Check Your ALTITUDE!

Going skiing for winter break? Whether you prefer downhill or cross country skiing, please remember that the high altitude might add in a few 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. Full disclosure, my destination of choice is Crested Butte, CO, which is one of the higher resorts...no pun intended.

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 and 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 altitude sickness begin?

Symptoms usually start 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!

Wait, Is It Broken?

Image B. Rushing

"I can move it, so it's clearly not broken..." Maybe, maybe not! In primary care settings, the majority of fractures that we treat are diagnosed days after they occur (sometimes weeks), ignored because of this inaccurate belief. Wrist fractures are notorious for this presentation, because often there is not dramatic bruising or deformity, and swelling may not be impressive. Finger, foot, and ankle fractures tend to have much more impressive dark bruising and swelling, but even with these injuries, the affected area can most frequently still be moved voluntarily (albeit with significant discomfort).

Fractures come in many shapes and sizes. Fortunately, most fractures are not "open", meaning most have no break in the skin (no bones sticking out anywhere). Some fractures are simple a hairline crack or a small buckle in the bone, while others break all the way through the bone and may shift out of place under the skin. The only way to be certain whether or not there is a fracture is with imaging- most commonly an ordinary X-ray.

What should you do if you think you may have broken a bone? Is it an emergency? If it is "open" (bone sticking out), of course this is an emergency, and this most likely would have occurred in a very traumatic situation such as a car wreck or other high speed injury. Call 911. If the limb is obviously distorted, or there is new and persistent numbness, tingling or decreased circulation (area turning cold, pale and/or blue), you need immediate medical help.  In less traumatic situations- you smash your toe against a door walking to the bathroom at night, you step off a curb funny, you fall on an outstretched hand- your injury may be urgent, but not emergent. Follow the RICE pneumonic- Rest, Ice, Compression (ace wrap) and Elevation while you are waiting for medical care.

BOTTOM LINE: Voluntary movement of a finger, toe, hand, foot or leg does NOT mean a bone is definitely not broken- head to your doctor if you are having persistent pain, swelling or bruising, and find out for sure.

STDs- The "Underestimated Opponent"

The CDC recently released the 2015 National Overview of Sexually Transmitted Diseases, and the rising numbers are disturbing. The CDC's forward begins by very accurately labeling STDs as a long-standing "underestimated opponent in the public health battle". We CANNOT continue to ignore sexually transmitted infections and assume it is "those people over there" and not OUR crowd who gets these infections! While ZIKA VIRUS has definitely opened up more non-judgmental discussions about STDs, we have a long way to go. Here are a few highlights from the report:

• CHLAMYDIA, the most common bacterial STD, has increased it's rate by 5.9% from 2014, with over 1.5 MILLION cases reported (and an estimated 3 MILLION actual cases), including 645.5 cases per 100,000 females, and 305.2 cases per 100,000 males. Simplified testing (with urine samples rather than only pelvic exams, for example) have increased the number of people tested, so yes that explains some increase, but the overall number is still...huge. And why do we care? Because undiagnosed and untreated chlamydia infection can lead to chronic pelvic pain, more serious infection (PID-Pelvic Inflammatory Disease), and even infertility. The vast majority of chlamydia infections are SILENT, so if you don't think you are "at risk" so you don't get screened, you will not know you have it. Between 10-30% of untreated chlamydia infections progress to PID, and 10-20% of those cause infertility. Think of the emotional, physical and financial burden that could be eased...if people simply were tested routinely, so diagnosed and treated. 

• GONORRHEA, another bacterial STD, was on track to be eliminated back in 2009, but we are going the wrong direction now with a rate increase of 12.8% AND increased drug resistance. We literally only have ONE recommended treatment now for gonorrhea (a combination of an injection of ceftriaxone and an oral dose of azithromycin) and resistance is growing. How many actual cases? Not the 1.5 MILLION reported number like chlamydia, but approaching a half million at 395, 216 cases. And once again, this is only the number reported. More disease + less cure = SCARY. Untreated gonorrhea, like untreated chlamydia, can cause chronic pelvic pain, PID, and infertility, not to mention spreading throughout the body to joints, the heart and the brain (meningitis).

• SYPHILIS is far less common that Chlamydia or Gonorrhea, with a bit less than 24,000 cases in 2015, but unfortunately this disease is rising as well, and sadly there were still 487 babies born with congenital syphilis last year.

These three STDs can be detected and treated successfully IF sexually active people will get tested regularly, but we have to improve our education and social dialogue so everyone understands that sexually transmitted diseases are underestimated on a personal basis, because we still think you can tell what "sort" of person would have these infections.

Bottom Line: If you are sexually active with a new partner, then you are that "sort" of person that could have an STD- because we ALL are, regardless of income, social status, religious beliefs or gender preferences. GET TESTED!! (And expect your partner to do the same.)

ZIKA's Unexpected Gifts

In no way do I want to minimize the serious complications of Zika. However, the media buzz surrounding Zika offers an unexpected gift- effective STI (sexually transmitted infection) education. What is Zika doing that AIDS did not?

·      Zika normalizes TALKING about STIs

Zika arrived as the newest “malaria”- a mosquito-borne illness, with the added threat of potentially devastating consequences in pregnant women. Like familiar flu season reports, headlines track Zika’s progress across geographical borders, firmly establishing Zika as a hot topic. Pictures of infants with birth defects tug at our hearts, while reporters jockey to broadcast the latest Zika developments. And then, BOOM- when health experts discovered that Zika could also be transmitted sexually...the conversation automatically extended to include condom usage and medically recommended abstinence. Zika fortunately lacks the “yuck” factor (and visual images) that shove other STIs out of well-mannered conversations, so the buzz continues.

·      Zika clearly shows ANYONE can get an STI

HIV/AIDS pointed a national spotlight on STIs, but that light was sharply focused on subpopulations at the highest risk- homosexual males, sex workers and IV drug users. The greatest myth is that STIs only occur “over there, in those people” (translation- not MY peers). After twenty years of private practice in an educated, affluent community, I can assure you that sexually transmitted infections also occur commonly in college students, soccer moms (and dads), and successful professionals who fit none of the traditional “high risk” subgroups. (Curious? Check out Seductive Delusions: how everyday people catch STIs for a sneak peak behind exam room doors.)

·      Zika, like most STDs, is often SILENT.

Zika may cause mild to severe symptoms including fever, rash, headache, painful joints and irritated eyes. In pregnant women, Zika can cause birth defects.  But Zika often causes no symptoms at all, which means infected people may have no idea they are carrying a disease that they can pass on to another person- which is the scariest truth about ALL sexually transmitted infections. For example, chlamydia, the most common bacterial STD, causes either very transient or no symptoms the vast majority of the time (90% in males, and at least 70% in females), yet if not diagnosed and treated, can lead to chronic pelvic pain and even infertility. Take home lesson?  “No symptoms” does NOT equal “no disease”. Get tested. Ask your partner to get tested.

·      PREVENTION is better than CURE

For Zika, prevention is all we have. Travel advisories, environmental pest control, and personal insect repellent target mosquito transmission. Consistent condom use for all types of sexual intimacy (oral, vaginal and anal sex) decreases the transmission every STI, including Zika. Effective vaccines extend our STI prevention for hepatitis B and HPV, and anti-viral medications help decrease transmission of herpes and HIV. While antibiotics can cure bacterial disease, they cannot undo damage already caused by long-standing untreated infections. Treatment is good, but prevention is better.

BOTTOM LINE:  Thank you, Zika, for expanding and normalizing discussions about sexually transmitted infections, and reminding us that the only way to know if you or a potential partner is carrying a silent infection is to GET TESTED- and START TALKING.

*This post was first published in the Johns Hopkins University Press Blog

No BULL...Get Your FLU SHOT!

Yes, it's only September, but we've been seeing cases of the flu all month! Today the University of Texas kicked off our 2016 flu shot campaign, and happily, students were lined up and ready to go. Our staff does a wonderful job of efficiently providing vaccines for students, faculty and staff- Hook 'em! The vaccines are widely available now, in your doctor's office, pharmacies and even grocery stores.

WHO: EVERYONE that is 6 months old & up (*with rare exceptions*)

WHY: THOUSANDS of people die from flu every year, here in the United States- between 3000-49,000 deaths. Hundreds of thousands are hospitalized, and many millions seek care with their own doctors, costing our healthcare system over $10 BILLION each year for direct flu-related costs. Closer to home- how many days can YOU (or your kids) afford to stay home sick or try to function with miserable flu symptoms?

The flu vaccine is not perfect, since new strains emerge each year and scientists are not yet clairvoyant. If you get the vaccine, you MIGHT still get the flu- but your illness should be much milder than if you were not vaccinated. Flu vaccines do NOT cause the flu- repeat- DO NOT CAUSE THE FLU. Note that influenza is not the same as the many viruses that cause "cold" symptoms, so the flu vaccine does not protect you against getting EVERY sore throat, runny nose, cough, sneeze and fever.

What's new for the 2016-2017 flu season?

• ONLY INJECTABLE VACCINES this year (NO nasal spray)
•  the nasal spray one with attenuated live virus will not be offered because last season's data has shown it to be significantly less effective than the injectable ones
• RECOMMENDATIONS for the 1.3% of children and 0.2% of adults with EGG ALLERGIES
• If your egg allergy means you get only hives after eating eggs, you may receive either type of vaccine available
• If you have a more severe egg allergy beyond hives (lip swelling, trouble breathing, passing out or vomiting), you may still receive either vaccine but it should be done in a medical setting with providers trained and able to manage severe allergic reactions.

BOTTOM LINE: Flu season is here once again. I got my flu vaccine last week- have you had yours?

Can College Students Get Ulcers?

"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 irritate the stomach lining, causing a gastritis (inflammation of the stomach lining) which might facilitate the development of ulcers:

• Drinking too much alcohol (more than one drink/day for women, or more than 2 drinks/day for men) 
• Using too many NSAIDs (Non Steroid Anti Inflammatory Drugs) like ibuprofen (aka. Advil/Motrin/etc).

Of course, college football weekends with prolonged tailgating and subsequent hangovers (treated with ibuprofen) are the perfect set up before "stress" from midterms is even a factor.

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.

If it's not an ulcer, what else could it be?
Persistent, recurrent upper abdominal pain and nausea could multiple other medical issues, including (but not limited to) gall stones, pancreatitis, hernias, colon disease (including celiac or inflammatory diseases like Crohn's) or other systemic illness. The key point here is not to worry you, but to encourage you not to suffer in silence. Avoid the temptation to self-diagnose or to try every over-the-counter remedy before heading in to see your family physician.

BOTTOM LINE: If you are having recurrent pain in your upper abdomen, nausea, bloating or other discomfort, stop taking NSAIDS and drinking alcohol, and head in to see your doctor. 

6 Tips for Freshmen Insomnia

Freshmen college students have many challenges as they adjust to their new environments, and sleepless nights in dorm rooms can trigger a downward spiral of fatigue, trouble concentrating, and poor grades...which leads to anxiety and more difficulty sleeping. What can students do to try and stop this cycle? Certainly there are multiple causes for insomnia, from roommate noise to seasonal allergies, to homesickness or academic stressors, but here are six basic steps to try first:

1. CONSISTENT SLEEP (& WAKE) TIMES- with MWF and T/Th schedules, often students have drastically different sleep and wake times each day, which doesn't jive with our body's internal clock. Getting up and going to bed at consistent times (within an hour's window) will help set your body on a schedule. Create a morning library study period for yourself on later start days that you treat as another class, or commit to an early exercise class.* (Daily aerobic exercise is a wonderful stress reducer, but because of the adrenaline it produces, make sure not to exercise within three hours of your normal bedtime.)
2. SLEEPING MASK- this is a great way to physically block out light in a shared space. Spend the extra few bucks for one that fits right, is easily washable and comfortable (usually around $15-$20). Side note- keep the mask ON during the night...resist the temptation to check the time. If you can't cover your eyes, cover the CLOCK. Our brains are clever, and can consistently wake us up at the exact time every night if we allow ourselves to look at the clock. 
3. BLOCK the NEW NOISE- like snoring roommates, hallway traffic or loud face-timing neighbors- with a combination of comfortable ear plugs or extra white noise from a portable fan (even if you have A/C). 
4.  GUIDED MEDITATION APP: consider one from Healthline's "Best Meditation Apps of 2016"
5. AVOID SCREENS at least the last hour or two before bed. Numerous studies have confirmed the detrimental affect of blue lights on sleep cycles. Students live on screens both socially and academically, so this is a tough one, but simple modifications include saving your actual book reading or off-screen math assignments for the end of your study evening, and taking your showers at night. And...not playing games or stalking social media as your "relaxation" time when you get in to bed. 
6. GO TO TUTORING. If academic stress is the primary source of your anxiety and subsequent insomnia, do not suffer in silence or wait till you "have" to talk to your professor! Almost everyone is initially overwhelmed by the volume and intensity of college courses, especially if you got in to your "dream" school. Learning to utilize study partners or groups, attending tutoring sessions, and discovering new interactive memorization techniques will help dramatically. Locking yourself in a room "until I finish", skipping fun activities as you try to force-feed yourself the information will be minimally productive, if at all. Alternating study locations, prioritizing sleep, and taking practice tests will improve your grades. All-nighters do not. 

BOTTOM LINE: College life is tough on sleep cycles- try these steps to start improving your chances of restful sleep, so your brain has the energy and focus to succeed!