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.