this past month at Anderson High School in Austin, TX, students and faculty were given a very unique opportunity to "roll a mile in someone else's wheels" through the Wheelchair Challenge.  For one school day, participants committed to spending the day in a wheelchair.  (A $20 donation was required to nominate a participant or self-volunteer. Those people nominated had the choice to participate or "buy out" for another $20.) The purpose of this program is two-fold: one, to raise awareness about disabilities, and two, to raise money to buy powered doors for our older, not-always-wheelchair-friendly public school. Sounds simple enough, right?

Here are a few things that our daughter learned from her Wheelchair Challenge: 

1. When you are at a different level physically (sitting, not standing),  you are often unintentionally ignored and left out of the conversation.

2. Trying to open and enter through a traditional outside door while staying seated in a wheelchair is virtually impossible by yourself (even when the door is officially not heavy enough to have an ADA mandated power opener.)

3. Arms and backs get tired or strained, and hands can blister quickly when self-propelling a wheelchair..."sitting" all day is much harder than being mobile.

4. With minor modifications and supportive teachers, wheelchair-bound students can be easily included in "extras" like pep rallies.

5. Bias/stigma against wheelchairs and disabilities still exists to the extent that many people didn't take advantage of this unique opportunity purely because they didn't want to feel or seem "weak" to their peers.

Many thanks to Archer Hadley, the truly inspirational young man behind the Wheelchair Challenge. (Watch his brief video story by clicking the link on his name!)

BOTTOM LINE: OPEN DOORS- figuratively and literally, for those who are differently abled, and help expand the wheelchair challenge to YOUR community!

2015 Flu Vaccine "Cattle Call"

BEVO says, "Healthy Horns get Flu Shots!"

Attention Longhorns, Aggies, and everyone else, flu season is upon us, so it's time for your annual flu vaccine.  UT students- we have completed our large flu vaccine clinics, but now you may schedule an appointment at UHS to receive your shot. 

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

What is different this year?
Last year, the vaccine was not a great match for the strain that ended up dominating the scene (H3N2). This year's vaccine includes two type A strains, both last year's H3N2 and the H1N1 that was so intense from 2009, as well as two less well- known type B strains.

But I hate needles...no problem, 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.

New this year: "Jet-Injectors" which use a "high-pressure, narrow stream of fluid" to directly penetrate the skin- no needle involved at all! The only vaccine to be delivered this way for 2015-2016 will include three (rather than four) strains of flu, the type A strains H3N3 and H1N1, along with one B strain, and recipients must be ages 18-64 years old.

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? Wash hands FREQUENTLY and 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:  Grab a friend, family member or co-worker and make time to get your FLU VACCINE!

Newly Diagnosed Cancer? Here is Your "What to Expect" Book

October is Breast Cancer Awareness month, but every month is the right time for preventative medicine (schedule that physical and mammogram!) For me, this is a milestone year, with daily Facebook reminders that my high school classmates are turning the big 5-0. As we start this wonderful "second half"of the game of life, more and more of us are facing the challenge of a cancer diagnosis.

As a family doctor, I have too often seen the deer-in-the-headlights look on my patient's face as I shared the difficult news of a cancer diagnosis. Each time, I feel like time stops for a few moments, and like a cartoon character babbling on, my words are collecting out there in a balloon while the word CANCER echoes back and forth in my patient's reality. I have had countless friends, colleagues and relatives face this challenge as well, and in every situation, my heart aches to help them as my medical brain searches for answers. I am a family physician, so while I am well versed at diagnosing a variety of cancers, I have limited hands-on experience in treatment.

Julie Silver, MD, is a Harvard doctor who specializes in rehabilitation medicine. She faced the diagnosis of breast cancer herself at only thirty-six, right in the middle of being a busy mom, wife and full time physician and medical author. As such, she is uniquely qualified to author "Before and After Cancer Treatment: Heal Faster, Better, Stronger" and the second edition has recently been released by Johns Hopkins University Press. From my perspective, Dr. Silver's book is the perfect blend of scientific analysis of cancer treatment and practical advice on "what to expect when you have cancer." My generation loved our "what to expect" books for pregnancy and toddler years, and now we have a book that meets that practical function when the cancer bomb explodes into our lives.

Dr. Silver addresses alternative medicine, meditation, exercise, spirituality, love, relationships and goal-setting. She advocates for patients to seek second opinions and be proactive about cancer PREhabilitiation to get "as strong as possible- physically and emotionally- BEFORE you begin treatment." She incorporates her personal experiences as well as those of many others, including excerpts from a book she published with the American Cancer Society called What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope, as well as vignettes from other books and survivors.

Facing cancer often means many hours of down time, when the chemo-fatigue drains you of productive energy. Sleep is good. True rest is VERY good. Friends providing family meals and pitching in on the "invisible work" of groceries, laundry, and house maintenance is extremely helpful. Let your friend diagnosed with cancer conserve their energy for the things that matter the MOST- their family, their passions. Tuck this book in with the first meal that you provide.

BOTTOM LINE: If you (or your friend) is diagnosed with cancer, Dr. Silver's new book is a great resource to HEAL FASTER, BETTER, STRONGER. 

Mammograms, Breasts, and Exams...oh My!

Thinking PINK? October is Breast Cancer Awareness month, and pink ribbons are popping up on everything from restaurants and t-shirts to football socks. I love that as a community, we can rally around a cause to raise not only awareness, but also much needed funds for research and support of those affected.

The American Cancer Society statistics reveal that here in the United States, over 230,000 women will be diagnosed with breast cancer during 2015, and sadly, over 40,000 women will likely lose their lives to this disease. The good news is detection methods continue to improve, allowing these cancers to be diagnosed and treated earlier, leading to better outcomes and treatments that are better tolerated.

With all the changes in women's preventative health, many are confused about current recommendations for breast cancer, including health care providers. Different organizations have conflicting guidelines, which fuels the continued media controversy surrounding mammograms.

The United States Preventative Services Task Force (USPSTF) recommends routing SCREENING mammograms every other year for women ages 50-74. I emphasize "screening" because this guideline is for women with no symptoms, no concerning breast lumps and no extra risk factors. If a woman goes to the doctor with a concerning lump in her breast, imaging is most likely indicated- this is not "screening" in this situation, it is "diagnostic." The USPSTF also no longer promotes self-breast exams, because some large studies have not shown these exams to be globally beneficial. Statistically, self breast exams do not cut down on the number of deaths from cancer, and do lead to extra imaging studies (mammograms) and breast biopsies.

The American Cancer Society (ACS) still recommends annual mammograms for women forty and over, as long as they are in good health (not stopping at age 74 purely for too many birthdays, but rather only stopping if the woman has a shortened life expectancy from other serious medical issues.) ACS also still supports self breast exams for women starting in their twenties.

Given this information, do I still teach self breast exams? Right now, I am only seeing patients in an urgent care setting, so I do not have the opportunity to perform "well woman" exams. However, if I am seeing a patient with a breast-related issue that involves me doing a clinical breast exam, then YES, I do explain to patients what to expect when they perform a self-breast exam. I am not on the band wagon insisting patient MUST do these exams religiously on the first of every month (or after their period) as I used to suggest.

One of the greatest challenges in modern medicine is trying to practice evidence-based medicine that is recommended for the global good, versus a clinician's personal experience and success with individual patients. In this case, during my twenty years of private practice, I had numerous patients who found their own breast cancers during routine self-exams, and were quickly diagnosed, treated and cured- often with simple surgical lumpectomies without additional chemo therapies. Would they have been so fortunate if they had not noticed a lump and simply waited for routine screening? We don't know, but most of these women within my practice were younger than 50, so I believe many may have developed more advanced cancers. And so I am conflicted, and continue to follow evidence-based research and extended discussions about pros and cons of breast exams.

BOTTOM LINE: Talk with your doctor about your personal risk for developing breast cancer, and together discuss your prevention strategy- including frequency and timing of breast exams, imaging with mammography or other modalities, and possible genetic testing if breast cancers run in your family.

What about Aleve?

On my Tylenol vs Advil blog, I did not directly mention naproxen, better known by a trade name, Aleve. Do I have that in the first aid kit? Yes.

How is naproxen(Aleve) different than ibuprofen (Advil)?
Let's start with how they are the SAME. Both are classified as "NSAIDs", which means Non-Steroid Anti-Inflammatory Drug. So both naproxen and ibuprofen can be used to decrease swelling and inflammation, and both will lower elevated body temperatures (fevers). The product insert explains that naproxen is indicated for the relief of pain and fever, including headaches, toothaches, muscle and back aches, arthritis pains and menstrual cramps.  Naproxen lasts longer than ibuprofen, so you only need to take it twice per day (every 12 hours) rather than ibuprofen's recommended 6-8 hours.

A quick perusal of the current medical literature does not reveal any shocking data between ibuprofen and naproxen- both have similar effectiveness in pain relief and in side effect profiles. That being said, in my clinical practice I have traditionally used naproxen as my NSAID of choice for menstrual cramps, especially when there is heavy bleeding along with the cramps. Physicians often use prescription strength* doses of naproxen twice daily for the week before menses, then go to as needed use of naproxen the week of menses. This frequently decreases the amount of menstrual bleeding and improves the cramps associated with periods. Could this be done with ibuprofen too? Yes, but since this is scheduled usage, it's nice to use a medication that is only twice per day versus three times.

All NSAIDs can potentially irritate the stomach lining and/or your kidneys, and they may cause fluid retention (do they make your rings feel tight?) In my clinical experience, though not supported by any recent evidence-based studies that I can find, the shorter acting NSAID ibuprofen often helps more with acute pain (especially injuries) than the longer acting naproxen, but this is really a personal preference.

BOTTOM LINE: Add "Aleve" (naproxen) to your first aid kit, and consider this a first choice for menstrual cramps. Figure out for yourself which type of NSAID (ibuprofen vs naprosyn) seems to work best for your other aches and pains, and talk with your doctor to be sure which one is right for you.

Tylenol VS Advil

Next into the First Aid kit should be a pain reliever/fever reducer...should you put in Advil* (meaning any brand of Ibuprofen) or Tylenol*( suggesting any brand of acetaminophen)?
Drum roll please...and the answer is BOTH.

Tylenol and Advil are two very different products that work in different pathways within the body. Although the exact mechanism is not fully understood, Tylenol works in the central nervous system to block production of prostaglandins, a substance that plays a key role in pain and fever. Advil-type products (known collectively as Non Steroid Anti Inflammatory Drugs, NSAIDs) work in the peripheral as well as the central nervous system also blocking production of prostaglandins, which gives them the added benefit of reducing inflammation.

Therefore, tylenol works for pain and fever, but not swelling. NSAIDs work for pain, fever and swelling. So why would you use tylenol, if it does less? A couple reasons:

• NSAIDs can irritate the stomach lining, so in the case of gastritis, stomach ulcers or nausea, tylenol would be a better choice
• NSAIDs may slow down blood clotting (increasing risk of bleeding) so for surgical patients or patients on blood thinners, tylenol would be a better choice
• If there are kidney problems* (NSAIDs can potentially harm the kidneys, but not the liver, whereas tylenol can potentially harm the liver, but not the kidneys)

When are NSAIDs better?

• High fevers often respond better to NSAIDs
• Muscle aches/sprains or swollen joints
• If the liver is inflamed or damaged* 

But wait, there's more!

One lesser known medical trick is to use BOTH, together (when there is not a medical reason to avoid using either one). Yes, at the same time. No, not for routine aches or pains. Evidence-based studies such as this Cochrane review on post-op pain medications have shown that using a combination of acetaminophen and an NSAID such as ibuprofen provide superior pain relief to either used alone. I tend to use two OTC ibuprofen pills along with two OTC extra strength acetaminophen for severe aches and pains such as an intense headache, severe pain from an injury, or for a high fever. The idea is that this combination packs a therapeutic punch as strong as a narcotic like codeine, but without the mind-altering sedation. 

Lastly- name brand or generic? In my opinion, this is purely an individual "cosmetic" decision. The name brand preparations often have coatings that make them easier to swallow vs. the generic, but otherwise I feel the generics have equivalent effectiveness overall.

BOTTOM LINE: Know the advantages and disadvantages of OTC pain relievers such as Advil (ibuprofen) and Tylenol (acetaminophen), and consider a combination dose for more intense pains. Talk with your doctor about the best choice for you!

Antihistamines VS Decongestants

Many people are confused about when to use an antihistamine vs a decongestant, which is not surprising since these medications both treat allergy symptoms, and in fact, are frequently put together in combination products. Here is a quick breakdown:

Antihistamines work "anti" (against) histamine, which is a chemical released in the body during an allergic response. Histamine causes itchy eyes, tearing, itchy nose, sneezing, and post-nasal drainage that creates scratchy or sore throats, as well as occasionally causing total skin itching or hives. Antihistamines, therefore, help decrease sneezing, dry up dripping noses, eyes and throats, and reduce hives.

Antihistamines may cause drowsiness, especially the original over the counter antihistamine known as diphenhydramine (brand name Benadryl.) More recently developed antihistamine products such as brand name Allegra, Claritin & Zyrtec are considered "non-sedating", but may still cause drowsiness in some people. All antihistamines cause some dryness of the mouth and nose- that is part of the goal.

Decongestants simply constrict blood vessels, which in the nose reduces that feeling of stuffiness. Decongestants alone do not affect sneezing, itchiness or sore throats. Decongestants are stimulating, similar to caffeine. Therefore, decongestants may cause some shakiness or anxiety, increased heart rate or increased blood pressure, or insomnia.

Both antihistamines and decongestants come in oral liquids, pills, and nasal sprays. Nasal decongestants should only be used very short term, however, because after a couple days of use, the body creates rebound congestion that defeats the purpose of using the decongestant.

Which should you keep in your first aid kit?
1. Diphenhydramine (Benadryl)- this is a sedating antihistamine; great for occasional difficulty falling asleep or for immediate treatment of an allergic reaction to a sting, food or medication.

2. NONsedating antihistamine of choice: for daytime use-choose a generic or brand name medication such as Allegra, Claritin or Zyrtec for seasonal allergic symptoms of sneezing, itching, drippy eyes, nose or throat or for hives.

3. Decongestant: phenylephrine is a common simple decongestant (the little red pills, common brand name Sudafed). Use when you have a stuffy nose. Okay to use the decongestant sprays (such as Afrin) for less than three days only; provides immediate effect to reduce stuffy nose sensation.

BOTTOM LINE: Rather than combination products, choose an antihistamine or decongestant separately based upon your specific symptoms. 

College First Aid Kit

Happy Fall 2015! I disappeared for the summer, as I finished writing the second edition of my first book (Seductive Delusions), as well as a series of medical articles for Livestrong.org. Since all of my patients are current college students, I thought I would share a series of posts about common health issues for otherwise healthy young adults. Pictured above is my favorite personalized gift for graduating high school seniors- a first aid kit, complete with  my instructions for "when and how to use what" to feel better.

Let's start with one very basic item that is RARELY found in dorm rooms: a THERMOMETER!

Knowing whether or not you have a true FEVER (temperature >100.4*) is a very helpful piece of information, especially when you are calling in to a nurse hotline to get advice about your symptoms. 

Allergies, for example, frequently cause sore throat, headache, and drainage, but do not elevate your temperature to a true fever level, but rather typically cause a slightly elevated temperature to 99*. Viral infections often will cause a SUBnormal temperature of around 98* (especially after the first day), even though you feel "feverish" or chilled. 

Not everyone "lives" at 98.6*, by the way. Check your temperature randomly a few times on different days/weeks when you feel perfectly fine, so you know what is YOUR normal. This is partly why we check temperatures on everyone who comes in to the doctor's office, at every visit- even when you are not sick (but there for a sprained ankle, blood pressure medication, insomnia, whatever.)  

A few side notes: if you are using an oral thermometer, be sure to wait a half hour after eating, drinking (or, heaven-forbid, smoking), because these activities will falsely elevate or lower the temperature measured in your mouth. Ear thermometers measure about a half degree Fahrenheit higher than oral thermometers. Finally, body temperature fluctuates roughly 1*F throughout the day, so check your baseline temperatures at different times. The goal is to find out your average normal temperature. Obviously, if your usual temperature is 97. 4*, a temperature of 100* really is a FEVER for you. 

Which type of thermometer is the best? 

For a college student, I recommend an inexpensive digital thermometer...maybe two, because the batteries wear out. The more expensive ear and temporal thermometers require more precision and effort to be accurate (removing ear wax, for example). Digital oral thermometers across the board seem to be fairly reliable. Old fashioned glass thermometers are no longer recommended, because of the risk of breaking and then exposure to mercury.

BOTTOM LINE: A college student's first aid kit should start with a thermometer, and encourage your son or daughter to learn their baseline temperature, AND to check their temperature before they call their university's health services advice line. 

PS. Virtually every university now has a 24 advice line staffed by an actual, live human being- be sure your college student has that number programmed in to their smart phone!

My Teacher Gave Me an Ulcer!

"Does STRESS cause stomach ulcers?" In a college health center, this is a question I hear fairly often, especially around midterms or finals. Certainly most of us have experienced stomach discomfort when we are anxious- whether that is nausea, cramping, diarrhea or pain- but the vast majority of people with those symptoms do not have actual ulcers. However, people who are stressed may have coping habits that CAN cause or trigger the development of ulcers, such as drinking too much alcohol (more than one drink/day for women, or more than 2 drinks/day for men) or frequent use of over the counter pain killers known as NSAIDs (Non Steroid Anti Inflammatory Drugs) like ibuprofen (aka. Advil/Motrin/etc).

Stomach ulcers, meaning an abrasion or "ulceration" in the inside lining of your stomach, are actually primarily caused by a bacteria called H. pylori, which lives in the GI tracts of approximately 30-40% of Americans. It may be present for decades before it causes any symptoms. This bacteria is identified within 70-95% of ulcers that are biopsied in the stomach and the first part of the small intestine, the duodenum.

What are symptoms of stomach ulcers?
The discomfort of ulcers starts off feeling like hunger to many people- a deep ache, located below your breastbone and above your belly button. The pains may come and go at first, and may also be associated with feeling nauseated or bloated after meals. Initially, taking an antacid such as TUMS will relieve this sensation. The timing of the pains tends to vary with the location of the ulcer, and the pains might come and go for weeks at a time.

How does a doctor check for ulcers?
For young people (under 55 years) who are otherwise healthy, the current standard of care is to test for the presence of H. pylori bacteria, and treat immediately if that is positive. There are blood tests, breath tests and stool tests available. For older patients or those with risk factors for stomach cancer, direct visualization with endoscopy is recommended to allow the doctor to biopsy any suspicious areas.

How are ulcers treated?
If your doctor finds H.pylori, you will be treated with not one, but several medications: one acid blocking medication called a proton pump inhibitor, and two antibiotics. There are different regimens, but all include at least these medications at different dosages and timing.

BOTTOM LINE: If you are having recurrent pain in your upper abdomen, stop taking NSAIDS and drinking alcohol, and head in to see your doctor to be tested for H.pylori. Oh, and stop blaming your teacher for your ulcer...

Are Vaccines Safe?

The MEASLES outbreak has again rekindled the fires of passion that surround VACCINES in the United States. As a family physician and mom, to me there is no debate. VACCINES SAVE LIVES. Are there risks with vaccines? Yes, (mostly transiently sore arms) but they are minor compared to the risks of the diseases that they minimize or prevent. Does my family vaccinate our children and ourselves? YES. We also wear seat belts, exercise, and try to make healthy food choices...but I digress.

In our country, we are fortunate to have extensive health monitoring systems in place, particularly in regards to VACCINE SAFETY. Three major organizations gather data:

• VAERS (Vaccine Adverse Event Reporting System)- which is open to the public; ANYONE can and should file any concerns about a vaccine-related event.
• VSD (Vaccine Safety Datalink)- cooperative effort between the CDC and 9 Major Health Care Organizations (such as Kaiser, simplified with data collection through Electronic Medical Records)
• CISA (Clinical Immunization Safety Assessment Network)- A CDC Project coordinated through 7 Major Medical Academic/Research Centers 

All of these organizations gather data from adverse events after vaccines, and then the data is analyzed to look for patterns. If one person in, let's say, ten thousand develop a problem after a vaccine, that pattern will be recognized and more information gathered to try and determine if there is a true link with the vaccine. It's important to recognize that there are medical problems (including rare cancers or blood disorders) that will be diagnosed in time proximity with someone receiving a vaccine. Obviously, if I get a flu vaccine on Monday and am diagnosed with Disease X on Friday, that does not mean that my flu vaccine CAUSED my disease X. The difficulty, of course, is determining when a vaccine does indeed CAUSE a medical problem, and for that, scientists look for consistent patterns.

I recognize that if MY family member were diagnosed with a difficult, awful, or rare disease, I would absolutely look for a cause...and if there had been a recent vaccine, I understand why fingers point that direction. However, for myself, my family and my patients, I trust that our vaccines are thoroughly monitored. I know that these vaccines SAVE LIVES and save countless sick days, expense and heartache, and I feel very fortunate to live in a country where vaccinations are recommended as routine health promotion.

BOTTOM LINE: Vaccines save lives. Period. 

Measles Memo: VACCINES WORK!

By now you have probably heard about the MEASLES outbreak that originated in Disneyland last month. At this point, over 100 cases (that span at least 14 states) have been documented since the first of this year...and we have only entered February. If you are my age or older (40-something), odds are good you remember HAVING the measles. In my case, I missed the coveted LAST DAY OF SCHOOL in 7th grade...miserably feverish, coughing, aching and covered in itchy red spots, so that particular event is etched in my middle school memories. I lay in bed sobbing in my self-pity for missing all the fun at school that day, as well as the first days of summer. But in truth, I was lucky. The worst part of measles for me was my pre-teenage angst.

Fast forward to medical school, during another measles outbreak in the late 1980's. Our pediatric hospital ward in Houston's medical center was literally filled with very sick kids dealing with complications of measles. Did you know that roughly three out of ten people infected with the measles develops complications? Most of the time, those complications are nonlethal medical "frustrations" like ear infections or diarrhea, but measles also can cause far more serious complications such as pneumonia or encephalitis (brain involvement). Watching a family grieve the loss of a young child from any cause is heartbreaking, but from a preventable disease...words escape me.

In 2000, measles was declared "eliminated" from the United States, meaning that this disease is no longer constantly present here. Measles was not, however, eliminated world-wide. In 2013, the World Health Organization recorded over 400 DEATHS from measles every DAY- primarily in young children under the age of 5. Before routine measles vaccination in the United States (which began in the 1960's), there were over 3 MILLION cases of measles per year, including over 500 annual deaths and nearly 50,000 hospitalizations (each year).  Today, thanks to widespread immunization, we are facing a measles outbreak that is only (so far) in the hundreds of cases.

The good news here is that vaccination WORKS- it saves lives. Worldwide immunization strategies with measles have decreased measles deaths by 75% in the last decade, saving an estimated 15.6 million lives. Who is at the most risk today? Anyone un-immunized, including our precious children too young to be immunized yet (less than one year old).

BOTTOM LINE: The major lesson learned from Measles immunization? VACCINES SAVE LIVES. Check with your doctor to be sure your family is up to date!

How Accurate are Flu Tests?

In primary care offices, we do many types of rapid testing to help us diagnose and treat patients- pregnancy tests, urine tests for infection, rapid strep tests, and of course, rapid flu tests. How accurate are these tests? If a rapid flu test is POSITIVE, it is extremely accurate- 98%. This means they are very SPECIFIC tests- if it says you have it, you have a 98% chance that you really do have the flu, so the likelihood of a false positive is very low. If your rapid flu test result is NEGATIVE, however, you might still have the flu...and your doctor should rely on her clinical judgement. The SENSITIVITY of these tests varies, but averages about 62%, meaning about 1/3 of the time when you DO have the flu, the test could miss it.  (The most recently published meta-analysis of rapid flu tests analyzed 26 different rapid test brands, but all had similar data on accuracy-http://www.ncbi.nlm.nih.gov/pubmed/22371850.)

Why do doctors even use these tests if they are not super sensitive? Because it affects our treatment plan. If we have confirmation that someone has the flu (with a positive test), then we can feel more confident in NOT prescribing an antibiotic, and limit our conversation to pros/cons of taking an antiviral medication as well as medications for symptomatic relief. This step greatly reduces unnecessary antibiotics, which is critical in an era of increasing antibiotic resistance.
Additionally, knowing a patient definitely has the flu helps us advise them about returning to work/school/activities, since we know flu stays infectious for up to a WEEK. (So STAY HOME at least several days, and until you are fever-free for at least 24 hours!)

If you had the flu vaccine, will that affect your rapid flu test?  If you had a shot- no. If your flu vaccine was the intranasal spray, there is a chance that you could have a false positive test. Studies have shown that in the first several days after receiving the nose spray vaccine, people may test positive for the flu (even though they are not infected.)

During epidemic years of the flu (including 2015) the CDC encourages doctors to treat all high risk individuals with suspected flu with antiviral medications, and in fact, last week the CDC put out a special Health Update.

Who should be treated with SUSPECTED illness? Some are obvious- anyone hospitalized, patients in nursing homes, and people with immune problems, significant chronic problems (lung or heart disease, for example) or with severe illness such as pneumonia. However, HIGH RISK also includes all otherwise healthy children under the age of two years,  adults over the age of 65, and women who are pregnant or have just delivered their baby within the past two weeks. There are also other less common subgroups that are high risk such as people who are very obese (BMI >40), American Indians or Alaska natives, and youth under 19 who are on chronic aspirin therapy.

Who should be treated with CONFIRMED illness? Anyone in the high risk categories above should be treated with antiviral medications if they have a positive test, because treatment definitely decreases severe complications, hospitalization and even death. Otherwise healthy, active adults who test positive for the flu should have a discussion with their physician about taking the antiviral medications. When taken within 48 hours of the onset of flu symptoms, these drugs have been shown to decrease the duration of the flu by one or two days...which can make a big difference to a student, parent or employee. However, these medications are not without side effects, and for some people, they may aggravate flu symptoms- particularly nausea. In controlled studies, the antiviral medications only cause about 10% more nausea/headaches/fatigue than placebo, but there is no doubt that in a minority of patients, the medicine causes more side effects than they are worth. However, since you have the FLU when you are taking the medications- you already likely HAVE nausea, headache, fatigue, etc- so it is often difficult to sort out. In my family, half of us can tolerate the antiviral medications with zero problems, and half...barely keep the pills down long enough to know.

BOTTOM LINE: If you have flu symptoms, get to the doctor as soon as possible (especially if you would consider taking antiviral medications), and understand that a positive test is REALLY positive, but a negative test does not definitely rule out the possibility of the flu. 

Flu Without Fever?

Can it be? Should you even wonder if you have the flu if you don't have a fever? Unfortunately, YES. While it is true that the classic presentation of seasonal flu includes an often HIGH fever, body aches, fatigue, sore throat, cough and abdominal symptoms like nausea, pain or diarrhea, no single symptom is absolutely necessary for a diagnosis.  Children under the age of 6 years frequently do not have fever and cough with their flu symptoms. This year in particular, I have seen more cases of flu with purely fatigue and stomach symptoms...including one in our family this week.

The incubation period for influenza averages about two days, so that means that you are exposed to flu 1-4 days before you have symptoms. Unfortunately, you are contagious (spreading germs yourself) the day BEFORE you have intense symptoms, and then continue to be contagious for roughly 5 - 7 days. Whether or not you have FEVER.

What's my point? We all have to be responsible about not spreading the flu. It's hard for anyone to miss work/school/sports, but when we go back too soon, we are just increasing the chance of passing on this illness to our peers. When SHOULD we return to work/school? If you HAVE fever, it's a clear recommendation to wait to go back until you have been completely fever-FREE for 24 hours, without the benefit of tylenol or ibuprofen (which obviously can lower temperatures, and therefore, mask a fever). If you do NOT have fever, but have a positive flu test, then it is less obvious when you should go back, but on average most otherwise healthy people will need to be at home for at least three days. If you are vomiting and having diarrhea, a good rule of thumb is to wait for 24 hours after these symptoms subside to return to work/school. As a parent, I cringe every time I here someone talking about sending their kid to school after that same kid was up "all evening last night vomiting" or they comment nonchalantly, "I know she's wiped out, but she hasn't thrown up since lunch yesterday... and they have a huge test this week."

The flu is spread via respiratory secretions, and this can be transmitted directly by coughing or sneezing (or simply by talking) or indirectly by transfer as the infected person touches their mouth or nose, then touches surface (leaving the virus there) and then the next person touches that surface before touching their own mouth/nose. Remember all of this is microscopic, not visible.

When we DO go back, perhaps we should at least take some antibacterial hand sanitizer with us. And tell your friends and family to get the flu vaccine. True, this year's vaccine is not a great match, but at least it lessens the severity of the flu if you still get it.

BOTTOM LINE: Please, if you get the flu, do your part to stop spreading this disease and STAY HOME from work, school, sports, (and restaurants, grocery stores, Starbucks, whatever!) until you feel significantly better AND are FEVER-FREE (and puke-free) for at least 24 hours without taking medicines to stop/blunt those symptoms.

Will You "Cervive" in 2015?

Is 2015 the year you finally truly prioritize YOUR health? The majority of Americans include weight loss and possibly exercise in their New Year's Resolutions each year...and do really well on their strict diets for a few days or maybe even a few weeks. While I absolutely applaud attention to weight and activity levels, I want to encourage you to think beyond diet and exercise for your 2015 health resolutions. (And I will spend time in future blogs this month talking more about what diets work best, but today I want to shift the focus...)

January happens to be Cervical Cancer Awareness month, so women- how about starting your 2015 Resolution list with scheduling your "annual" exam, especially if your last "annual" was way more than a year ago? The GOOD news is that screening recommendations have changed quite a bit, so women no longer need to have Pap tests every year. Current guidelines tell us for young women to have their FIRST Pap test at age 21, then (assuming tests do not show a problem) every 3 years between 21-29, and then after age 30, testing can actually occur simply every 5 years (by using both the Pap test and a specific HPV test combined).

In the United States, cervical cancer is still diagnosed in over  12,000 women per year, and tragically, still causes over 4000 deaths per year. We can do better! The vast majority of women with cervical cancer have little to NO symptoms- this is a silent killer. While prevention (with the HPV vaccine) is optimal, early detection absolutely saves lives- so do NOT put off getting your Pap test.

While most of us have run 5K's or worn PINK for breast cancer awareness, few people know or talk about their diagnosis of cervical cancer. Tamika Felder, a now 13 year survivor of cervical cancer, is leading the charge to increase personal and community support for cervical cancer. For my fellow AUSTINITES- if you or someone you love has been diagnosed with cervical cancer (whether that diagnosis was recent or many years ago), please let them know about CERVIVOR SCHOOL- a four day learning, connecting and revitalizing retreat NEXT WEEK, starting Thursday evening, 1/15/15 through Sunday afternoon.

BOTTOM LINE: Women, if you are due for a Pap test, please move that to the top of your 2015 Resolution list!